IJG-08343; No of Pages 2 International Journal of Gynecology and Obstetrics xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
BRIEF COMMUNICATION
Hyperbaric oxygen therapy in a case of vaginal and uterine necrosis after embolization for postpartum hemorrhage Jean dit Gautier Estelle a,⁎, Marco Midulla b, Jean-Philippe Lucot a, Pierre Aguettaz b, Raphael Favory c, Damien Subtil a,d a
Hospital Jeanne de Flandre, Lille University Hospital Center, Lille, France Interventional Vascular Radiology, Cardiology Hospital, Lille University Hospital Center, Lille, France Department of Hyperbaric Oxygen Therapy, Intensive Care Pavillon, Lille University Hospital Center, Lille, France d EA 2694, PRES University of Lille, Lille, France b c
a r t i c l e
i n f o
Article history: Received 13 October 2014 Received in revised form 2 March 2015 Accepted 30 April 2015 Keywords: Embolization Hyperbaric oxygen therapy Necrosis Postpartum hemorrhage
showed an intrauterine mass (Fig. 1). This mass was evacuated by curettage, although the degree of adhesion caused difficulty. Pathologic analysis identified ischemic myometrial necrosis. Hyperbaric oxygen therapy was prescribed for the intense pain. The patient attended three 90-min sessions per week for 10 weeks. Clinical improvement was clearly perceptible after 12 sessions: areas of healthy endometrial mucosa were seen on hysteroscopy, which was undertaken to remove an obstructive synechia in the uterine isthmus. In the case described here, uterine and vaginal necrosis followed embolization of the uterine and cervicovaginal arteries, which was justified by the patient’s severe postpartum hemorrhage, hematoma, and stable hemodynamic status [1]. Ischemic complications of embolization have been principally described when the particles used were either small
Uterine artery embolization is an alternative to surgical treatment of postpartum hemorrhage. However, it can cause ischemic complications. The present report describes a case of uterine and vaginal necrosis after embolization, which was relieved by hyperbaric oxygen therapy. Informed consent for publication of the present report was obtained from the patient. After a normal pregnancy, a nulliparous woman aged 36 years had a spontaneous vaginal delivery at Hospital Jeanne de Flandre, Lille University Hospital Center, Lille, France. She had a postpartum hemorrhage, with a blood loss of 2000 mL, necessitating a sulprostone infusion. A left pararectal hematoma was drained through an incision in the nymphocaruncular sulcus, but rapidly recurred. Bilateral selective embolization of the uterine and cervicovaginal arteries was undertaken using pledgets of absorbable gelatin sponge (Curaspon, Curamedical BV, Assendelft, Netherlands), which stopped the bleeding. During the postpartum period, the patient reported persistent abdominal and pelvic pain that prevented her from sitting up. On speculum examination, three well delimited reddish lesions were seen on the posterior vaginal wall; the patient reported pain on contact. Vaginal necrosis was suspected. Ultrasonography and computed tomography
⁎ Corresponding author at: Hôpital Jeanne de Flandre, University of Lille Nord de France, Avenue Eugene Avinee, 59037 Lille, France. Tel.: + 33 3 03 20 44 66 26; fax: + 33 3 03 20 44 63 11. E-mail address: [email protected] (J.G. Estelle).
Fig. 1. Computed tomography showing a heterogeneous intrauterine mass measuring 56 × 22 mm (arrow).
http://dx.doi.org/10.1016/j.ijgo.2015.03.034 0020-7292/© 2015 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
Please cite this article as: Estelle JG, et al, Hyperbaric oxygen therapy in a case of vaginal and uterine necrosis after embolization for postpartum hemorrhage, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/j.ijgo.2015.03.034
2
J.G. Estelle et al. / International Journal of Gynecology and Obstetrics xxx (2015) xxx–xxx
or non-resorbable [2]. However, in the present case, large pledgets (3–5 mm) of an absorbable gelatin sponge were used. In a review of postembolization uterine necrosis after postpartum hemorrhage [2], several cases were identified, all of which were managed by hysterectomy. Despite the abdominal pain, an exploratory laparotomy was not performed in the present case in view of the patient's stable hemodynamic status. Vaginal necrosis following postpartum hemorrhage is rarely reported. Although no biopsy sample was obtained, the appearance of the lesions and the severe pain described by the patient resembled what has been described in perineal ischemia in Fournier disease [3]. Hyperbaric oxygen therapy seems to be a logical treatment of refractory ischemic lesion [4]. In the present case, such treatment apparently accelerated regression of the pelvic pain and vaginal lesions. Although assessing its effects on the uterine necrosis is difficult, the hysteroscopy showed an apparently healthy mucosa. Therefore, hyperbaric oxygen
therapy could be useful in the case of uterine and vaginal necrosis after embolization for severe postpartum hemorrhage. Conflict of interest The authors have no conflicts of interest. References [1] Dildy III GA. Postpartum hemorrhage: new management options. Clin Obstet Gynecol 2002;45(2):330–44. [2] Poujade O, Ceccaldi PF, Davitian C, Amate P, Chatel P, Khater C, et al. Uterine necrosis following pelvic arterial embolization for post-partum hemorrhage: review of the literature. Eur J Obstet Gynecol Reprod Biol 2013;170(2):309–14. [3] Shyam DC, Rapsang AG. Fournier’s gangrene. Surgeon 2013;11(4):222–32. [4] Soh CR, Pietrobon R, Freiberger JJ, Chew ST, Rajgor D, Gandhi M, et al. Hyperbaric oxygen therapy in necrotising soft tissue infections: a study of patients in the United States Nationwide Inpatient Sample. Intensive Care Med 2012;38(7):1143–51.
Please cite this article as: Estelle JG, et al, Hyperbaric oxygen therapy in a case of vaginal and uterine necrosis after embolization for postpartum hemorrhage, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/j.ijgo.2015.03.034
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
BRIEF COMMUNICATION
Hyperbaric oxygen therapy in a case of vaginal and uterine necrosis after embolization for postpartum hemorrhage Jean dit Gautier Estelle a,⁎, Marco Midulla b, Jean-Philippe Lucot a, Pierre Aguettaz b, Raphael Favory c, Damien Subtil a,d a
Hospital Jeanne de Flandre, Lille University Hospital Center, Lille, France Interventional Vascular Radiology, Cardiology Hospital, Lille University Hospital Center, Lille, France Department of Hyperbaric Oxygen Therapy, Intensive Care Pavillon, Lille University Hospital Center, Lille, France d EA 2694, PRES University of Lille, Lille, France b c
a r t i c l e
i n f o
Article history: Received 13 October 2014 Received in revised form 2 March 2015 Accepted 30 April 2015 Keywords: Embolization Hyperbaric oxygen therapy Necrosis Postpartum hemorrhage
showed an intrauterine mass (Fig. 1). This mass was evacuated by curettage, although the degree of adhesion caused difficulty. Pathologic analysis identified ischemic myometrial necrosis. Hyperbaric oxygen therapy was prescribed for the intense pain. The patient attended three 90-min sessions per week for 10 weeks. Clinical improvement was clearly perceptible after 12 sessions: areas of healthy endometrial mucosa were seen on hysteroscopy, which was undertaken to remove an obstructive synechia in the uterine isthmus. In the case described here, uterine and vaginal necrosis followed embolization of the uterine and cervicovaginal arteries, which was justified by the patient’s severe postpartum hemorrhage, hematoma, and stable hemodynamic status [1]. Ischemic complications of embolization have been principally described when the particles used were either small
Uterine artery embolization is an alternative to surgical treatment of postpartum hemorrhage. However, it can cause ischemic complications. The present report describes a case of uterine and vaginal necrosis after embolization, which was relieved by hyperbaric oxygen therapy. Informed consent for publication of the present report was obtained from the patient. After a normal pregnancy, a nulliparous woman aged 36 years had a spontaneous vaginal delivery at Hospital Jeanne de Flandre, Lille University Hospital Center, Lille, France. She had a postpartum hemorrhage, with a blood loss of 2000 mL, necessitating a sulprostone infusion. A left pararectal hematoma was drained through an incision in the nymphocaruncular sulcus, but rapidly recurred. Bilateral selective embolization of the uterine and cervicovaginal arteries was undertaken using pledgets of absorbable gelatin sponge (Curaspon, Curamedical BV, Assendelft, Netherlands), which stopped the bleeding. During the postpartum period, the patient reported persistent abdominal and pelvic pain that prevented her from sitting up. On speculum examination, three well delimited reddish lesions were seen on the posterior vaginal wall; the patient reported pain on contact. Vaginal necrosis was suspected. Ultrasonography and computed tomography
⁎ Corresponding author at: Hôpital Jeanne de Flandre, University of Lille Nord de France, Avenue Eugene Avinee, 59037 Lille, France. Tel.: + 33 3 03 20 44 66 26; fax: + 33 3 03 20 44 63 11. E-mail address: [email protected] (J.G. Estelle).
Fig. 1. Computed tomography showing a heterogeneous intrauterine mass measuring 56 × 22 mm (arrow).
http://dx.doi.org/10.1016/j.ijgo.2015.03.034 0020-7292/© 2015 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
Please cite this article as: Estelle JG, et al, Hyperbaric oxygen therapy in a case of vaginal and uterine necrosis after embolization for postpartum hemorrhage, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/j.ijgo.2015.03.034
2
J.G. Estelle et al. / International Journal of Gynecology and Obstetrics xxx (2015) xxx–xxx
or non-resorbable [2]. However, in the present case, large pledgets (3–5 mm) of an absorbable gelatin sponge were used. In a review of postembolization uterine necrosis after postpartum hemorrhage [2], several cases were identified, all of which were managed by hysterectomy. Despite the abdominal pain, an exploratory laparotomy was not performed in the present case in view of the patient's stable hemodynamic status. Vaginal necrosis following postpartum hemorrhage is rarely reported. Although no biopsy sample was obtained, the appearance of the lesions and the severe pain described by the patient resembled what has been described in perineal ischemia in Fournier disease [3]. Hyperbaric oxygen therapy seems to be a logical treatment of refractory ischemic lesion [4]. In the present case, such treatment apparently accelerated regression of the pelvic pain and vaginal lesions. Although assessing its effects on the uterine necrosis is difficult, the hysteroscopy showed an apparently healthy mucosa. Therefore, hyperbaric oxygen
therapy could be useful in the case of uterine and vaginal necrosis after embolization for severe postpartum hemorrhage. Conflict of interest The authors have no conflicts of interest. References [1] Dildy III GA. Postpartum hemorrhage: new management options. Clin Obstet Gynecol 2002;45(2):330–44. [2] Poujade O, Ceccaldi PF, Davitian C, Amate P, Chatel P, Khater C, et al. Uterine necrosis following pelvic arterial embolization for post-partum hemorrhage: review of the literature. Eur J Obstet Gynecol Reprod Biol 2013;170(2):309–14. [3] Shyam DC, Rapsang AG. Fournier’s gangrene. Surgeon 2013;11(4):222–32. [4] Soh CR, Pietrobon R, Freiberger JJ, Chew ST, Rajgor D, Gandhi M, et al. Hyperbaric oxygen therapy in necrotising soft tissue infections: a study of patients in the United States Nationwide Inpatient Sample. Intensive Care Med 2012;38(7):1143–51.
Please cite this article as: Estelle JG, et al, Hyperbaric oxygen therapy in a case of vaginal and uterine necrosis after embolization for postpartum hemorrhage, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/j.ijgo.2015.03.034
