Author
Information
Agarwal
S*, Warke HS**, Satia MN***
(* Third
Year Resident, ** Associate Professor, Professor, Department of Obstetrics and
Gynecology, Seth GS Medical College & KEM Hospital ,
Mumbai , India
Abstract
We
present a case report of a 45 year old female with a large cervical fibroid in
a known case of dilated cardiomyopathy with cardiac arrhythmias with an
ejection fraction of 30 % who presented with severe anemia due to menorrhagia.
Prior to surgery the patient underwent uterine artery embolization to decrease
the vascularity of the large cervical fibroid in view of suspected large
intraoperative hemorrhage. She was planned for surgery within 48 hours of the
procedure but developed persistent ventricular premature beats on the day of
surgery for which surgery was deferred after cardiac opinion. She presented 2
weeks later with a prolapsed fibroid through the vagina with necrosis and
infection for which antibiotics were started. She underwent total abdominal
hysterectomy with bilateral salpingo-oophorectomy and had an uneventful
postoperative recovery.
Introduction
Dilated
cardiomyopathy is a group of diseases that primarily affects the myocardium. It
is the most common form of non-ischemic cardiomyopathy.[1] It has a prevalence
of 36 per 100000 and is commonly seen between 20 and 60 years of age.[2]
Dilated cardiomyopathy may cause congestive cardiac failure in about one in
three cases.[1] There is dilatation of a part of myocardium, the etiology of
which is unclear.
Case
Report
A 45
year old woman post-menopausal since 1 year had come to our outpatient
department (OPD) with complaints of lump in the abdomen which had increased to
the present size gradually over 2 years with excessive bleeding per vaginum
since 3 days. On examination she was extremely pale with pulse rate of 110/min,
blood pressure of 100/60 mm Hg and 2x2 cm thyroid nodule with a 32-34 weeks’
size mass arising from the pelvis, hard in consistency with restricted
mobility. Her Hb was 6 g/dl, PCV of 21 with hypochromasia and microcytosis.
Ultrasonography was suggestive of multiple uterine fibroids, intramural and
submucosal in location with largest anterior wall fibroid measuring 18x15x15
cm. She was a case of trivial tricuspid regurgitation, trivial mitral
regurgitation and global hypokinesia with ejection fraction of 30% with dilated
cardiomyopathy. She was started on intravenous tranexamic acid and was given 5
units of packed cell volume transfusion. CT scan revealed multiple uterine
fibroids, largest measuring 18x15x15 cm arising from anterior lower uterine
segment compressing the sigmoid colon, lower ureters and bladder bilaterally
with mild hydronephrosis on both sides with well-defined fat planes. Serial
ECGs were suggestive of ventricular bigeminy with ventricular premature beats.
Chest radiograph indicated mild cardiomegaly with bilateral prominent hilar
shadows suggestive of pulmonary hypertension. Her serum calcium was 6.9 mg/dl
and hypocalcemia was treated with 20 ml of 20% calcium gluconate followed by
oral calcium supplements. Cardiac stress test was done which showed ill
sustained monomorphic ventricular tachycardia in stage 1 with recovery in stage
2 with return to baseline sinus rhythm in stage 3 suggestive of need of
electrophysiological studies followed by radiofrequency ablation. Cardiac MRI was suggestive of dilated non infiltrative
cardiomyopathy. USG thyroid was
suggestive of enlarged thyroid gland with a benign thyroid nodule in the right
lobe. Her serum TSH was 2.71 Miu/L
on tablet Thyronorm 50 μg OD .Endocrine
opinion was taken and the drug was continued.
Bilateral
uterine artery embolization was done with fine polyvinyl alcohol 300 particles
so as to reduce intraoperative blood loss. Excessive blood loss in this patient
with an ejection fraction of 30% would be life threatening. She was posted for
total abdominal hysterectomy with bilateral salpingo-oophorectomy with moderate
cardiac risk. She had persistent ventricular premature beats on operation table
which did not subside. Serum
electrolytes sent were within normal limits. After discussion with anesthetist
and cardiologist surgery was deferred. She was started on oral frusemide 20 mg
1-1-0, carvedilol 3.125 mg1-0-1, ramipril 2.5 mg 0-0-1 and spironolactone 25 mg
0-1-0 and cardiologists advised to postpone surgery for 4 weeks. Patient was
started on tablet medroxyprogesterone acetate 10 mg tds so as to control
vaginal bleeding and was discharged. She presented 2 weeks later in our out
patients department with heavy bleeding per vaginum and a prolapsed mass
outside the introitus. On examination vital parameters were stable with a 30 weeks’
mass arising from pelvis and a 10x10
cm fleshy mass extruding from the introitus with
necrosis and foul smell. This probably
was due to necrosis of the fibroid following the procedure of uterine artery
embolization.
Intravenous ceftriaxone, metronidazole and
analgesics were started. Swab for culture sensitivity was sent from fleshy mass
which showed Pseudomonas aeruginosa sensitive to levofloxacin and polymyxin B.
Intravenous levofloxacin and polymyxin B ointment was given for local
application over the mass. She was posted for surgery with consent for
requirement of intraoperative and perioperative intensive cardiac care and
ventilator.
Figure
1: Sloughed off necrosed fibroid outside the introitus.
Intraoperatively
uterus was 30 weeks’ size with multiple fibroids. There was a large cervical
fibroid of size 22x20 cm. Bilateral fallopian tubes were edematous and bilateral
ovaries were normal. Total abdominal hysterectomy with bilateral
salpingo-oophorectomy was done under general and epidural anesthesia. Foul
smelling pus was present at the base of the cervical fibroid which was sent for
culture and sensitivity.
Figure
2: Large cervical fibroid of 18x15x15 cm.
Intraoperatively
and postoperatively her vital parameters were stable. Two units packed cell
volume transfusion was given intra-operatively. Swab sent for antibiotic
culture sensitivity suggested Escherichia coli sensitive to levofloxacin which
was continued along with injectable ceftriaxone, metronidazole and gentamicin postoperatively.
She was discharged on day 10 of surgery after suture removal. The scar site was
healthy with no pain, discharge and induration. Histopathology report was
suggestive of benign leiomyoma with hyaline changes. She was advised to follow
up in cardiology OPD for electrophysiological studies and further management.
Discussion
20-30%
women in reproductive age group have leiomyoma uteri, the usual anatomical
location being the body of the uterus and only 1-2% are confined to the
cervix.[3] These women often present with an abdominal mass without any other
symptoms, retention of urine, menstrual abnormalities, constipation or may
mimic an ovarian tumor.[4] Our patient presented with a 32 weeks’ size mass
with heavy bleeding per vaginum. She was a case of dilated cardiomyopathy with
global hypokinesia with ejection fraction of only 30% with ECG changes showing
ventricular bigeminy with ventricular premature beats. Dilated cardiomyopathy
is characterized by progressive cardiac dilatation leading to impaired
ventricular function.[1] There is global decrease in myocardial contractility
which reduces left ventricular ejection fraction. According to Frank–Starling
relationship, initially compensation occurs with enlargement of the left
ventricular cavity leading to an increase in stroke volume with associated
increase in the force of contraction.[1] Eventually these compensatory
mechanisms fail, cardiac output decreases, resulting in left ventricular
failure. In severe cases, there is combined systolic and diastolic dysfunction
with impaired relaxation and elevated left ventricular end-diastolic pressures
(LVEDP). This can lead to congestive cardiac failure and arrhythmias if not
managed optimally. Medical therapy with various drugs used as disease modifying
agents includes angiotensin-converting enzyme inhibitors (ACEIs), angiotensin
II inhibitors and diuretics. Other drugs used are β-blockers, spironolactone,
digoxin, biventricular pacing, and anticoagulants.
Our
patient was started preoperatively with oral frusemide 20 mg 1-1-0, carvedilol
3.125 mg 1-0-1, ramipril 2.5 mg 0-0-1 and spironolactone 25 mg 0-1-0 to improve
the postoperative outcome. Optimal management with these drugs can reduce the
chances of development of arrhythmias and worsening of cardiac function. From anesthesia
point of view the main aim was to prevent hypotension so as to avoid myocardial
hypoperfusion. The goals of anesthesia are to avoid tachycardia, minimize the
effects of negative inotropic agents, especially anesthetic drugs, to prevent
increases in afterload and to maintain adequate preload in the presence of
elevated LVEDP.
Preoperatively
uterine artery embolization (UAE) was done to decrease the vascularity of the
fibroid. It is a minimally invasive technique in which small polyvinyl alcohol
(PVA) particles are used to occlude the blood supply to the fibroids. These
particles stick in the lumen of the blood vessels forming a clot, thus
occluding the blood supply. Eventually the fibroids reduce in size, and the
symptoms get reduced or disappear. Preoperative embolization of the uterine
arteries is also useful to decrease perioperative bleeding complications. It
causes ischemia and necrosis of fibroids while preserving the uterus. UAE is
technically successful in 95-99% of patients. It is successful in controlling
menorrhagia in 85-95%. Transcervical sloughing of the necrosed fibroid can
occur in about 5% of patients. 20-25% of patients with dominant submucosal
fibroids can undergo sloughing.[5] This may resolve with spontaneous passage of
tissue or may require surgical evacuation of the uterus. Other adverse effects
of UAE include septicemia resulting in multiple organ failure,[6]
endometritis[7], uterine necrosis[8], misembolisation from microspheres of PVA
particles leading to ovarian failure,[9] infertility, menopause, loss of
menstruation. Post embolization syndrome may occur, leading to chronic pain,
nausea, vomiting, malaise, fever, night sweats. There can be fibroid expulsion,
vaginal discharge containing pus and blood with foul odor coming from the
infected necrotic tissue which remains inside the uterus, unsuccessful fibroid
expulsion with fibroid being trapped in the cervix causing infection requiring
surgical removal. Our patient presented with fibroid expulsion with foul
vaginal discharge with bleeding and infection 2 weeks after uterine artery
embolization requiring surgical intervention after a course of antibiotics.
This
was an extremely high risk case from surgical, medical and anesthesia point of
view. There was an increased risk of excessive intraoperative hemorrhage with
difficult surgical technique due to the large size and location of the cervical
fibroid. The management of the case was a challenge to the anesthetist and
cardiologist due the ejection fraction being 30% with ventricular arrhythmias.
She was managed with a multidisciplinary approach with involvement of gynecologist,
cardiologist and anesthetist working as a team.
References
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- Schoen FJ, Mitchell RN. The Heart. In Robbins SL, Kumar V, Cotran RS,
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- Bhatla N. Tumours of the corpus uteri. In Pratap K, Narendra M, editors. Jeffcoate’s
Principles of Gynaecology. 7th ed.
- Suneja A, Taneja A, Guleria K, Yadav P, Agarwal N. Incarcerated
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- Radeleff B, Eiers M, Bellemann N, Ramsauer S, Rimbach S, Hans-Ulrich Kauczor, Goetz M. Richter GM. Expulsion of dominant submucosal fibroids after uterine artery embolization. European Journal of Radiology. 2010; 57–63.
- de Block S, de Bries C, Prinssen HM . Fatal Sepsis after Uterine Artery Embolization with Microspheres. Journal of Vascular and Interventional Radiology. 2003;14:779–783.
- Rajan DK, Beecroft JR, Clark TW, Asch MR, Simons ME, Kachura JR, et al. Risk of intrauterine infectious complications after uterine artery embolization. J Vasc Interv Radiol. 2004 Dec;15(12):1415-21.
- Gabriel H, Pinto CM, Kumar M, Nikolaidis P, Miller FH, Weinrach DM et al, MRI detection of uterine necrosis after uterine artery embolization for fibroid. AJR Am J Roentgenol. 2004;183:733–736.
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Citation
Agarwal
S, Warke HS, Satia MN