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Anesthetic Management of Large Volume Cervical Varix in the Second Trimester
Abstract Number: S-51
Abstract Type: Case Report/Case Series
Cervical varices are an extremely rare, potentially life-threatening complication associated with pregnancy. The incidence of cervical varices in pregnancy is difficult to determine, as there are fewer than 10 documented cases1. They are often associated with significant secondary hemorrhage1, resulting in both maternal and fetal morbidity and mortality. It is critical that the anesthesiologist be knowledgeable of the potential management concerns; timing and mode of interventions such as embolization, as well as the potential for emergent delivery. Among the obstetric community, there is limited evidence in the management of these cases which further complicates decision making, and requires close communication between the patient, anesthesia, and obstetric teams. We present our management of a patient with uncontrolled hemorrhage secondary to cervical variceal bleeding in second trimester.
A 22 year old primigravida, at 16 weeks gestation, presented to the ED with one week of intermittent heavy vaginal bleeding. She reported a recent admission at an outside hospital requiring 2 units PRBCs, at which time she was told her bleeding was due to uterine fibroids. Upon workup she was found to have a hemoglobin of 6.0, placenta previa with a small placental abruption, and a large vascular mass in the anterior portion of her cervix suspected to be an AVM or varix. Following transfusion, the patient stabilized and her bleeding temporarily resolved. After extensive counseling, the patient opted for a uterine artery embolization with subsequent dilatation and evacuation of the fetus, should she continue to have significant bleeding. However, prior to her scheduled embolization, the patient developed sudden massive hemorrhage. Emergent embolization in IR was unsuccessful, requiring urgent surgical intervention. Unfortunately, for this patient, the circumstances warranted an emergent hysterectomy, under general anesthesia. Although in this case, the complication of a cervical varix lead to termination of the pregnancy and emergent hysterectomy, careful management by obstetric and anesthesia teams limited morbidity to the patient and her post-operative course was uneventful.
We present a rare case, acute hemorrhage in a gravid, second trimester female. In such patients, an adequate plan is key and communication between providers is critical. Anesthesiologists are trained in managing hemodynamically unstable patients secondary to massive hemorrhage. However, special consideration needs to be directed towards the gravid parturient.
1.Lesko, Jennifer MD, MPH; Carusi, Daniela MD; Shipp, Thomas D. MD; Dutton, Caryn MD. 2014.Uterine Artery Embolization of Cervical Varices Before Second Trimester Abortion. Obstet Gynecol 2014;123:458–62).
2.Brown, John V III, Mills, Marlin D., Wong, Humberto, Goldstein, Bram H. 2013. Large volume cervical varix bleeding in a gravid patient. Gynecologic Oncology Reports 4(2013) 20-22.