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Late anaphylactic shock after hysterosalpingography
FERTILITY AND STERILITY
Vol. 54, No.3, September 1990
Printed on acid-free paper in U.S.A.
Copyright © 1990 The American Fertility Society
Late anaphylactic shock after hysterosalpingography
Nico W. E. Schuitemaker, M.D.*t Frans M. Helmerhorst, M.D., Ph.D.* Richenel T. O. Tjon A Tham, M.D.:!: Jan L. C. van Saase, M.D., Ph.D.§ Leiden University Medical Center, Leiden, The Netherlands
Hysterosalpingography (HSG) is used to search for uterine and tubal abnormalities. All contrast media contain iodine and potentially can cause allergic reactions. 1 Adverse reactions may occur in 1 % to 10% of those exposed for the first time to such agents. Risk is highest with intravenous (IV) administration. 2 In HSG the incidence of adverse reactions is probably <0.5%.3 In most patients, mild reactions like urticaria were observed. 1 Only two cases of anaphylactic· shock associated with HSG have been reported in literature. 4 ,5 Both of them occurred within 10 minutes after instillation of the contrast medium. One of the patients had a history of allergies and intravasation occurred during HSG. We recently observed a patient who developed an acute allergic reaction leading to shock 1 hour after HSG. CASE REPORT
A 30-year-old female was evaluated for primary infertility. She had a history of allergies and of mild hypertension (blood pressure 140/95 mm Hg). Skin tests were positive for housedust. She never had a reaction to iodine. The patient had not used any medication recently. To reduce discomfort, a suppository of 10 mg buReceived September 20,1989; revised and accepted May 14, 1990. * Department of Obstetrics and Gynecology. t Reprint requests: Nico W. E. Schuitemaker, M.D., Department of Obstetrics and Gynecology, Leiden University Medical Center, Rijnsburgerweg 10, 2333 AA Leiden, The Netherlands. :j: Department of Radiology. § Department of Intensive Care.
Vol. 54, No.3, September 1990
tylscopolamine was administered rectally 1 hour before HSG. The vagina and the cervix were disinfected by an iodine solution (1 % iodine, 70% ethanol). Subsequently, a plastic suction cup was placed on the cervix. As contrast medium, 10 mL 50% methylglucamine-acetrizoate polividon (Vasurix-polyvidone; Guerbet, Aulnay Sous Bois Cedex, France) was used. The contrast medium was slowly injected into the uterus under continuous monitoring, and no signs of intravasation were observed. The uterine cavity was normal, and the tubes were patent. Soon after injection, the contrast medium spread in the peritoneal cavity. During the injection of contrast medium, the patient noted slight abdominal pain that increased, and she vomited. One hour later, during the follow-up x ray, generalized urticaria appeared. The patient experienced a sensation of a "thick tongue," became confused, and started to shiver. No signs of laryngeal edema or dyspnea developed. Blood pressure dropped to 70/50 mm Hg, and her pulse was 68. Two subcutaneous injections of epinephrine 0.5 mL (1/1,000),4 mg clemastine (an antihistamine) IV, and hydrocortisone-sodium succinate 100 mg IV were administered. An infusion with plasma expanders was started. . Major allergic manifestations disappeared within 30 minutes, urticaria after 1 hour. The patient was admitted to the intensive care unit and 8 hours later, a less severe relapse ofthe symptoms was observed. Again, treatment with clemastine and hydrocortisone was initiated. The next day, urticaria recurred, but 36 hours after HSG the patient left the hospital in good health. Clemastine medication was continued for another 4 days.
Schuitemaker et al.
Communications-in-brief
535
DISCUSSION
The term anaphylaxis has been variably employed to denote a defined immunoglobulin (Ig)Emediated antigen-induced reaction or as a descriptive term delineating a severe, abrupt, untoward event of unstated immunologic significance. This latter use of the term coincides with the most prevalent clinical usage, and so defined, it is a clinical syndrome with a multiplicity of inciting etiologic agents and a variety of pathogenetic mechanisms. 2 Histamine is an important mediator of anaphylaxis. Contrast media have the ability to release histamine from mast cells and basophilleucocytes by a direct, probably not IgE-mediated, effect. A separate histamine-releasing mechanism of contrast media is the ability to activate directly the alternative pathway of the complement system. 2 A reliable test to detect a potential allergic reaction to contrast media does not exist. 6 Patients with a history of adverse reaction to contrast media, allergies to seafood, or other allergies are believed to be at risk. 3 Distinction should be made between patients who claim to be allergic to iodine and those who are allergic to iodide salts in contrast media, although cross-reactivity may exist. Intravasation of contrast medium during HSG, which was not observed in our patient, would be another risk factor. I Usually the reaction is maximal within 30 minutes after contact with the allergen and then subsides, but in the case of some patients may be delayed for up to an hour.2 One could postulate that the initial symptoms in our patient, such as abdominal pain and vomiting, were related to chemical irritation of the peritoneum. I ,3 The late occurrence of the majority of signs and symptoms may be explained by a delayed resorption of contrast medium after mobilization of the patient to make the follow-up x ray and sub-
536
Schuitemaker et al.
Communications-in-brief
sequent spreading of contrast medium within the peritoneal cavity. Alternatively, one may hypothetize that the initial complaints were an early anaphylactic response, followed by a second episode of anaphylaxis, characterized as a late phase reaction. 2 Finally the relapses that were observed several hours after the procedure may have been caused by ungoing resorption or ongoing reaction after antiallergic therapy was stopped. 2 SUMMARY
We observed a patient who had a severe anaphylactic reaction 1 hour after HSG. Allergic symptoms recurred several hours after antiallergic therapy was stopped. The initial complaints of pain and vomiting could have been due to peritoneal irritation or alternatively to an early anaphylactic reaction. Patients who are at risk should be carefully evaluated before performing HSG. These patients and those with complaints after HSG should stay under observation for 1 or 2 hours after HSG. REFERENCES 1. Soules MR, Spandoni LR: Oil versus aqueous media for
2.
3.
4.
5. 6.
hysterosalpingography: a continuing debate based on many opinions and few facts. Fertil Steril38:1, 1982 Wasserman SI, Marquardt DL: Anaphylaxis. In Allergy: Principles and Practice, Vol. 2, 3rd edition, Edited by E Middleton, CE Reed, EF Ellis, NF Adkinson, JW Yunginger. St Louis, C. V. Mosby Co, 1988, p 1365 Sanfilippo JS, Yussman MA, Smith 0: Hysterosalpingography in the evaluation of infertility: a six-year review. Fertil Steril 30:636, 1978 Elias JA: Systemic reaction to radiocontrast media during hysterosalpingography. J Allergy Clin Immunol 66:242, 1980 Capdeville R, Remy J: Un accident majeur d' Hysterosalpingographie. J RadioI64:561, 1983 Siegler AM: Hysterosalpingography. Fertil Steril 40:139, 1983
Fertility and Sterility
Vol. 54, No.3, September 1990
Printed on acid-free paper in U.S.A.
Copyright © 1990 The American Fertility Society
Late anaphylactic shock after hysterosalpingography
Nico W. E. Schuitemaker, M.D.*t Frans M. Helmerhorst, M.D., Ph.D.* Richenel T. O. Tjon A Tham, M.D.:!: Jan L. C. van Saase, M.D., Ph.D.§ Leiden University Medical Center, Leiden, The Netherlands
Hysterosalpingography (HSG) is used to search for uterine and tubal abnormalities. All contrast media contain iodine and potentially can cause allergic reactions. 1 Adverse reactions may occur in 1 % to 10% of those exposed for the first time to such agents. Risk is highest with intravenous (IV) administration. 2 In HSG the incidence of adverse reactions is probably <0.5%.3 In most patients, mild reactions like urticaria were observed. 1 Only two cases of anaphylactic· shock associated with HSG have been reported in literature. 4 ,5 Both of them occurred within 10 minutes after instillation of the contrast medium. One of the patients had a history of allergies and intravasation occurred during HSG. We recently observed a patient who developed an acute allergic reaction leading to shock 1 hour after HSG. CASE REPORT
A 30-year-old female was evaluated for primary infertility. She had a history of allergies and of mild hypertension (blood pressure 140/95 mm Hg). Skin tests were positive for housedust. She never had a reaction to iodine. The patient had not used any medication recently. To reduce discomfort, a suppository of 10 mg buReceived September 20,1989; revised and accepted May 14, 1990. * Department of Obstetrics and Gynecology. t Reprint requests: Nico W. E. Schuitemaker, M.D., Department of Obstetrics and Gynecology, Leiden University Medical Center, Rijnsburgerweg 10, 2333 AA Leiden, The Netherlands. :j: Department of Radiology. § Department of Intensive Care.
Vol. 54, No.3, September 1990
tylscopolamine was administered rectally 1 hour before HSG. The vagina and the cervix were disinfected by an iodine solution (1 % iodine, 70% ethanol). Subsequently, a plastic suction cup was placed on the cervix. As contrast medium, 10 mL 50% methylglucamine-acetrizoate polividon (Vasurix-polyvidone; Guerbet, Aulnay Sous Bois Cedex, France) was used. The contrast medium was slowly injected into the uterus under continuous monitoring, and no signs of intravasation were observed. The uterine cavity was normal, and the tubes were patent. Soon after injection, the contrast medium spread in the peritoneal cavity. During the injection of contrast medium, the patient noted slight abdominal pain that increased, and she vomited. One hour later, during the follow-up x ray, generalized urticaria appeared. The patient experienced a sensation of a "thick tongue," became confused, and started to shiver. No signs of laryngeal edema or dyspnea developed. Blood pressure dropped to 70/50 mm Hg, and her pulse was 68. Two subcutaneous injections of epinephrine 0.5 mL (1/1,000),4 mg clemastine (an antihistamine) IV, and hydrocortisone-sodium succinate 100 mg IV were administered. An infusion with plasma expanders was started. . Major allergic manifestations disappeared within 30 minutes, urticaria after 1 hour. The patient was admitted to the intensive care unit and 8 hours later, a less severe relapse ofthe symptoms was observed. Again, treatment with clemastine and hydrocortisone was initiated. The next day, urticaria recurred, but 36 hours after HSG the patient left the hospital in good health. Clemastine medication was continued for another 4 days.
Schuitemaker et al.
Communications-in-brief
535
DISCUSSION
The term anaphylaxis has been variably employed to denote a defined immunoglobulin (Ig)Emediated antigen-induced reaction or as a descriptive term delineating a severe, abrupt, untoward event of unstated immunologic significance. This latter use of the term coincides with the most prevalent clinical usage, and so defined, it is a clinical syndrome with a multiplicity of inciting etiologic agents and a variety of pathogenetic mechanisms. 2 Histamine is an important mediator of anaphylaxis. Contrast media have the ability to release histamine from mast cells and basophilleucocytes by a direct, probably not IgE-mediated, effect. A separate histamine-releasing mechanism of contrast media is the ability to activate directly the alternative pathway of the complement system. 2 A reliable test to detect a potential allergic reaction to contrast media does not exist. 6 Patients with a history of adverse reaction to contrast media, allergies to seafood, or other allergies are believed to be at risk. 3 Distinction should be made between patients who claim to be allergic to iodine and those who are allergic to iodide salts in contrast media, although cross-reactivity may exist. Intravasation of contrast medium during HSG, which was not observed in our patient, would be another risk factor. I Usually the reaction is maximal within 30 minutes after contact with the allergen and then subsides, but in the case of some patients may be delayed for up to an hour.2 One could postulate that the initial symptoms in our patient, such as abdominal pain and vomiting, were related to chemical irritation of the peritoneum. I ,3 The late occurrence of the majority of signs and symptoms may be explained by a delayed resorption of contrast medium after mobilization of the patient to make the follow-up x ray and sub-
536
Schuitemaker et al.
Communications-in-brief
sequent spreading of contrast medium within the peritoneal cavity. Alternatively, one may hypothetize that the initial complaints were an early anaphylactic response, followed by a second episode of anaphylaxis, characterized as a late phase reaction. 2 Finally the relapses that were observed several hours after the procedure may have been caused by ungoing resorption or ongoing reaction after antiallergic therapy was stopped. 2 SUMMARY
We observed a patient who had a severe anaphylactic reaction 1 hour after HSG. Allergic symptoms recurred several hours after antiallergic therapy was stopped. The initial complaints of pain and vomiting could have been due to peritoneal irritation or alternatively to an early anaphylactic reaction. Patients who are at risk should be carefully evaluated before performing HSG. These patients and those with complaints after HSG should stay under observation for 1 or 2 hours after HSG. REFERENCES 1. Soules MR, Spandoni LR: Oil versus aqueous media for
2.
3.
4.
5. 6.
hysterosalpingography: a continuing debate based on many opinions and few facts. Fertil Steril38:1, 1982 Wasserman SI, Marquardt DL: Anaphylaxis. In Allergy: Principles and Practice, Vol. 2, 3rd edition, Edited by E Middleton, CE Reed, EF Ellis, NF Adkinson, JW Yunginger. St Louis, C. V. Mosby Co, 1988, p 1365 Sanfilippo JS, Yussman MA, Smith 0: Hysterosalpingography in the evaluation of infertility: a six-year review. Fertil Steril 30:636, 1978 Elias JA: Systemic reaction to radiocontrast media during hysterosalpingography. J Allergy Clin Immunol 66:242, 1980 Capdeville R, Remy J: Un accident majeur d' Hysterosalpingographie. J RadioI64:561, 1983 Siegler AM: Hysterosalpingography. Fertil Steril 40:139, 1983
Fertility and Sterility