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CASE REPORT
Year : 2019  |  Volume : 16  |  Issue : 1  |  Page : 75-78

Huge vulvar edema in a primigravida with severe preeclampsia – Emergency caesarean section and spontaneous resorption: A case report


1 Department of Obstetrics and Gynaecology, Aminu Kano Teaching Hospital, Kano, Kano State, Nigeria
2 Department of Obstetrics and Gynaecology, Muhammadu Abdullahi Wase Hospital, Kano, Kano State, Nigeria

Date of Web Publication5-Mar-2019

Correspondence Address:
Dr. H M Abdullahi
Aminu Kano Teaching Hospital, Kano, Kano State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njbcs.njbcs_10_18

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  Abstract 


Vulvar edema refers to accumulation of fluid within the interstitial space of the vulvar. It can result from inflammatory conditions, infections, infestations, trauma, pregnancy, tumours and iatrogenic causes. It is an unusual complication of pregnancy and is difficult to determine the cause. It may occur due to underlying systemic pathology and has also been associated with preeclampsia. It has the potential to interfere with vaginal delivery and compromise tissue integrity and has been associated with maternal mortality postpartum. We present a case of huge vulvar edema in a 23 years old primigravida woman that was managed elsewhere as a case of vulvar edema with elevated blood pressure and subsequently discharged home. She presented to us with severe preeclampsia and worsening massive vulvar edema at 32 weeks of gestation. Conservative management failed because of worsening symptoms. Caesarean section was performed with regressing of symptoms within few days. It is important for the clinicians to note that vulvar edema complicating preeclampsia could be a poor prognostic sign.

Keywords: Management, pre-eclampsia, primigravida, Vulvar edema


How to cite this article:
Abdullahi H M, Suleiman M M, Abdullahi M M. Huge vulvar edema in a primigravida with severe preeclampsia – Emergency caesarean section and spontaneous resorption: A case report. Niger J Basic Clin Sci 2019;16:75-8

How to cite this URL:
Abdullahi H M, Suleiman M M, Abdullahi M M. Huge vulvar edema in a primigravida with severe preeclampsia – Emergency caesarean section and spontaneous resorption: A case report. Niger J Basic Clin Sci [serial online] 2019 [cited 2019 Mar 25];16:75-8. Available from: http://www.njbcs.net/text.asp?2019/16/1/75/253401




  Introduction Top


Edema refers to abnormal accumulation of fluid within the interstitial space that is associated with a variety of conditions. Vulvar edema refers to accumulation of fluid within the interstitial space of the vulvar. It can result from inflammatory conditions, infections, infestations, trauma, pregnancy, tumors, and iatrogenic causes.[1],[2],[3],[4] It is difficult most of the times to determine the cause of vulvar edema. It is also an unusual complication of pregnancy that may occur due to underlying systemic pathology but has also been associated with preeclampsia. It has the potential to interfere with vaginal delivery and compromise tissue integrity and has been associated with maternal mortality postpartum.[1],[2] The physiological changes in pregnancy that include significant increase in blood volume, blood pressure, and vascular permeability, coupled with compression of the inferior vena cava by the growing uterus, can result in edema formation.

Preeclampsia is a potentially life-threatening multisystem disorder that contributes to maternal and perinatal mortality and morbidity worldwide.[5],[6],[7] It is a disease unique to human pregnancy characterized by new-onset hypertension and proteinuria after the 20th week of gestation and can be mild or severe. It affects 3%–10% of all pregnancies.[8] It is characterized by both systemic and localized vascular endothelial dysfunctions and is demonstrated focally in pulmonary edema, cerebral edema, hepatic capsule rupture and failure, and decreased renal function that affects serum protein concentrations and salt retention.[8],[9],[10],[11],[12]

Huge vulvar edema during pregnancy can result in serious discomfort with subsequent complications of increased blood loss and poor wound healing if not treated appropriately.

Huge vulvar edema in association with preeclampsia is rare during pregnancy and may indicate the severity of the disease coupled with patient discomfort and management challenges.[13],[14]


  Case Report Top


Our patient was a primigravida attending antenatal care at Muhammad Abdullahi Wase Specialist Hospital and had a total of four uncomplicated antenatal visits. She was well until a week before presentation, when she started having swelling in her genital area, which was initially mild and painless. It subsequently increased in size and became painful. She went to the hospital where she was booked for antenatal care and was told that she had a genital swelling and elevated blood pressure. She was admitted and placed on tablets augmentin 625 mg bd for a week, paracetamol 1 g 8 hourly for 5 days, aldomet 500 mg 8 hourly, and diazepam intramuscular bolus of 10 mg and continued on oral diazepam 5 mg nocte for 5 days and was discharged after 48 h with some improvement. Her condition, however, continued to deteriorate with unremitted genital pain and limitation of movement few days after discharge. She presented to us at gestational age of 32 weeks and 2 days with above complaints and additional history of insomnia, headache and blurring of vision, and epigastric discomfort. She was found to be a young woman, conscious, in painful distress, not pale, anicteric, febrile to touch (temperature of 38.6°C) with bilateral pitting pedal edema. Her chest was clinically clear. The pulse rate was 120/min, regular, and moderate volume. Blood pressure was 170/120 mmHg. Heart sounds were I and II only. Urinalysis revealed a proteinuria of 3+.

The abdomen was uniformly enlarged and moved with respiration. The fundal height was 31 cm. A single fetus was palpated lying longitudinal and presenting cephalic, in left occipito anterior position. The fetal heart rate was 164 beats/min and regular.

Pelvic examination revealed a huge vulvar swelling that extended to mons pubis. It was tender and fluctuant. Other findings could not be demonstrated because of pain. A diagnosis of huge vulvar edema in a patient with preeclampsia at 32 weeks was entertained.

She was admitted, and magnesium sulfate was commenced using zuspan regimen. Intramuscular injection of dexamethasone 12 mg was given. Intravenous hydrallazine 10 mg for 10 min was given. Intravenous augmentin 1.2 g was also given 12 hourly with intravenous metronidazole 500 mg 8 hourly. She was given intravenous pentazocine 30 mg stat and intravenous paracetamol 1 g 8 hourly.

The following investigations were carried out:

Packed cell volume (PCV): 36%

Hemoglobin concentration: 12 g/dL

White blood cell count: 6.2 × 109/L

Differentials

Neutrophils: 60%

Lymphocyte: 40%

Platelet count: 280 × 109/L

Bedside clotting time: 4 min

Liver function test

Alkaline phosphatase: 18 (20–48 U/L)

SGOT: 10 (<12)

SGPT: 7 (<12)

Random blood sugar: 4.6 mmol/L

Electrolytes and urea

Sodium: 132 mmol/L

Potassium: 3.2 mmol/L

Chloride: 96 mmol/L

Bicarbonate: 120 mmol/L

Creatinine: 94 mmol/L

Urea: 3.6 mmol/L

Uric acid: 152 mmol/L

Urinalysis

Sugar: Negative

Ketones: Negative

Proteinuria: (3+)

Urine M/C/S

Did not isolate any organism after 48 h of incubation.

She was counseled for emergency caesarean section in view of worsening symptoms. It was done under spinal anesthesia after preanesthetic review, which revealed no history of previous anesthetic exposure and no history of major medical illnesses. Airway examination revealed Mallampati score of 3, thyromental distance of greater than 7 cm, and normal mouth opening. Lumbar region was edematous, hence making lumbar spine difficult to palpate. Baseline vitals were taken using a unigold M.9000 mutiparameter monitor with a noninvasive blood pressure of 154/89 mmHg, pulse rate of 112 beats/min, peripheral oxygen saturation of 99%, axillary temperature of 36.8°C, and respiratory rate of 15 cycles/min.

Intravenous access was achieved using size 16G cannular. No preloading was done. Spinal anesthesia was instituted using size 27G Whitacre spinal needle with introducer. Spinal block was achieved up to T8. Intravenous normal saline was used to maintain normotension. No complications were noted. She delivered an alive male baby that weighed 2 kg with APGAR score of 6 and 8 at first and fifth minutes, respectively. Ascites of about 500 mL were also noted.

She was maintained on magnesium sulfate for the next 24 h and continued on intravenous normal saline 500 mL 6 hourly for 24 h. She had postoperative control of blood pressure. Blood pressure was 140/90 mmHg within the first 24 h. She also had intravenous pentazocine 30 mg 6 hourly for 48 h for analgesia, and she was given intravenous augmentin 1.2 g 12 hourly and metronidazole 500 mg 8 hourly for prophylaxis and she was changed to oral augmentin 625 mg 12 hourly and metronidazole 400 mg 8 hourly for 5 days on the second postoperative day. Urethral catheter was removed on the second postoperative day after the drip was discontinued. The urine output remained adequate. Blood pressure was 130/80 mmHg by 72 h after the surgery and vulvar edema subsided within 1 week. Her condition remained stable. She was discharged on the seventh postoperative day to be seen in postnatal clinic in 2 weeks.

She had no complaints on her follow-up. Examination revealed no abnormality. Her blood pressure was normal being 110/70 mmHg. Her operation scar had healed well. Vulvar edema had subsided completely. The baby was breastfeeding well, but still on admission in special care baby unit. She was discharged to family planning clinic after she was counseled to book subsequent pregnancy in a tertiary center.


  Discussion Top


Edema is very common in pregnancy and tends to appear more in lower extremities, hand, and face. Vulvar edema is a rare complication of pregnancy and is found to be associated with few cases of preeclampsia as it happened in Mrs. N I. Some of the changes that happen during pregnancy can result in edema formation. Such changes include increase in blood volume, blood pressure, and also compression of the inferior venacava by the growing gravid uterus.[15] The vulva has a thin epithelium and loose connective tissue and is usually affected by pressure–volume disturbances. The ascites noted in Mrs. N I and also developed in preeclamptic patients are probably from hypo-albuminemia and increased capillary permeability and might be considered a poor prognostic sign because in some cases preeclampsia worsens with the appearance of vulvar edema as it happened in this patient.[3],[4]

Preeclampsia is a life-threatening condition and is associated with an increase in maternal as well as perinatal morbidity and mortality. The exact pathophysiology of preeclampsia remains unknown; however, the disease is characterized by both systemic and localized vascular endothelial dysfunctions and is associated with pulmonary edema, cerebral edema, and hepatic capsule rupture and failure.[9] Decreased renal function is also implicated, in that it affects serum protein concentrations and salt retention.[10] Venous congestion, narrowing of venules, which increases pressure in capillary beds, and a defective venoarteriolar reflex are also part of the mechanisms involved.[11],[12] Together, many of these mechanisms may result in both systemic and localized edema, as vasculature leaks fluid into the interstitial spaces.

Vulvar edema can be managed conservatively or surgically. Most cases of vulvar edema are managed conservatively with spontaneous resorption in the postpartum period.[15] Conservative measures are, however, not feasible in some situations because of the worsening symptoms. Other measures can be taken to alleviate the symptoms and such measures include trendelenburg positioning, application of ice bags, correction of nutrient deficiencies, and water immersion therapy.[16],[17] Treatment of vulvar edema is necessary because of pain, discomfort, occlusion of the vaginal outlet, and worsening of symptoms and that was why Mrs. N I was offered emergency caesarean section a day after admission. Heparin therapy and mechanical drainage are also offered by some authors by making a small incision on the affected area, which helps in relieving fluid and pressure with subsequent resolution of symptoms. Mrs, N I was, however, offered bed rest and systemic antibiotics.


  Conclusion Top


Huge vulvar edema in association with preeclampsia is rare during pregnancy and may indicate the severity of the disease coupled with patient discomfort and management challenges. Appropriate interventive measures should be instituted to alleviate the symptoms.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Daponte A, Skentou H, Dimopoulos KD, Kallitsaris A, Messinis IE. Massive vulvar edema in a patient with preeclampsia. J Reprod Med 2007;52:1067-9.  Back to cited text no. 1
    
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8.
McClure EM, Saleem S, Pasha O, Goldenberg RL. Stillbirth in developing countries: A review of causes, risk factors and prevention strategies. J Matern Fetal Neonatal Med 2009;22:183-90.  Back to cited text no. 8
    
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TA Jido, IA Yakasai. Preeclampsia: A review of the evidence. Ann Afr Med 2013;12:75-85.  Back to cited text no. 9
    
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Shah A, Fawole B, M'imunya JM, Amokrane F, Nafiou I, Wolomby JJ, et al. Cesarean delivery outcomes from the WHO global survey on maternal and perinatal health in Africa. Int J Gynaecol Obstet 2009;107:191-7.  Back to cited text no. 10
    
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Hernández-Díaz S, Toh S, Cnattingius S. Risk of pre-eclampsia in first and subsequent pregnancies: Prospective cohort study. BMJ 2009;338:b2255.  Back to cited text no. 11
    
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Kooffreh ME, Ekott M, Ekpoudom DO. The prevalence of pre-eclampsia among pregnant women in the University of Calabar Teaching Hospital, Calabar. Saudi J Health Sci 2011;14:418-21.  Back to cited text no. 12
    
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DiPasquale LR, Lynett K. The use of water immersion for treatment of massive labial edema during pregnancy. MCN Am J Matern Child Nurs 2003;28:242-5.  Back to cited text no. 13
    
14.
Hubb AJ, Orr KL, Stockdale CK. Puerperal vulvar edema and hematoma complicated by overuse of cold therapy – A report of two cases. J Low Genit Tract Dis 2015;19:e28-30.  Back to cited text no. 14
    
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Abdul MA, Odogwu K, Madugu N. Gross vulva edema complicating severe pre eclampsia and eclampsia: A case series. Niger J Med 2011;20:380-2.  Back to cited text no. 15
    
16.
Guven ES, Guven S, Durukan T, Onderoglu L. Massive vulval oedema complicating pregnancy. J Obstet Gynaecol 2005;25:216-8.  Back to cited text no. 16
    
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Wallis AB, Saftlas AF, Hsia J, Atrash HK. Secular trends in the rates of preeclampsia, eclampsia, and gestational hypertension, United States, 1987–2004. Am J Hypertens 2008;21:521-6.  Back to cited text no. 17
    




 

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