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Pulmonary Oil Embolism Following Hysterosalpingography
Pulmonary Oil Embolism Following Hysterosalpingography JOHN M. LEVINSON, M.D.
is one of the common major complications in operative obstetrics and gynecology. But little attention has been given to an uncommon type, namely, that following hysterosalpingography. The entry of oil-contrast medium into the uterine venous sinuses with rapid transit to the lungs and other organs is fortunately an unusual phenomenon, since it may have serious, even fatal, consequences. A brief review of the reported cases with the addition of a personal one should emphasize the seriousness of the problem.
RMONARY EMBOLISM
CASE REPORT Mrs. L. C. ( 14-08-14) was a gravida 3, para 0, attended by the author for her second and third pregnancies. In spite of rest, vitamins, and hormones, both pregnancies terminated in incomplete abortion at 2~ months, requiring curettage. A septum was noted dividing the uterine corpus to just above the internal os. Hysterosalpingography confirmed a "uterus septus," and subsequently she underwent a Strassman metroplasty. In the next 6 months she had oligomenorrhea, but a pregnancy test was negative, and hysterosalpingography was performed. During the injection of the dye, 0 the patient developed a diffuse mild pain in the anterior chest, dyspnea, and mild tachycardia, and approximately 10 hr. later had a temperature of 102.2°F. The first hysterosalpingogram, inadvertently a pelvic phlebogram as well, demonstrated dye in the endometrial cavity, intravasated into the myometrium (Fig. 1). A chest X-ray taken following hysterosalpingography was essentially normal, with some elevation of the diaphragm (Fig. 2). A clinical diagnosis of pulmonary embolism was made. The patient was seen in From the Memorial Hospital, Wilmington, Dela. Presented at the Third World Congress of the International Federation of Gynecology and Obstetrics, Vienna, Austria, September 1961. The author expresses his appreciation to Dr. Paul A. Shaw, Radiologist, and Dr. Leonard Tucker of the Department of Medicine at the Memorial Hospital for their participation in the case presented. *Iodochlorol, 27% iodine with 7%% chlorine organically combined with refined peanut oil, made by G. D. Searle & Co., Chicago, Ill.
21
22
LEVINSON
FERTILITY
& STERILITY
Fig. 1. Hysterogram showing myometrial intravasation of contrast medium. Pelvic veins are visualized.
Fig, 2. First chest X-ray.
VoL. 14,No.l,l963
PuLMONARY OIL EMBOLISM
23
consultation by an internist, who noted abnormal breath sounds in the right lower lobe posteriorly. An EKG demonstrated tachycardia with an elevated P wave. On the next day, a friction rub was noted at the right base posteriorly, and a chest X-ray (Fig. 3) demonstrated elevation of the diaphragm on the right with some costophrenic clouding; absent breath sounds were noted in this area. In addition, the film demonstrated a disseminated micronodulation effect probably representing droplet embolic phenomena in a rather prominent degree. No single major embolic or infarcted process was indicated. On the following day, the patient was afebrile, and on the sixth day following hysterosalpingography, the chest was almost normal clinically; the patient was asymptomatic, and the third chest X-ray (Fig. 4) was normal. Treatment had consisted of bedrest, analgesics, and anticoagulants. DISCUSSION
In 1931 Gajzajo of Budapest reported the case of a 60-year old female who died 9 hr. after hysterosalpingography done with 40% iodipin (iodized poppy seed oil). Autopsy disclosed oil embolism in the lungs, heart, and kidneys.
Pig. S. Second chest X-ray.
24
LEVINSON
FERTILITY
& STERILITY
Since that time 25 nonfatal cases of pulmonary oil embolism after hysterosalpingography done with iodized vegetable oil have been reported. 2 • 4 • 6 • 7 • 1015· 17 • 21 • 24 - 26 Only some of these reports were documented by reproductions of X-rays.
Fig. 4. Last chest X-ray.
In addition, one nonfatal case29 following myelography and one28 following the subcutaneous injection of iodized oil in the treatment of tuberculosis have been reported. Four fatalities from pulmonary embolism following the urethral injection of mineral oil ( 3 cases 19 • 20 ) and vegetable oil ( 1 case3 ) in attempts to relieve urinary retention have been described. Clinical Findings
Most symptoms develop during or immediately after injection of the oiP0 Tightness in the chest, cough, nausea, dyspnea, cyanosis, experiencing a transient smell of iodine/ 6 and fever may develop9 • 19 • 20 hours to days after the injection. CNS symptoms are seen in fatal cases and are due to cerebral oil embolism.
VoL. 14, No. 1, 1963
PuLMONARY OIL EMBOLISM
25
Radiologic Aspects
Hemmeler in 1938 first reported pulmonary radiologic changes as illdefined opacities in both lung fields 24 hr. after hysterosalpingography. Most patients show either fine, dense, or sharply defined opacities throughout both lung fields or a diffuse, fine, faint stippling. Most X-rays showing the abnormalities were taken between the second and tenth day, although changes in chest X-rays within 5 min. of hysterosalpingography were noted by Grossman. Treabnent
There is no agreement on therapy, but it has mainly been symptomatic. The prognosis is usually good unless secondary complications occur; and, as stated above, death is a possibility. Experimental Studies
Sicard and Forestier carried out investigations of the reactions of dogs and humans to intravenous injections of Lipiodol."' In humans they found that the oil reached the pulmonary capillaries in 3-4 sec., remained visible on serial X-rays of the lungs for ~ min., and then disappeared. Cough was the only symptom noted. Walther found that following intravenous injection, the oil was held up in the arterioles and capillaries of the lungs, where it rapidly was split into its two principal constituents, iodine and fat, by blood lipase and the lipolytic action of lung tissue. Most of the iodine was excreted as potassium iodide by the kidneys within ~ days. The oil was saponified by blood lipases and removed by phagacytosis. Localized eosinophilia in lung tissue of the experimental animal and eosinophilia in peripheral blood have been noted. 8 An increase in circulating eosinophils has not been reported in humans. Venous Intravasation
In 1929 the exact mode of entry of iodized oil into the circulation was first described. 22 The incidence of this complication of hysterosalpingography varies from 0 to 4.6 per cent in various series. 1 • 5 • 6 • 16• 18 • 23 More recently Wegryn and Harron studied normal and pathologic anatomy of living patients by pelvic phlebography with the use of Hypaque,t a water-soluble preparation, without serious complications in 50 subjects. *E. Fougera & Co., Inc., Hicksville, Long Island, N.Y. tWinthrop Laboratories, New York, N.Y.
26
LEVINSON
FERTILITY & STERILITY
Contraindications to Hysterosalpingography
Pulmonary oil embolism probably cannot occur without uterine venous intravasation, which can be due to the following: 16 • 32 ( 1) injection of the oil under excessive pressure; ( 2) injection very early in the postmenstrual period; ( 3) trauma during the procedure; ( 4) tuberculosis of the endometrium; ( 5) injection following curettage and during pregnancy; ( 6) any pathologic condition which produces increased fragility of the uterine vessels. Venous intravasation has been reported in many large series of hysterosalpingograms, but pulmonary embolization appears to be a rare phenomenon not noted either clinically or radiologically except as mentioned above-only in instances in which an oil medium was used. SUMMARY AND CONCLUSIONS
A case of pulmonary oil embolism following hysterosalpinography is presented. The 26 previously reported cases are reviewed. Experimental studies, pathiophysiology, and contraindications to hysterosalpingography are cited. The use of oil medium for hysterosalpingography is open to question-It appears that water-soluble dye is safer. Until the ideal medium for hysterosalpingography has been found, one must be constantly alert to the dangers of pulmonary embolism. ADDENDUM
On Dec. 27, 1961, the patient underwent emergency cesarean section because of a placental abruption. A living 3-lb., 14}4-oz. female was delivered. At 6 weeks post-partum, the patient and her infant were both doing well. 1003 Delaware Ave. Wilmington 6, Dela.
REFERENCES 1. 2. 3. 4. 5. 6. 7. 8.
BARNETT, E. ]. Fac. Radial. 7:115, 184, 1956. BLOOMFIELD, A. J. Obst. & Gynaec. Brit. Emp. 53:345, 1946. CARR, L., and JoHNSON, C. M. ].A.M.A. 104:1973, 1935. CoVENTRY, W. A. Am.]. Obst. & Gynec. 27:912, 1934. DAVIDS, A.M. Am./. Obst. & Gynec. 65:1167, 1953. DRUKMAN, A., and RoziN, S. ]. Obst. & Gynaec. Brit. Emp. 58:73, EISEN, D., and GoLDSTEIN, Radiology 45:603, 1945. EssELIER, VoN A. F., MARTI, H. R., MoRANDI, L., and WAGNER,
J.
J.
1951.
K. Internat. Arch. Allergy 3:279, 1952. 9. GAJZAGO, VoN E. Zentralbl. Gyniik. 55:543, 1931. 10. GRANT, I. W. B., CALLAM, W. D. A., and DAVIDSON, J. K. J. Fac. Radiol. 8:410, 1957. 11. GROSSMAN, M. E. Brit. f. Radial. 19:178, 1946. 12. HEMMELER, G. Schweiz. med. Wchnschr. 68:717, 1938. 13. INGERSOLL, F. M., and RoBBINS, L. L. Am. J. Obst. & Gynec. 53:301, 1947.
VoL.
14,
No.
1, 1963
PULMONARY
OIL
EMBOLISM
27
14. KARSHMER, N., and STEIN, W. Am.]. Obst. & Gynec. 61:458, 1951. 15. KELLER, R. Gynec. et obst. 47:21, 1948. 16. KIKA, E. Am.]. Obst. & Gynec. 67:56, 1954. 17. LIN, Y. Y., and Tsou, S. H. Chinese Med.]. 49:1241, 1935. 18. MARSHAK, R. H., PooLE, C. S., and GoLDBERGER, M.A. Surg. Gynec. & Obst. 91:182, 1950. 19. MITCHELL, D. R., and 0RTVED, W. E. ]. Urol. 68:652, 1952. 20. PATTERSON, E. A. ].A.M.A. 97:1147, 1931. 21. PrATT, A. D. Ohio M.]. 43:821, 1947. 22. PUJOL, Y., BRULL, A., VANRELL, J., and CARULLA RIERA, V. ]. Radiol. Electrol. 1.3:38, 1929. 23. RoBINS, S. A., and SHAPIRA, A. A. New England]. Med. 205:380, 1931. 24. RoBLEE, M. A., and MooRE, S. South. M. ]. 38:89, 1945. 25. SAPPEY, P., FABRE, H., and JouFFREY, A. Gynec. et obst. 51:298, 1952. 26. SHAPmo, J. H., RuBENSTEIN, B., JAcOBSON, H. G., and PoPPEL, M. H. Am. ]. Roentgenol. 77:1055, 1957. 27. SICARD, J. A., and FoRESTIER, J. Compts. rends. Soc. Biol. 88:1200, 1923. 28. SoLARIS, I. A. Prensa med. Argent. 22:2136, 1935. 29. STEINBACH, H. L., and HILL, W. B. Radiology 56:735, 1951. 30. WALTHER, 0. Acta. radiol. 20:457, 1939. 31. WEGRYN, S. P., and HARRON, R. A. Obst. & Gynec. 15:73, 1960. 32. WILLIAMS, E. R. Brit.]. Radiol.17:13, 1944.
New York University Post-Graduate Medical School Course in Gynecological Endocrinology New York University announces a postgraduate course (563R) in gynecological endocrinology. The course offers a practical, didactic, and clinical presentation with emphasis on the therapeutic management of endocrine disorders in the female, including a discussion of the diagnosis and management of intersex and endocrine therapy for menstrual abnormalities and ovulatory defects. Adrenocortical, thyroid, ovarian, and pituitary abnormalities will be emphasized. Practical diagnostic tests, including the most recent procedures, will be described and demonstrated. The therapeutic use of the newer progestational, gonadal, and corticoid steroids will be discussed, as well as available pituitary preparations. Some pertinent aspects of male and pediatric endocrinology will be included. The diagnostic importance of the chromosomal analysis will be elaborated upon. The 5-day, full-time course, under the direction of Dr. Herbert S. Kupperman, will be held from Mar. 25 through Mar. 29,1963. Further information may be obtained from the Office of the Associate Dean, New York University Post-Graduate Medical School, 550 First Avenue, NewYorkl6,N. Y.
is one of the common major complications in operative obstetrics and gynecology. But little attention has been given to an uncommon type, namely, that following hysterosalpingography. The entry of oil-contrast medium into the uterine venous sinuses with rapid transit to the lungs and other organs is fortunately an unusual phenomenon, since it may have serious, even fatal, consequences. A brief review of the reported cases with the addition of a personal one should emphasize the seriousness of the problem.
RMONARY EMBOLISM
CASE REPORT Mrs. L. C. ( 14-08-14) was a gravida 3, para 0, attended by the author for her second and third pregnancies. In spite of rest, vitamins, and hormones, both pregnancies terminated in incomplete abortion at 2~ months, requiring curettage. A septum was noted dividing the uterine corpus to just above the internal os. Hysterosalpingography confirmed a "uterus septus," and subsequently she underwent a Strassman metroplasty. In the next 6 months she had oligomenorrhea, but a pregnancy test was negative, and hysterosalpingography was performed. During the injection of the dye, 0 the patient developed a diffuse mild pain in the anterior chest, dyspnea, and mild tachycardia, and approximately 10 hr. later had a temperature of 102.2°F. The first hysterosalpingogram, inadvertently a pelvic phlebogram as well, demonstrated dye in the endometrial cavity, intravasated into the myometrium (Fig. 1). A chest X-ray taken following hysterosalpingography was essentially normal, with some elevation of the diaphragm (Fig. 2). A clinical diagnosis of pulmonary embolism was made. The patient was seen in From the Memorial Hospital, Wilmington, Dela. Presented at the Third World Congress of the International Federation of Gynecology and Obstetrics, Vienna, Austria, September 1961. The author expresses his appreciation to Dr. Paul A. Shaw, Radiologist, and Dr. Leonard Tucker of the Department of Medicine at the Memorial Hospital for their participation in the case presented. *Iodochlorol, 27% iodine with 7%% chlorine organically combined with refined peanut oil, made by G. D. Searle & Co., Chicago, Ill.
21
22
LEVINSON
FERTILITY
& STERILITY
Fig. 1. Hysterogram showing myometrial intravasation of contrast medium. Pelvic veins are visualized.
Fig, 2. First chest X-ray.
VoL. 14,No.l,l963
PuLMONARY OIL EMBOLISM
23
consultation by an internist, who noted abnormal breath sounds in the right lower lobe posteriorly. An EKG demonstrated tachycardia with an elevated P wave. On the next day, a friction rub was noted at the right base posteriorly, and a chest X-ray (Fig. 3) demonstrated elevation of the diaphragm on the right with some costophrenic clouding; absent breath sounds were noted in this area. In addition, the film demonstrated a disseminated micronodulation effect probably representing droplet embolic phenomena in a rather prominent degree. No single major embolic or infarcted process was indicated. On the following day, the patient was afebrile, and on the sixth day following hysterosalpingography, the chest was almost normal clinically; the patient was asymptomatic, and the third chest X-ray (Fig. 4) was normal. Treatment had consisted of bedrest, analgesics, and anticoagulants. DISCUSSION
In 1931 Gajzajo of Budapest reported the case of a 60-year old female who died 9 hr. after hysterosalpingography done with 40% iodipin (iodized poppy seed oil). Autopsy disclosed oil embolism in the lungs, heart, and kidneys.
Pig. S. Second chest X-ray.
24
LEVINSON
FERTILITY
& STERILITY
Since that time 25 nonfatal cases of pulmonary oil embolism after hysterosalpingography done with iodized vegetable oil have been reported. 2 • 4 • 6 • 7 • 1015· 17 • 21 • 24 - 26 Only some of these reports were documented by reproductions of X-rays.
Fig. 4. Last chest X-ray.
In addition, one nonfatal case29 following myelography and one28 following the subcutaneous injection of iodized oil in the treatment of tuberculosis have been reported. Four fatalities from pulmonary embolism following the urethral injection of mineral oil ( 3 cases 19 • 20 ) and vegetable oil ( 1 case3 ) in attempts to relieve urinary retention have been described. Clinical Findings
Most symptoms develop during or immediately after injection of the oiP0 Tightness in the chest, cough, nausea, dyspnea, cyanosis, experiencing a transient smell of iodine/ 6 and fever may develop9 • 19 • 20 hours to days after the injection. CNS symptoms are seen in fatal cases and are due to cerebral oil embolism.
VoL. 14, No. 1, 1963
PuLMONARY OIL EMBOLISM
25
Radiologic Aspects
Hemmeler in 1938 first reported pulmonary radiologic changes as illdefined opacities in both lung fields 24 hr. after hysterosalpingography. Most patients show either fine, dense, or sharply defined opacities throughout both lung fields or a diffuse, fine, faint stippling. Most X-rays showing the abnormalities were taken between the second and tenth day, although changes in chest X-rays within 5 min. of hysterosalpingography were noted by Grossman. Treabnent
There is no agreement on therapy, but it has mainly been symptomatic. The prognosis is usually good unless secondary complications occur; and, as stated above, death is a possibility. Experimental Studies
Sicard and Forestier carried out investigations of the reactions of dogs and humans to intravenous injections of Lipiodol."' In humans they found that the oil reached the pulmonary capillaries in 3-4 sec., remained visible on serial X-rays of the lungs for ~ min., and then disappeared. Cough was the only symptom noted. Walther found that following intravenous injection, the oil was held up in the arterioles and capillaries of the lungs, where it rapidly was split into its two principal constituents, iodine and fat, by blood lipase and the lipolytic action of lung tissue. Most of the iodine was excreted as potassium iodide by the kidneys within ~ days. The oil was saponified by blood lipases and removed by phagacytosis. Localized eosinophilia in lung tissue of the experimental animal and eosinophilia in peripheral blood have been noted. 8 An increase in circulating eosinophils has not been reported in humans. Venous Intravasation
In 1929 the exact mode of entry of iodized oil into the circulation was first described. 22 The incidence of this complication of hysterosalpingography varies from 0 to 4.6 per cent in various series. 1 • 5 • 6 • 16• 18 • 23 More recently Wegryn and Harron studied normal and pathologic anatomy of living patients by pelvic phlebography with the use of Hypaque,t a water-soluble preparation, without serious complications in 50 subjects. *E. Fougera & Co., Inc., Hicksville, Long Island, N.Y. tWinthrop Laboratories, New York, N.Y.
26
LEVINSON
FERTILITY & STERILITY
Contraindications to Hysterosalpingography
Pulmonary oil embolism probably cannot occur without uterine venous intravasation, which can be due to the following: 16 • 32 ( 1) injection of the oil under excessive pressure; ( 2) injection very early in the postmenstrual period; ( 3) trauma during the procedure; ( 4) tuberculosis of the endometrium; ( 5) injection following curettage and during pregnancy; ( 6) any pathologic condition which produces increased fragility of the uterine vessels. Venous intravasation has been reported in many large series of hysterosalpingograms, but pulmonary embolization appears to be a rare phenomenon not noted either clinically or radiologically except as mentioned above-only in instances in which an oil medium was used. SUMMARY AND CONCLUSIONS
A case of pulmonary oil embolism following hysterosalpinography is presented. The 26 previously reported cases are reviewed. Experimental studies, pathiophysiology, and contraindications to hysterosalpingography are cited. The use of oil medium for hysterosalpingography is open to question-It appears that water-soluble dye is safer. Until the ideal medium for hysterosalpingography has been found, one must be constantly alert to the dangers of pulmonary embolism. ADDENDUM
On Dec. 27, 1961, the patient underwent emergency cesarean section because of a placental abruption. A living 3-lb., 14}4-oz. female was delivered. At 6 weeks post-partum, the patient and her infant were both doing well. 1003 Delaware Ave. Wilmington 6, Dela.
REFERENCES 1. 2. 3. 4. 5. 6. 7. 8.
BARNETT, E. ]. Fac. Radial. 7:115, 184, 1956. BLOOMFIELD, A. J. Obst. & Gynaec. Brit. Emp. 53:345, 1946. CARR, L., and JoHNSON, C. M. ].A.M.A. 104:1973, 1935. CoVENTRY, W. A. Am.]. Obst. & Gynec. 27:912, 1934. DAVIDS, A.M. Am./. Obst. & Gynec. 65:1167, 1953. DRUKMAN, A., and RoziN, S. ]. Obst. & Gynaec. Brit. Emp. 58:73, EISEN, D., and GoLDSTEIN, Radiology 45:603, 1945. EssELIER, VoN A. F., MARTI, H. R., MoRANDI, L., and WAGNER,
J.
J.
1951.
K. Internat. Arch. Allergy 3:279, 1952. 9. GAJZAGO, VoN E. Zentralbl. Gyniik. 55:543, 1931. 10. GRANT, I. W. B., CALLAM, W. D. A., and DAVIDSON, J. K. J. Fac. Radiol. 8:410, 1957. 11. GROSSMAN, M. E. Brit. f. Radial. 19:178, 1946. 12. HEMMELER, G. Schweiz. med. Wchnschr. 68:717, 1938. 13. INGERSOLL, F. M., and RoBBINS, L. L. Am. J. Obst. & Gynec. 53:301, 1947.
VoL.
14,
No.
1, 1963
PULMONARY
OIL
EMBOLISM
27
14. KARSHMER, N., and STEIN, W. Am.]. Obst. & Gynec. 61:458, 1951. 15. KELLER, R. Gynec. et obst. 47:21, 1948. 16. KIKA, E. Am.]. Obst. & Gynec. 67:56, 1954. 17. LIN, Y. Y., and Tsou, S. H. Chinese Med.]. 49:1241, 1935. 18. MARSHAK, R. H., PooLE, C. S., and GoLDBERGER, M.A. Surg. Gynec. & Obst. 91:182, 1950. 19. MITCHELL, D. R., and 0RTVED, W. E. ]. Urol. 68:652, 1952. 20. PATTERSON, E. A. ].A.M.A. 97:1147, 1931. 21. PrATT, A. D. Ohio M.]. 43:821, 1947. 22. PUJOL, Y., BRULL, A., VANRELL, J., and CARULLA RIERA, V. ]. Radiol. Electrol. 1.3:38, 1929. 23. RoBINS, S. A., and SHAPIRA, A. A. New England]. Med. 205:380, 1931. 24. RoBLEE, M. A., and MooRE, S. South. M. ]. 38:89, 1945. 25. SAPPEY, P., FABRE, H., and JouFFREY, A. Gynec. et obst. 51:298, 1952. 26. SHAPmo, J. H., RuBENSTEIN, B., JAcOBSON, H. G., and PoPPEL, M. H. Am. ]. Roentgenol. 77:1055, 1957. 27. SICARD, J. A., and FoRESTIER, J. Compts. rends. Soc. Biol. 88:1200, 1923. 28. SoLARIS, I. A. Prensa med. Argent. 22:2136, 1935. 29. STEINBACH, H. L., and HILL, W. B. Radiology 56:735, 1951. 30. WALTHER, 0. Acta. radiol. 20:457, 1939. 31. WEGRYN, S. P., and HARRON, R. A. Obst. & Gynec. 15:73, 1960. 32. WILLIAMS, E. R. Brit.]. Radiol.17:13, 1944.
New York University Post-Graduate Medical School Course in Gynecological Endocrinology New York University announces a postgraduate course (563R) in gynecological endocrinology. The course offers a practical, didactic, and clinical presentation with emphasis on the therapeutic management of endocrine disorders in the female, including a discussion of the diagnosis and management of intersex and endocrine therapy for menstrual abnormalities and ovulatory defects. Adrenocortical, thyroid, ovarian, and pituitary abnormalities will be emphasized. Practical diagnostic tests, including the most recent procedures, will be described and demonstrated. The therapeutic use of the newer progestational, gonadal, and corticoid steroids will be discussed, as well as available pituitary preparations. Some pertinent aspects of male and pediatric endocrinology will be included. The diagnostic importance of the chromosomal analysis will be elaborated upon. The 5-day, full-time course, under the direction of Dr. Herbert S. Kupperman, will be held from Mar. 25 through Mar. 29,1963. Further information may be obtained from the Office of the Associate Dean, New York University Post-Graduate Medical School, 550 First Avenue, NewYorkl6,N. Y.