Importanța crucială a examenului ginecologic înainte de avortul medicamentos – prezentare de caz

Introduction

Uterine fibroids (also known as uterine leiomyomas) are the most common tumors in women of reproductive age, with an incidence of approximately 70% in the general population. About 20% to 40% of women with uterine fibroids will develop noticeable symptoms such as abnormal uterine bleeding, dysmenorrhea, abdominal pain, infertility and recurrent miscarriage⁽¹⁾.

Previous epidemiologic studies have suggested that the most common risk factors of uterine fibroids are linked to stress and obesity⁽²⁾, and with an inverse association with parity, cigarette smoking, physical activity and the use of oral contraceptives in some but not all studies⁽³⁾.

Uterine fibroids induce significant changes in the vascular architecture and functional properties of the endometrium. The production of angiogenic factors increase the endometrial surface and the size of the uterine cavity. The aberrant angiogenesis enhances the appearance of immature and fragile vessels⁽⁴⁾. Furthermore, on the surface of uterine fibroids, the blood vessels are dilated, the pressure causes venous ectasia, and the impaired myometrial contractility explain why abnormal uterine bleeding may occur⁽⁵⁾. Hemostasis may be disturbed because of platelet dysfunction compensated by increased vascular flow in engorged vessels⁽⁶⁾.

Regarding the effect of uterine leiomyoma during pregnancy, most of the studies describe a significant growth in the first trimester, but this trend is attenuated later in pregnancy. As a particularity, the cervical leiomyomas have the highest rate of increase in size com­pared to leiomyomas in other location. Although the etiology of uterine fibroids remains unknown, ovarian hormones, including estrogen and progesterone, are be­lieved to influence the development of these benign tu­mors⁽⁷⁾. Other studies have described the human chorio­nic gonadotropin (hCG) as a major contributor towards leio­myoma growth⁽⁸⁾.

Moreover, the termination of pregnancy in a patient known with uterine fibroids may represent a challenge, even though the presence of a leiomyoma is not regarded as a contraindication to either medical or surgical abortion⁽⁹⁾. The effectiveness of medical abortion may be diminished by the compromised myometrial contractility⁽¹⁰⁾. Consequently, the endometrial cavity may be distorted, thereby increasing the technical difficulty of surgical abortion procedures⁽⁹⁾.

Ultrasonography is the preferred first-line imaging modality for the evaluation of uterine fibroids. Expectant management is recommended for asymptomatic patients, as most fibroids tend to decrease in size after menopause. The management strategies should be individualized. Medical management aimed at reducing heavy menstrual bleeding includes hormonal contraceptives, tranexamic acid and nonsteroidal anti-inflammatory drugs. Gonadotropin-releasing hormone agonists and selective progesterone receptor modulators may be considered for short-term symptom control, particularly in patients approaching menopause or those requiring preoperative optimization⁽¹¹⁾. The definitive cure for symptomatic fibroids is the hysterectomy which provides complete resolution of symptoms and improved quality of life⁽¹²⁾.

Case report

A 43-year-old patient with an ultrasound confirmation of an eight-week pregnancy decided the medical termination of the pregnancy with mifepristone and misoprostol at the medical recommendation. The patient received one oral tablet of mifepristone 200 mg, followed 48 hours later by the intravaginal administration of four tablets of misoprostol 0.2 mg. After five days of bleeding, there were no more symptoms associated for the next four days. The patient presented to our hospital for vaginal bleeding more intense compared with the first episode. The patient reported no other episodes of abnormal bleeding prior to this abortion. She had regular menstrual cycles, and she had never used any form of contraceptive methods. The patient’s obstetric history included two spontaneous vaginal deliveries and two previous abortions. No other significant medical comorbidities were reported.

During the clinical examination, we discovered that the cervix was obliterated by the presence of an irregular solid mass of 5.6 cm, that was bleeding profusely. The width of the pedicle from the uterine cavity could not be evaluated. The transvaginal ultrasound examination revealed a normal sized uterus with linear cavity (Figure 1), and at the level of the cervix, a vascularized mass of 5/6 cm (Figures 2 and 3).

The blood test revealed severe anemia, with hemoglobin 5.2 g/dl, therefore the patient received hematological products after which the hemoglobin increased to 7.8 g/dl.

After four days of hemodynamic rebalancing, the bleeding continued, therefore the emergency medical committee decided that total hysterectomy with bilateral salpingectomy was necessary for an effective hemostasis.

The intraoperative inspection revealed macroscopically normal uterus, fallopian tubes and ovaries, with pale-appearing tissues. A hysterectomy was subsequently performed with meticulous hemostasis control, and the entire surgical piece was submitted for histopathological examination (Figure 5). The postoperative evolution of the patient was favorable under anticoagulant, hydroelectrolytic, analgesic and antibiotic therapy, and she was discharged home with supplementary iron therapyfor the next months.

Discussion

We present the case of a 43-year-old patient who received medical treatment with misoprostol and mifepristone for the termination of the pregnancy, without taking into consideration the irregular solid mass that imprinted the cervix.

Elective termination of pregnancy is typically achieved through either surgical evacuation or pharma­co­logical methods. Medical termination of pregnancy is frequently considered a safer and more physiological alternative to surgical procedures. Misoprostol has been one of the most used medications for abortion, with an effectiveness of 61% for single dose and 93% for repeated doses⁽¹³⁾. The introduction of mifepristone in addition to misoprostol has revolutionized abortion, with a greater result of 95% effectiveness⁽¹⁴⁾. Nevertheless, incomplete abortion occurs in up to 5% of cases, necessitating subsequent surgical intervention to achieve completion⁽¹⁵⁾.

Vaginal bleeding is a common occurrence following abortion, and it is typically comparable to – or heavier than – a normal menstrual period. Patients undergoing medical abortion generally experience greater bleeding than those who have surgical procedures, and may present with clinical features similar to those observed in spontaneous abortion^(16,17). Such bleeding generally does not require additional treatment or intervention; fewer than 1% of patients undergoing safe first-trimester abortion require acute clinical intervention, and approximately 0.05% require blood transfusion⁽¹⁸⁾. The side effects of medical treatment may include abdominal cramping, vaginal bleeding, brief low-grade fever, headache, dizziness, nausea, vomiting and diarrhea⁽¹⁹⁾. The bleeding after administering medication is usually bimodal, with moderate or heavy bleeding 3-8 hours right after⁽²⁰⁾. One study reported that blood loss ranged between 84 and 101 ml in patients undergoing safe medical abortion and 53 ml in abortion by aspiration⁽²¹⁾. In our case, the patient had two episodes of bleeding which lasted 5-6 days each, associated with foul smell and dizziness. Due to the heavy bleeding and secondary severe anemia, she necessitated blood transfusion, placing her within the 0.05% of rare cases.

Other complications that might occur after the termination of a pregnancy may include bleeding, retained products of conception, retained cervical dilator, uterine perforation, amniotic fluid embolism, misoprostol toxicity and endometritis⁽²²⁾. Ultrasound may help identify the main complications after such a procedure by visualizing if there are any retained products of conception, ongoing pregnancy, ectopic masses, echogenic material within the uterus, hematoma formation or even intraabdominal free fluid, which may suggest a uterine perforation, rupture or vascular injury⁽¹⁷⁾. Regarding our patient, the ultrasound revealed a linear uterine cavity, but at the cervical level, it was observed a mass of 5/6 cm with increased vascularity, suggesting a uterine fibroid.

The presence of uterine fibroids can interfere with the uterine contractility, contributing to increased bleeding during medical abortion. The intensity of the bleeding may also be influenced by the anatomical location of the fibroids. In particular, intramural fibroids exert a greater effect on uterine contractile function, whereas subserosal fibroids appear to have a more limited influence⁽²²⁾. Our patient presented an irregular solid mass at the cervix level with thick and elongated pedicle that was bleeding profusely and continuously regardless of any hemostatic treatment. Due to the severe anemia and continuous bleeding, it was decided to perform hysterectomy.

Extrafascial hysterectomy for benign uterine conditions is the second most common surgical procedure in operative gynecology, after caesarean section⁽²³⁾. The main cause of hysterectomy is the presence of uterine fibroids that cause severe symptomatology, such as abnormal uterine bleeding, accounting for at least one-third of all hysterectomies, whereas all types of gynecologic cancers account for less than 10%⁽²⁴⁾. For symptomatic fibroids, hysterectomy provides a permanent solution to menorrhagia and the pressure symptoms related to an enlarged uterus⁽²⁵⁾.

Our case is particular because a 43-year-old woman had a severe vaginal bleeding after taking medication for pregnancy termination, causing severe secondary anemia that necessitated hysterectomy for hemostasis reasons. The vaginal bleeding was continuous, the hemoglobin decreasing despite the hemostatic treatment and blood transfusions.

Conclusions

Elective abortion is a very common procedure worldwide, and, accordingly, the associated risks increase proportionally. The most frequent symptom is heavy bleeding, which may be exacerbated by the presence of uterine fibroids, as these also tend to increase in size during pregnancy. A thorough clinical examination can help reduce and prevent potential complications. The management of an elective abortion should be individualized for each patient, based on her medical history and the associated comorbidities.

Autor corespondent: Mihaela Amza E-mail: mihaela.amza@umfcd.ro

CONFLICT OF INTEREST: none declared.

FINANCIAL SUPPORT: none declared.

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