Septic Uterus After Uterine Artery Embolization for Uterine ... - JOGC

CASE REPORT
CASE REPORT
Septic Uterus After Uterine Artery Embolization
for Uterine Myomas Triggered by
Endometrial Biopsy
Shauna L. Reinblatt, MDCM, Srinivasan Krishnamurthy, MD, David Valenti, MD,
Togas Tulandi, MD, MHCM
Department of Obstetrics and Gynecology, and Radiology, McGill University, Montreal QC
Abstract
Background: Women who undergo uterine artery embolization
(UAE) and subsequently have heavy vaginal bleeding require
assessment to establish the cause. Endometrial sampling in such
women should not necessarily carry more than the usual risk
Cases: Two women who had undergone UAE presented with
recurrence of heavy vaginal bleeding. In order to rule out possible
endometrial malignancy, we performed an endometrial biopsy.
Both patients had large and necrotic intramural myomas adjacent
to the endometrium. They developed septic uterus shortly after
endometrial biopsy and each required a hysterectomy. The
postoperative course in the first case was complicated by deep
vein thrombosis and enterovaginal fistula.
Conclusion: Because of the high risk of infection, women with a
history of UAE and necrotic myoma adjacent to the endometrium
should not undergo endometrial biopsy. We recommend
evaluation of the relation of myomas to the endometrium.
Résumé
Contexte : Les femmes qui subissent une embolisation de l’artère
utérine (EAU) et qui, par la suite, connaissent des saignements
vaginaux abondants nécessitent une évaluation visant à en établir
la cause. Chez ces femmes, le prélèvement endométrial ne
devrait pas nécessairement s’accompagner de risques plus
importants que la normale.
Cas : Deux femmes qui avaient subi une EAU présentaient une
récurrence de saignements vaginaux abondants. Afin d’écarter la
présence possible d’une malignité endométriale, nous avons
effectué une biopsie endométriale. Les deux patientes
présentaient des myomes intramuraux importants et nécrosés
adjacents à l’endomètre. Elles ont présenté un utérus septique
peu après la biopsie endométriale; une hystérectomie s’est avérée
nécessaire pour chacune d’entre elles. Dans le premier cas,
l’évolution postopératoire a été compliquée par une thrombose
veineuse profonde et une fistule entérovaginale.
Conclusion : En raison des risques élevés d’infection, les femmes
qui présentent des antécédents d’EAU et un myome nécrosé
Key Words: Uterine artery embolization, septic uterus, myoma
Competing Interests: None declared.
Received on August 18, 2007
Accepted on October 1, 2007
adjacent à l’endomètre ne devraient pas subir une biopsie
endométriale. Nous recommandons l’évaluation de la relation
entre les myomes et l’endomètre.
J Obstet Gynaecol Can 2008;30(4):344–346
INTRODUCTION
Uterine artery embolization is a useful treatment option
for women with symptomatic uterine myoma. This
procedure is associated with high success rates and low
complication rates in appropriately selected patients. 1–4 The
average reduction in the volume of the myoma is about
30% to 50%, with improvement in the symptoms and
menorrhagia in over 90% of patients. 1–4 Serious complications
are rare. 3 We report severe uterine infection occurring
at 10 and 16 days after endometrial biopsy in two women
who had had UAE.
THE CASES
Case One
A 54-year-old woman suffering from progressive
menorrhagia and dysmenorrhea had transvaginal ultrasound
and MRI that showed multiple myomas, with the
largest intramural myoma measuring 7.8 7.7 8.3 cm.
After discussion of treatment options, she consented to
undergo UAE. This was performed bilaterally without
complications in May 2006. Her symptoms improved initially,
but after several months vaginal bleeding again
became irregular and heavy. Repeat MRI in November
2006 showed complete necrosis of the myoma (Figure 1).
Intimate contact between the myoma and the endometrium
was seen.
The patient returned in March 2007 with a complaint of
excessive uterine bleeding in the past two months. In order
to rule out endometrial pathology, an endometrial biopsy
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Septic Uterus After Uterine Artery Embolization for Uterine Myomas Triggered by Endometrial Biopsy
Figure 1. Magnetic resonance-coronal image showing
intimate contact between a necrotic myoma and the
endometrium
Figure 2. Magnetic resonance imaging of a large
intramural myoma with no visible myometrium separating
the necrotic area and the endometrium
was performed. The histopathology of the specimen
showed benign necrotic endometrium.
Ten days later, the patient presented with abdominal pain,
fever, and clinical evidence of sepsis. Transvaginal ultrasound
examination showed the necrotic myoma and a posterior
intramyometrial complex cystic mass suggestive of an
abscess, measuring 11 9 10 cm. At exploratory
laparotomy, a large pelvic abscess was found arising from
the posterior aspect of the uterus and surrounded by
adhesions to small bowel and omentum. The patient underwent
total abdominal hysterectomy and bilateral salpingooophorectomy.
The postoperative course was complicated by bilateral deep
vein thrombosis and an enterovaginal fistula, which
required three weeks of total parenteral nutrition and hospitalization.
Histopathologic examination of the excised specimen
revealed endometritis, salpingitis, and oophoritis. The
uterus weighed 310 g and had an extensively hyalinized
myoma.
MRI
UAE
ABBREVIATIONS
magnetic resonance imaging
uterine artery embolization
Case Two
A 50-year-old woman underwent UAE in December 2006
for menorrhagia with pressure symptoms. Transvaginal
ultrasound and MRI performed prior to UAE showed an
enlarged uterus with several intramural myomas, the largest
myoma measuring 10.5 8.7 11.4 cm. The image of a
large intramural myoma with no visible myometrium separating
the necrotic area and the endometrium is shown in
Figure 2.
In April 2007, the patient presented with vaginal discharge,
painful cramping, and increasing uterine bleeding. An
endometrial biopsy showed secretory endometrium. Her
hemoglobin was 63 g/L, but the white blood cell count was
normal. A repeat MRI showed that the largest myoma, originally
intramural, had become submucous and had
prolapsed into the uterine cavity. It measured 12 7.4 8.1 cm.
Sixteen days later, the patient presented with urinary retention
and foul-smelling vaginal discharge. Pelvic examination
showed a large necrotic myoma distending the vagina.
She underwent laparoscopic total hysterectomy and bilateral
salpingo-oophorectomy, during which a large,
foul-smelling, necrotic uterus with a large prolapsing
myoma was found. The postoperative course was uneventful.
The histopathology of the excised tissue demonstrated
severe endomyometritis with microabscesses and a large
infarcted myoma. The uterus weighed 287g.
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CASE REPORT
DISCUSSION
Uterine artery embolization is an alternative to hysterectomy
in women seeking treatment for symptomatic uterine
myomas. It is associated with a good success rate in properly
selected patients, with few major complications. The
overall rate of serious complications after UAE, including
infection and thrombotic events, is approximately 5%, 3
most often occurring within three months of the procedure
when patients are still being closely monitored for
symptoms. 5
Our patients developed uterine sepsis at four and nine
months after UAE, and at 10 and 16 days after endometrial
sampling. Although the myomas were initially intramural,
one of the myomas in the second case had become
submucous when recurrence of symptoms was reported.
This phenomenon occurs because the uterus becomes
smaller after UAE, and the intramural myoma is forced
towards the uterine cavity. Submucous myomas carry a
higher risk of becoming infected because they may prolapse
and be exposed to the vaginal flora after becoming
necrotic. 3–6 After UAE, uterine infection may be more common
in the presence of submucous myoma. 4 In the cases
described here, the endometrial biopsy appears to have triggered
the infection, and the presence of a large and necrotic
intramural myoma adjacent to the endometrium was a predisposing
factor. Septic uterus is a serious condition; in fact,
the first reported death following UAE was due to septic
uterus. 7 The infection in our second case was limited to the
uterus, whereas infection in the first case had spread beyond
the uterus with development of pelvic abscesses. The subsequent
surgery was difficult and complicated by injury to
the bowel.
In general, endometrial biopsy is associated with a minimal
risk of complications. 8 However, the risk is high in the
presence of necrotic tissue adjacent to or inside the uterine
cavity. In retrospect, endometrial biopsy should not have
been performed. The optimal treatment in such patients is
hysterectomy.
CONCLUSION
Because of the high risk of infection, women who have had
UAE and present with necrotic myoma adjacent to the
endometrium should not undergo endometrial biopsy. We
recommend routine evaluation of the myoma in relation to
the endometrium by means of imaging.
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