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Uterine artery embolization as treatment for life-threatening haemorrhage from a cervical choriocarcinoma: A case report
European Journal of Obstetrics & Gynecology and Reproductive Biology 141 (2008) 87–92
Contents lists available at ScienceDirect
European Journal of Obstetrics & Gynecology and Reproductive Biology journal homepage: www.elsevier.com/locate/ejogrb
LETTERS TO THE EDITOR—BRIEF COMMUNICATION Uterine artery embolization as treatment for life-threatening haemorrhage from a cervical choriocarcinoma: A case report Dear Editor, Primary cervical choriocarcinoma is an extremely rare and highly vascular tumour, usually associated with heavy vaginal bleeding [1]. The use of uterine artery embolization as a treatment for life-threatening haemorrhage from a cervical choriocarcinoma is described. A 32-year-old woman, gravida 3, para 2, was admitted for massive vaginal bleeding, which had started 1 day before. The patient described having had abnormal vaginal bleeding for 18 months, which was attributed to an IUD. The patient had no significant personal or family history of gestational trophoblastic disease. Further investigation (clinical examination and cervical biopsies) had led to the diagnosis of a cervical tumour a week earlier in another hospital, but the patient had no further knowledge regarding the diagnosis. The clinical examination showed massive bleeding coming from the cervix without blood clotting. The blood pressure was 100/60 mmHg and the heart rate was 100 beats per minute. During the exam, the patient began to lose consciousness, the blood pressure dropped to 42/24 mmHg and the HemoCue indicated 6.7 g/dl. Haemorrhagic shock was diagnosed and treated with 6 ml of intravenous ephedrine, 1000 cm3 of colloid and transfusion of 2 units of packed red cells. The patient quickly came back to consciousness and was cared for in the intensive care unit. Vaginal packing was used during initial resuscitation to stop the haemorrhage before embolisation. Meanwhile, the other hospital was contacted for more information and it was discovered that the histopathologic examination had revealed a primary cervical choriocarcinoma. The initial blood level of beta-human chorionic gonadotrophin (HCG) was 14,000 IU/l, which increased to 30,750 IU/l during this hospitalisation. Immediately after admission and after resuscitation, a common femoral artery approach with bilateral internal iliac artery embolisation, using a gelatine sponge and clear acrylic microspheres, was used for this massive genital haemorrhage instead of invasive emergency surgery and the vaginal bleeding stopped. The patient was transferred back to the initial hospital. Abdominal ultrasonography and cerebral and thoracic computed tomography imaging were normal. Two days later, the patient had a recurrence of the vaginal bleeding, had a transfusion of 2 units of packed red cells, and transferred back for a second emergency artery embolisation. The FIGO 2000 criteria showed a stage I choriocarcinoma (confined to the uterus) with a FIGO score of 8: childbirth before choriocarcinoma (2 points), delay between pregnancy and choriocarcinoma of over 12 months (4 points), and HCG blood level of between 10,000 and 100,000 (2 points). According to this 0301-2115/$ – see front matter ß 2008 Elsevier Ireland Ltd. All rights reserved.
classification, the French Centre for Trophoblastic Disease counselled six courses of combination chemotherapy (EMA-CO) using etoposide, methotrexate, actinomycin D, alternating with cyclophosphamide and oncovine. A second recurrence of massive vaginal bleeding was diagnosed during the first course of chemotherapy and the patient was transferred for a third emergency uterine artery embolization. The patient was monitored weekly and the HCG level decreased. No side effects due to the embolisations were described by the patient. Five months after the diagnosis, the HCG level was negative and the cervix was free of tumour, without surgery. Magnetic resonance imaging and power Doppler ultrasonographic imaging studies of cervical choriocarcinoma have demonstrated highly vascular tumours with high diastolic blood flow in tumoural vessels resulting from angiogenesis and neovascularisation [2]. Each time it has been described, the investigation of this type of tumour has included biopsies for histological examination, often leading to heavy bleeding, which has been treated with a gauze uterine tamponade. Vaginal haemorrhage can be a difficult problem when medical management fails. Although it is an extremely rare entity, the prognosis can be worse as bleeding appears spontaneously and massively leading to death by haemorrhagic shock. Uterine artery embolisation has been successfully used to treat acute and massive genital bleeding in gestational trophoblastic disease, providing specific occlusion of the uterine vessels [3,4]. Uterine artery embolisation provides several advantages in an emergency, including avoidance of radical life-saving management such as hysterectomy and general anaesthesia [3]. Another advantage is the ability to preserve fertility. Since successful pregnancies have been described after artery uterine embolisation in patients with gestational trophoblastic tumours [5], such embolisation could be a safe and highly effective alternative procedure in patients with cervical choriocarcinoma and should be the treatment of choice for women who wish to preserve their fertility. Quick, timely referral to a centre with an interventional radiology department is necessary in these cases.
References [1] Fu Y, Lu W, Zhou C, Xie X. Primary cervical choriocarcinoma: report of four cases and literature review. Int J Gynecol Cancer 2007;17:715–9. [2] Yahata T, Kodama S, Kase H, et al. Primary choriocarcinoma of the uterine cervix: clinical, MRI, and color Doppler ultrasonographic study. Gynecol Oncol 1997;64:274–8. [3] Carlini L, Villa A, Busci L, Trezzi G, Agazzi R, Frigerio L. Selective uterine artery embolization: a new approach in a patient with low-risk gestational trophoblastic disease. Am J Obstet Gynecol 2006;195:314–5. [4] Tse KY, Chan KK, Tam KF, Ngan HY. 20-year experience of managing profuse bleeding in gestational trophoblastic disease. J Reprod Med 2007;52:397– 401. [5] Garner EI, Meyerovitz M, Goldstein DP, Berkowitz RS. Successful term pregnancy after selective arterial embolization of symptomatic arteriovenous
Letters to the Editor / European Journal of Obstetrics & Gynecology and Reproductive Biology 141 (2008) 87–92
88
malformation in the setting of gestational trophoblastic tumor. Gynecol Oncol 2003;88:69–72.
Albane Frati Guillaume Ducarme* Department of Obstetrics and Gynecology, Hoˆpital Beaujon, AP-HP, Universite´ Paris 7, Clichy, France Anne Wernet Department of Anesthesiology, Hoˆpital Beaujon, AP-HP, Universite´ Paris 7, Clichy, France Ahmed Chuttur Department of Obstetrics and Gynecology, Hoˆpital Simone Veil, Montmorency, France Vale´rie Vilgrain Department of Radiology, Hoˆpital Beaujon, AP-HP, Universite´ Paris 7, Clichy, France Dominique Luton Department of Obstetrics and Gynecology, Hoˆpital Beaujon, AP-HP, Universite´ Paris 7, Clichy, France *Corresponding author at: Department of Obstetrics and Gynecology, Hoˆpital Beaujon, Assistance Publique-Hoˆpitaux de Paris, 100 Boulevard du Ge´ne´ral Leclerc, 92110 Clichy, France. Tel.: +33 140875221; fax: +33 147313527 E-mail address: [email protected] (G. Ducarme) 11 January 2008 doi:10.1016/j.ejogrb.2008.05.008
A case of deep vein thrombosis complicating laparoscopic treatment of ectopic pregnancy Dear Editors, A case of deep vein thrombosis (DVT) following laparoscopic treatment of an ectopic pregnancy was recently managed in our unit. A literature search found no previous report of this complication. The case is presented to raise awareness about this rare but potentially serious complication associated with a procedure that has become quite popular. A 23-year-old primigravida presented at the Early Pregnancy Assessment Unit with a history of suprapubic pain and vaginal bleeding of 5 days duration. Her last menstrual period was 7 weeks prior to presentation. She had no personal or family history of venous thrombo-embolism (VTE). Her body mass index was 29 kg/m2. Her serum beta-hCG was 2301 IU/l. Pelvic ultrasound scan showed features of a right ectopic pregnancy. She was admitted and the procedure of laparoscopic right salpingectomy was performed using tripolar diathermy. Pneumatic compressive leg stockings were employed and the operation lasted 42 min. She was discharged home the following day.
Six days later, she was re-admitted with 3 days history of pain in her left leg. The left leg appeared slightly swollen, warm and tender over the calf area. There were no symptoms or signs of pulmonary embolism. Doppler ultrasound showed filling defects in the peroneal and soleal veins consistent with calf DVT. She was managed jointly with the medical team. She was given enoxaparin subcutaneous injection 140 mg and oral warfarin tablets 5–10 mg daily. She was discharged to the anticoagulant clinic 5 days after re-admission. Enoxaparin injection was discontinued after achieving an international normalized ratio (INR) of 2.5–3. Warfarin was stopped after 5 months and a repeat Doppler ultrasound of the left leg was negative. Thrombophilia screening was done 7 weeks after she stopped taking warfarin and the result was negative. There has been an upsurge in the use of laparoscopic surgery due to recognition of its benefits. Many units now manage most cases of ectopic pregnancy laparoscopically. A recent audit in our own unit showed that 83% of ectopic pregnancies were treated laparoscopically. Laparoscopic surgery is considered a low risk procedure for postoperative VTE because it is minimally invasive and permits early mobilisation. There are very few reports of VTE following gynaecological laparoscopic surgery. A recent prospective study [1] found no case of VTE in 266 consecutive patients undergoing laparoscopic surgery for benign gynaecological conditions. Similarly, in a review of 31 cases of thromboembolic disease after 6077 gynaecologic procedures, Chan et al. [2] found no case of DVT following laparoscopic treatment of ectopic pregnancy. To our knowledge, this is the first reported case. Certain peri-operative events can predispose to DVT by causing vascular stasis, vascular endothelial damage and changes in blood constituents (Virchow’s triad). Alishahi et al. [3] demonstrated significant haemodynamic changes during laparoscopic procedures with positive pressure pneumoperitoneum resulting in venous stasis. Other studies have also demonstrated an activation of the coagulation system during laparoscopic surgery [4]. Furthermore, VTE would more likely develop at home (because of early discharge after laparoscopic surgery) and so detection may be delayed. In fact it is possible that the condition is underdiagnosed and under-reported. To reduce the risk of VTE, we advise that during laparoscopic treatment of ectopic pregnancy and indeed other laparoscopic procedures, attention should be paid to positioning, duration of surgery and the use of pneumatic compression to prevent vascular stasis. Once trocars are inserted, maximum intra-abdominal pressure should be reduced to 12–14 mmHg. Individual patients’ risk of thrombo-embolism should be assessed and if considered significant, prophylaxis should be given. Patients should be given clear instructions regarding this complication (mobilisation, adequate fluid intake and symptoms).
References [1] Ageno W, Manfredi E, Dentali F, et al. The incidence of venous thromboembolism following gynecologic laparoscopy: a multicentre, prospective cohort study. J Thromb Haemost 2007;5(3):503–6. [2] Chan LYS, Yuen PM, Lo WK, Lau TK. Symptomatic venous thromboembolism in Chinese patients after gynecologic surgery: incidence and disease pattern. Acta Obstet Gynecol Scand 2002;81:343–6. [3] Alishahi A, Francis N, Crofts S, Duncan L, Bickel A, Cuschieri A. Central and peripheral adverse hemodynamic changes during laparoscopic surgery and their reversal with a novel intermittent sequential pneumatic compression device. Ann Surg 2001;233(2):176–82. [4] Vecchio R, Cacciola E, Martino M, Cacciola RR, MacFayden BV. Modifications of coagulation and fibrinolytic parameters in laparoscopic cholecystectomy. Surg Endoscopy 2003;17(3):428–33.
Contents lists available at ScienceDirect
European Journal of Obstetrics & Gynecology and Reproductive Biology journal homepage: www.elsevier.com/locate/ejogrb
LETTERS TO THE EDITOR—BRIEF COMMUNICATION Uterine artery embolization as treatment for life-threatening haemorrhage from a cervical choriocarcinoma: A case report Dear Editor, Primary cervical choriocarcinoma is an extremely rare and highly vascular tumour, usually associated with heavy vaginal bleeding [1]. The use of uterine artery embolization as a treatment for life-threatening haemorrhage from a cervical choriocarcinoma is described. A 32-year-old woman, gravida 3, para 2, was admitted for massive vaginal bleeding, which had started 1 day before. The patient described having had abnormal vaginal bleeding for 18 months, which was attributed to an IUD. The patient had no significant personal or family history of gestational trophoblastic disease. Further investigation (clinical examination and cervical biopsies) had led to the diagnosis of a cervical tumour a week earlier in another hospital, but the patient had no further knowledge regarding the diagnosis. The clinical examination showed massive bleeding coming from the cervix without blood clotting. The blood pressure was 100/60 mmHg and the heart rate was 100 beats per minute. During the exam, the patient began to lose consciousness, the blood pressure dropped to 42/24 mmHg and the HemoCue indicated 6.7 g/dl. Haemorrhagic shock was diagnosed and treated with 6 ml of intravenous ephedrine, 1000 cm3 of colloid and transfusion of 2 units of packed red cells. The patient quickly came back to consciousness and was cared for in the intensive care unit. Vaginal packing was used during initial resuscitation to stop the haemorrhage before embolisation. Meanwhile, the other hospital was contacted for more information and it was discovered that the histopathologic examination had revealed a primary cervical choriocarcinoma. The initial blood level of beta-human chorionic gonadotrophin (HCG) was 14,000 IU/l, which increased to 30,750 IU/l during this hospitalisation. Immediately after admission and after resuscitation, a common femoral artery approach with bilateral internal iliac artery embolisation, using a gelatine sponge and clear acrylic microspheres, was used for this massive genital haemorrhage instead of invasive emergency surgery and the vaginal bleeding stopped. The patient was transferred back to the initial hospital. Abdominal ultrasonography and cerebral and thoracic computed tomography imaging were normal. Two days later, the patient had a recurrence of the vaginal bleeding, had a transfusion of 2 units of packed red cells, and transferred back for a second emergency artery embolisation. The FIGO 2000 criteria showed a stage I choriocarcinoma (confined to the uterus) with a FIGO score of 8: childbirth before choriocarcinoma (2 points), delay between pregnancy and choriocarcinoma of over 12 months (4 points), and HCG blood level of between 10,000 and 100,000 (2 points). According to this 0301-2115/$ – see front matter ß 2008 Elsevier Ireland Ltd. All rights reserved.
classification, the French Centre for Trophoblastic Disease counselled six courses of combination chemotherapy (EMA-CO) using etoposide, methotrexate, actinomycin D, alternating with cyclophosphamide and oncovine. A second recurrence of massive vaginal bleeding was diagnosed during the first course of chemotherapy and the patient was transferred for a third emergency uterine artery embolization. The patient was monitored weekly and the HCG level decreased. No side effects due to the embolisations were described by the patient. Five months after the diagnosis, the HCG level was negative and the cervix was free of tumour, without surgery. Magnetic resonance imaging and power Doppler ultrasonographic imaging studies of cervical choriocarcinoma have demonstrated highly vascular tumours with high diastolic blood flow in tumoural vessels resulting from angiogenesis and neovascularisation [2]. Each time it has been described, the investigation of this type of tumour has included biopsies for histological examination, often leading to heavy bleeding, which has been treated with a gauze uterine tamponade. Vaginal haemorrhage can be a difficult problem when medical management fails. Although it is an extremely rare entity, the prognosis can be worse as bleeding appears spontaneously and massively leading to death by haemorrhagic shock. Uterine artery embolisation has been successfully used to treat acute and massive genital bleeding in gestational trophoblastic disease, providing specific occlusion of the uterine vessels [3,4]. Uterine artery embolisation provides several advantages in an emergency, including avoidance of radical life-saving management such as hysterectomy and general anaesthesia [3]. Another advantage is the ability to preserve fertility. Since successful pregnancies have been described after artery uterine embolisation in patients with gestational trophoblastic tumours [5], such embolisation could be a safe and highly effective alternative procedure in patients with cervical choriocarcinoma and should be the treatment of choice for women who wish to preserve their fertility. Quick, timely referral to a centre with an interventional radiology department is necessary in these cases.
References [1] Fu Y, Lu W, Zhou C, Xie X. Primary cervical choriocarcinoma: report of four cases and literature review. Int J Gynecol Cancer 2007;17:715–9. [2] Yahata T, Kodama S, Kase H, et al. Primary choriocarcinoma of the uterine cervix: clinical, MRI, and color Doppler ultrasonographic study. Gynecol Oncol 1997;64:274–8. [3] Carlini L, Villa A, Busci L, Trezzi G, Agazzi R, Frigerio L. Selective uterine artery embolization: a new approach in a patient with low-risk gestational trophoblastic disease. Am J Obstet Gynecol 2006;195:314–5. [4] Tse KY, Chan KK, Tam KF, Ngan HY. 20-year experience of managing profuse bleeding in gestational trophoblastic disease. J Reprod Med 2007;52:397– 401. [5] Garner EI, Meyerovitz M, Goldstein DP, Berkowitz RS. Successful term pregnancy after selective arterial embolization of symptomatic arteriovenous
Letters to the Editor / European Journal of Obstetrics & Gynecology and Reproductive Biology 141 (2008) 87–92
88
malformation in the setting of gestational trophoblastic tumor. Gynecol Oncol 2003;88:69–72.
Albane Frati Guillaume Ducarme* Department of Obstetrics and Gynecology, Hoˆpital Beaujon, AP-HP, Universite´ Paris 7, Clichy, France Anne Wernet Department of Anesthesiology, Hoˆpital Beaujon, AP-HP, Universite´ Paris 7, Clichy, France Ahmed Chuttur Department of Obstetrics and Gynecology, Hoˆpital Simone Veil, Montmorency, France Vale´rie Vilgrain Department of Radiology, Hoˆpital Beaujon, AP-HP, Universite´ Paris 7, Clichy, France Dominique Luton Department of Obstetrics and Gynecology, Hoˆpital Beaujon, AP-HP, Universite´ Paris 7, Clichy, France *Corresponding author at: Department of Obstetrics and Gynecology, Hoˆpital Beaujon, Assistance Publique-Hoˆpitaux de Paris, 100 Boulevard du Ge´ne´ral Leclerc, 92110 Clichy, France. Tel.: +33 140875221; fax: +33 147313527 E-mail address: [email protected] (G. Ducarme) 11 January 2008 doi:10.1016/j.ejogrb.2008.05.008
A case of deep vein thrombosis complicating laparoscopic treatment of ectopic pregnancy Dear Editors, A case of deep vein thrombosis (DVT) following laparoscopic treatment of an ectopic pregnancy was recently managed in our unit. A literature search found no previous report of this complication. The case is presented to raise awareness about this rare but potentially serious complication associated with a procedure that has become quite popular. A 23-year-old primigravida presented at the Early Pregnancy Assessment Unit with a history of suprapubic pain and vaginal bleeding of 5 days duration. Her last menstrual period was 7 weeks prior to presentation. She had no personal or family history of venous thrombo-embolism (VTE). Her body mass index was 29 kg/m2. Her serum beta-hCG was 2301 IU/l. Pelvic ultrasound scan showed features of a right ectopic pregnancy. She was admitted and the procedure of laparoscopic right salpingectomy was performed using tripolar diathermy. Pneumatic compressive leg stockings were employed and the operation lasted 42 min. She was discharged home the following day.
Six days later, she was re-admitted with 3 days history of pain in her left leg. The left leg appeared slightly swollen, warm and tender over the calf area. There were no symptoms or signs of pulmonary embolism. Doppler ultrasound showed filling defects in the peroneal and soleal veins consistent with calf DVT. She was managed jointly with the medical team. She was given enoxaparin subcutaneous injection 140 mg and oral warfarin tablets 5–10 mg daily. She was discharged to the anticoagulant clinic 5 days after re-admission. Enoxaparin injection was discontinued after achieving an international normalized ratio (INR) of 2.5–3. Warfarin was stopped after 5 months and a repeat Doppler ultrasound of the left leg was negative. Thrombophilia screening was done 7 weeks after she stopped taking warfarin and the result was negative. There has been an upsurge in the use of laparoscopic surgery due to recognition of its benefits. Many units now manage most cases of ectopic pregnancy laparoscopically. A recent audit in our own unit showed that 83% of ectopic pregnancies were treated laparoscopically. Laparoscopic surgery is considered a low risk procedure for postoperative VTE because it is minimally invasive and permits early mobilisation. There are very few reports of VTE following gynaecological laparoscopic surgery. A recent prospective study [1] found no case of VTE in 266 consecutive patients undergoing laparoscopic surgery for benign gynaecological conditions. Similarly, in a review of 31 cases of thromboembolic disease after 6077 gynaecologic procedures, Chan et al. [2] found no case of DVT following laparoscopic treatment of ectopic pregnancy. To our knowledge, this is the first reported case. Certain peri-operative events can predispose to DVT by causing vascular stasis, vascular endothelial damage and changes in blood constituents (Virchow’s triad). Alishahi et al. [3] demonstrated significant haemodynamic changes during laparoscopic procedures with positive pressure pneumoperitoneum resulting in venous stasis. Other studies have also demonstrated an activation of the coagulation system during laparoscopic surgery [4]. Furthermore, VTE would more likely develop at home (because of early discharge after laparoscopic surgery) and so detection may be delayed. In fact it is possible that the condition is underdiagnosed and under-reported. To reduce the risk of VTE, we advise that during laparoscopic treatment of ectopic pregnancy and indeed other laparoscopic procedures, attention should be paid to positioning, duration of surgery and the use of pneumatic compression to prevent vascular stasis. Once trocars are inserted, maximum intra-abdominal pressure should be reduced to 12–14 mmHg. Individual patients’ risk of thrombo-embolism should be assessed and if considered significant, prophylaxis should be given. Patients should be given clear instructions regarding this complication (mobilisation, adequate fluid intake and symptoms).
References [1] Ageno W, Manfredi E, Dentali F, et al. The incidence of venous thromboembolism following gynecologic laparoscopy: a multicentre, prospective cohort study. J Thromb Haemost 2007;5(3):503–6. [2] Chan LYS, Yuen PM, Lo WK, Lau TK. Symptomatic venous thromboembolism in Chinese patients after gynecologic surgery: incidence and disease pattern. Acta Obstet Gynecol Scand 2002;81:343–6. [3] Alishahi A, Francis N, Crofts S, Duncan L, Bickel A, Cuschieri A. Central and peripheral adverse hemodynamic changes during laparoscopic surgery and their reversal with a novel intermittent sequential pneumatic compression device. Ann Surg 2001;233(2):176–82. [4] Vecchio R, Cacciola E, Martino M, Cacciola RR, MacFayden BV. Modifications of coagulation and fibrinolytic parameters in laparoscopic cholecystectomy. Surg Endoscopy 2003;17(3):428–33.