A rare case of life-threatening epistaxis in late pregnancy Open Access

Abstract

Introduction

Epistaxis is frequently experienced by the general population, with most cases not requiring any medical intervention [1]. The majority of individuals that present to hospital are treated and discharged by staff in the emergency department.

Epistaxis during pregnancy is common with a prevalence of 20.3% compared to 6.2% of non-pregnant women [2]. The aetiology that causes epistaxis episodes during pregnancy is largely thought to be linked to increased blood volume and hormonal changes affecting blood vessel permeability.

However, torrential or life-threatening episodes of nasal bleeding during pregnancy are rarely reported in the literature. Those that have been documented are largely attributable to an additional aetiology aside from the pregnancy such as nasal pyogenic granuloma, nasal polyps, and clotting disorders [3–5]. In cases where an associated pathology has not been identified, the cessation of bleeding has often been credited to surgical intervention or in extreme circumstance the delivery of the baby [6, 7].

In the event that conservative measures or chemical cautery fail to control bleeding, National Institute for Health and Care Excellence (NICE) guidelines currently recommend endoscopic assessment and electrocautery, examination under anaesthesia, and surgical intervention (such as diathermy, septal surgery, arterial ligation, and laser treatment) or radiological arterial embolization [8].

Case report

A 36-year-old female, at 30 weeks gestation of her fourth pregnancy, presented to hospital with 2 hours of severe left sided epistaxis. Initial management with ‘floseal’ failed and her left nasal cavity was packed with a 7.5 cm rapid rhino (a pneumatic nasal tamponade device) with 8 ml of air. Persistent bleeding after one hour resulted in her right nasal cavity being packed with a 5.5 cm rapid rhino with 5 ml of air. Haemostasis was achieved. The patient’s laboratory haemoglobin was 114 g/L.

The following day the patient had three further episodes of epistaxis that lead to nasal packing with a foley catheter and bismuth iodoform paraffin paste (BIPP). The patient was started on oral tranexamic acid as per the obstetric team. Bleeding was controlled until a significant re-bleed warranted surgical exploration and cautery of the left sphenopalatine artery and further BIPP packing. No specific bleeding point was identified but a unit of blood was transfused due to haemoglobin of 75 g/L.

The patient remained stable for 48 hours during which time the BIPP packs were partly removed. However, in the evening 4 days after admission the patient had further severe left sided epistaxis. BIPP packing from the previous operation was removed and a Foley catheter was inserted and inflated in the post-nasal space. The left nasal cavity was then repacked with BIPP. This failed and she returned to theatre for a second left sphenopalatine artery cautery, she required two units of packed red cells in theatre increasing her haemoglobin to 73 g/L and two further units were transfused immediately post-operatively.

The following night the patient suffered a further left sided epistaxis and was taken to interventional radiology where her left maxillary artery was embolized via right femoral puncture. Immediately afterwards, her packs where deflated and she re-bled necessitating a second femoral puncture to allow placement of coils in a vessel anastomosing with the left maxillary artery. Haemostasis was achieved, however two further units of packed red cells where required.

Within three hours of embolization bleeding had recommenced, her haemoglobin was 89 g/L and she was taken back to theatre for ligation of her left maxillary artery by a rhinologist. She was packed intra-operatively with ‘floseal’ and a left sided rapid rhino was re-inserted. She had a minor re-bleed in recovery, which was controlled with a rapid rhino to her right nasal cavity. She was transfused a further two units of packed red cells. Following obstetric advice, she was commenced on labetalol and steroids as a pre cautionary measure.

The patient continued to experience small, self-limiting bleeds over the next 48 hours and required a further two units of packed red cells. She was seen by the haematology team, neonatology team and was discussed at the high risk pregnancy multi-disciplinary meeting. The decision was made for an emergency caesarean section.

A healthy child 30 + 6 was delivered safely by caesarean section the following afternoon. The patient had one small episode of epistaxis in recovery post operatively, after which there were no further bleeds.

Discussion

Two commonly used pharmalogical treatments for epistaxis, ‘Floseal’ and ‘BIPP’ are not currently recommended to use in pregnant woman due to in sufficient data to support their safe administration. However, when faced with bleeding, a clinician must weigh up the risk versus benefits of such measures whilst simultaneously assessing the potential complications of ongoing hemorrhage and the possible adverse outcomes of subjecting a pregnant patient to surgical measures that require a general anaesthetic. A large-scale observational study carried out in the UK investigated the outcomes of pregnant women that underwent a general anaesthetic for non-obstetric related condition. The authors found that pregnant women who had surgery had a very slight increased risk of adverse birth outcomes compared with those who did not have surgery but they concluded that general anaesthetic was generally safe [9]. Interventional radiology procedures such as ligation and embolization offer an alternative treatment options as the patient does not require a general anaesthetic and high success rates have been reported [10, 11]. These options inevitably involve radiation exposure and such procedures pose their own specific set of potential risks which can range from minor (e.g. facial pain, headache, groin haematoma) to more major ones such as facial scarring following ischemia, monocular blindness, facial nerve paralysis and cerebral infarction [12].

The case adds an additional consideration to current NICE guidance in the management of epistaxis, that is, to deliver the baby. Unfortunately, there is a scarcity of cases reporting severe epistaxis during pregnancy that ceased with the delivery of the baby. Invariably more research is needed to ascertain why in rare cases during pregnancy, measures aimed at local control of epistaxis fail.

Conclusion

This case highlights the complexities involved in managing a critically unwell surgical patient who is pregnant and it identifies the strengths in employing a multi-disciplinary team approach to achieve a positive outcome.

Author contributions

A.C. contributed to data collection, write up and subsequent revisions. R.S. contributed to data collection and assisted with the drafting of the original manuscript. A.O.K. assisted with the revisions.

Conflict of interest statement

No conflict of interest is declared.

Funding

None declared.

References