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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 29  |  Issue : 1  |  Page : 73-75

Spontaneous massive vulvar edema in the postnatal period


1 Department of Plastic Reconstructive and Aesthetic Surgery, University of Health Sciences, Gülhane Medical School, Ankara, Turkey
2 Department of Plastic, Reconstructive and Aesthetic Surgery, Aydın State Hospital, Aydın, Turkey

Date of Submission11-Feb-2020
Date of Acceptance22-Apr-2020
Date of Web Publication31-Dec-2020

Correspondence Address:
Dr. Simay Ersahin
Department of Plastic Reconstructive and Aesthetic Surgery, University of Health Sciences, Gülhane Medical School, Ankara; Aşağı Eğlence, Emrah Mahallesi General Doktor Tevfik Sağlam Caddesi 06010, Keçiören, Ankara
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjps.tjps_8_20

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  Abstract 


Spontaneous and isolated massive vulvar edema is seen as a rare condition in pregnancy in the postpartum period. Underlying causes have to be well understood, and treatment plans has to be well organized because of its association with high maternal mortality rate. We report a case of postpartum massive vulvar edema in a 19-year-old-primigravida patient presented with vulvar pain and difficulty in mobilization in the postpartum 4th day. The vulvar edema resolved progressively with surgical incisions on the labia minoras. The aim of this report is to inform clinicians that surgical intervention can be a successful treatment modality.

Keywords: Pregnancy, surgical treatment, vulvar edema


How to cite this article:
Ersahin S, Gunes D, Oksuz S. Spontaneous massive vulvar edema in the postnatal period. Turk J Plast Surg 2021;29:73-5

How to cite this URL:
Ersahin S, Gunes D, Oksuz S. Spontaneous massive vulvar edema in the postnatal period. Turk J Plast Surg [serial online] 2021 [cited 2021 Dec 9];29:73-5. Available from: http://www.turkjplastsurg.org/text.asp?2021/29/1/73/305911




  Introduction Top


Peripheral edema is a normal condition in pregnancy, especially in the third trimester.[1] The edema is mostly seen in lower extremities and can extend to the genital area, but an isolated marked vulvar edema can demonstrate an underlying serious systemic disease.[2] Due to loose areolar tissue and rich blood supply in the vulva, this region is very prone to show edema.[3]

We present a massive vulvar edema case in a 19-year-old primigravida patient presented with vulvar pain in the postpartum 4th day treated with surgical intervention.


  Case Report Top


The patient applied to Obstetrics and Gynecology (O&G) Department in her 26 weeks gestation. Her obstetric history, physical examination, former fetal ultrasound (US), and fetal echocardiography were normal. She had a mixed respiratory tract pathology due to scoliosis. She was in bed rest and having difficulty in ambulation. She was under antibiotic treatment for her urinary tract infection and proteinuria.

US examination showed an anterior breech presentation in her second visit at the 28th week of gestation.

Three days later, the patient was hospitalized by O&G Department with abdominal pain and contractions. Vaginal opening was 3 cm, a cesarean section was performed. Abnormal blood results were; white blood cells: 22.800 cells/uL, %NE: %83.1, total protein: 4.79 g/dL, albumin: 2.09 g/dL, C-reactive protein: 74.99 mg/L.

In the postpartum 2nd day, she developed pretibial edema and hypoalbuminemia, and her complete urinalysis showed proteinuria, 82 erythrocytes, and 75 leukocytes. The urinary culture showed no bacteria.

She experienced vulvar edema and massive vulvar pain on the postpartum 4th day. Her examination revealed pretibial edema in the right leg and no edema in her left leg, her blood pressure was 140/90. Her nifedipine therapy was stopped, and carvedilol and furosemide therapy was started with a preliminary diagnosis of nephrotic syndrome. Because of the diameter differences between two legs, a Doppler US was made to eliminate deep vein thrombosis, no pathology was observed.

The patient was consulted to our department in postpartum 5th day with massive edema around the vulvar area, most remarkably around labia minoras [Figure 1]. Two oblique five millimeters incisions by number 15 scalpel was made to the labia minoras under local anesthesia. A massive serous discharge occurred with a little manipulation. Her pain was relieved dramatically just after the procedure, and edematous appearance regressed [Figure 2]. Almost a normal view of the vulvar area was observed in her postoperative 3rd day [Figure 3].
Figure 1: The view of vulvar area before incisions and drainage. There were 10 cm × 4 cm edema on both sides on labia minoras

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Figure 2: Three minutes after incisions and drainage had been made. We can see two oblique 5 mm incisions which made by 15 number scalpel bilaterally just to the superolateral aspects of midline between two labia minoras

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Figure 3: Postoperative 3rd day

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  Discussion Top


Total body water increases to 6–9 L in pregnancy and two-third of it is intracellular.[4]

Edema is the accumulation of excess body fluid in interstitial space and is a normal situation in pregnancy. Structure and function of the blood and lymphatic microvasculature and connective tissue mucopolysaccharides is changed due to the activation of renin-angiotensin system and estrogen secretion, respectively.[1],[2] The compression of inferior vena cava by the gravid uterus leads to lymphatic stasis and outflow from femoral and iliac veins.[5],[6]

The vulva has a rich blood supply,[3] distensible skin, and abundant loose connective tissue. Therefore, it is prone to expansion in case of pressure and volume changes.[5],[6],[7] Edema accumulates in vulva by gravity in prolonged bed rest patients.[2],[6]

Inflammatory conditions, infections, trauma, pregnancy, neoplasms, congenital anomalies, metabolic disorders, and iatrogenic causes can lead to vulvar edema.[8],[9] Contact dermatitis, allergic reactions, pelvic tumor blocking the lymphatic vessels, or inguinal lymph nodes can show themselves as vulvar edema and swelling.[2],[7] It can be a local manifestation of a systemic disease such as Chron disease, nephrotic syndrome, diabetes mellitus, lupus, leukemia, and lymphoma. Hidradenitis suppurativa, HSV infection, recurrent vulvovaginal candidiasis, radiation, surgery, syphilis, filariasis, and streptococcal infection due to tuberculosis can lead to vulvar edema. There are several conditions that can mimic vulvar edema, such as subcutaneous tumors (lipomas, cysts) or abscess.[7],[8],[9],[10] Vulvar edema relates to hypertension, obesity, immobilization,[2] and low socioeconomic status.[10]

There are a few reported cases of massive vulvar edema in pregnancy, which are related to preeclampsia, hypoproteinemia, ovarian hyperstimulation syndrome, the prolonged second stage of labor, intravenous tocolytic therapy, anemia due to iron, folate and B12 deficiencies, thrombocytopenia, malnutrition, pelvic lymphangiectasis with ascites, pelvic phlebothrombosis.[2],[7],[9],[11]

Massive vulvar edema in the antepartum or postpartum period can be an indicator of cardiovascular collapse.[6],[9] Eighty percent of maternal mortality rate has been reported due to vascular collapse and cardiorespiratory arrest.[9],[12] The treatment plan should address the underlying systemic disease.[7],[8],[13] Vulvar edema complicated by infection due to immunologic deficiencies should be treated with antibiotics.[12]

Pain and difficulty in mobilization cause patient discomfort. Management strategy should include resolving these symptoms.[2] Edema can block urinary tract outlet, resulting in urinary retention.[8] Bedrest, Trendelenburg position, Foley's catheter insertion, ice packs, hypertonic saline bags, lactated Ringer's solution, painkillers, local and oral antibiotics, diuretic administration, human albumin, low-molecular-weighted heparin, and elastic stockings to prevent venous thrombosis,[2],[3],[9],[11] manual lymphatic drainage and multilayer compression therapy, multichambered pneumatic compression device and skin care[2],[7],[9] can be used to treat the edema. Mechanical drainage was used in a few cases.[11]

According to Silva et al., manual lymphatic drainage and multilayer compression therapy took 2–5 days for resolution of edema. Regression of vulvar edema required 10 days with diuretic administration. The edema decreased in 14 days with daily vulvar immersion in an antiseptic solution. No intervention had 1–2 weeks resolution period.[2]

This patient's vulvar edema was most probably due to hypoproteinemia from urinary protein loss. It happened in the postpartum 4th day, she was immobilized because of her mixed respiratory tract pathology and spent her time mostly in bed. In treatment, we use human albumin replacement, furosemide as diuretic administration, but mainly the surgical intervention. After the surgical procedure, we recommend a topical antibiotic and topical anaesthetic application.

Immediate surgical intervention relieved patients from pain dramatically. She was able to sit in bed and mobilized quickly. Skin tension and tissue necrosis risk due to edema were prevented. Prolonged edema might have resulted in lasting tissue damage.


  Conclusions Top


Massive vulvar edema is an uncomfortable and serious condition. Patients should be assessed individually, and treatment modalities should aim systemic problems. There are multiple symptomatic and mechanical treatment options available. Surgical intervention is a fast-responding symptomatic treatment for pain relief and quick mobilization.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Henry F, Quatresooz P, Valverde-Lopez JC, Piérard GE. Blood vessel changes during pregnancy: A review. Am J Clin Dermatol 2006;7:65-9.  Back to cited text no. 1
    
2.
Silva MP, Bassani MA, Miquelutti MA, Marques Ade A, do Amaral MT, de Oliveira MM, et al. Manual lymphatic drainage and multilayer compression therapy for vulvar edema: A case series. Physiother Theory Pract 2015;31:527-31.  Back to cited text no. 2
    
3.
Khamsi N, Mendez MD, Rojas-Mendez P, Sanchez S, Reddy S. Unilateral labial edema in a female adolescent: A gynecologic presentation of rhabdomyolysis. J Pediatr Adolesc Gynecol 2018;31:644-7.  Back to cited text no. 3
    
4.
Pisani I, Tiralongo GM, Lo Presti D, Gagliardi G, Farsetti D, Vasapollo B, et al. Correlation between maternal body composition and haemodynamic changes in pregnancy: Different profiles for different hypertensive disorders. Pregnancy Hypertens 2017;10:131-4.  Back to cited text no. 4
    
5.
Lawford AM, Scott K, Lust K. A case of massive vulvar oedema due to septic pubic symphysitis complicating pregnancy. Aust N Z J Obstet Gynaecol 2010;50:576-7.  Back to cited text no. 5
    
6.
Hernandez C, Lynn R. Massive antepartum labial edema. Cutis 2010;86:148-52.  Back to cited text no. 6
    
7.
Amankwah Y, Haefner H. Vulvar edema. Dermatol Clin 2010;28:765-77.  Back to cited text no. 7
    
8.
Hadžavdić SL, Jović A, Hadžavdić A, Grgec DL. Vulvar oedema. Contact Dermatitis 2018;78:226-7.  Back to cited text no. 8
    
9.
Kulas T, Habek D, Hrgović Z. Massive labia minor hypertrophy following vulvar edema and abscess in pregnancy – Case report. Z Geburtshilfe Neonatol 2009;213:207-9.  Back to cited text no. 9
    
10.
Bergström S. Vulvar oedema among pregnant Mozambican women. Gynecol Obstet Invest 1992;34:73-5.  Back to cited text no. 10
    
11.
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. 11
    
12.
Trice L, Bennert H, Stubblefield PG. Massive vulvar edema complicating tocolysis in a patient with twins. A case report. J Reprod Med 1996;41:121-4.  Back to cited text no. 12
    
13.
Debiec KE, Lee SD, Wahbeh GT, Oelschlager AM. Outcomes of therapy for vulvar manifestation of inflammatory bowel disease in adolescents. J Pediatr Adolesc Gynecol 2018;31:149-52.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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