A 39-year-old woman comes to the office for evaluation of vaginal discharge. For the past few days, the patient has had pink-tinged vaginal discharge, requiring her to wear a menstrual pad. She has had associated pelvic cramping, which has improved with ibuprofen. A week ago, the patient underwent a uterine artery embolization for symptomatic uterine fibroids. Temperature is 36.7 C (98 F), blood pressure is 122/76 mm Hg, and pulse is 82/min. The abdomen is soft, nontender, and without rebound or guarding. There is diffuse pelvic discomfort to deep palpation. On pelvic examination, there is profuse, blood-tinged, watery vaginal discharge. Wet mount microscopy shows multiple leukocytes, but no clue cells, pseudohyphae, or trichomonads. Complete blood count results are as follows: Urine pregnancy testing is negative. Which of the following is the best next step in management of this patient?

Question

A 39-year-old woman comes to the office for evaluation of vaginal discharge.  For the past few days, the patient has had pink-tinged vaginal discharge, requiring her to wear a menstrual pad.  She has had associated pelvic cramping, which has improved with ibuprofen.  A week ago, the patient underwent a uterine artery embolization for symptomatic uterine fibroids.  Temperature is 36.7 C (98 F), blood pressure is 122/76 mm Hg, and pulse is 82/min.  The abdomen is soft, nontender, and without rebound or guarding.  There is diffuse pelvic discomfort to deep palpation.  On pelvic examination, there is profuse, blood-tinged, watery vaginal discharge.  Wet mount microscopy shows multiple leukocytes, but no clue cells, pseudohyphae, or trichomonads.  Complete blood count results are as follows:  Urine pregnancy testing is negative.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

This patient recently underwent uterine artery embolization, a treatment for symptomatic uterine fibroids (ie, leiomyoma) in patients who wish to avoid major surgery and/or preserve their uterus. The procedure involves injection of embolic material into the uterine arteries, which leads to selective embolization of the vessels that supply the symptomatic fibroids (due to their greater diameter and blood flow rate). The remaining myometrium, supplied by smaller vessels and collateral flow from the ovarian arteries, typically remains intact. This selective, abrupt decrease in fibroid perfusion leads to fibroid ischemia, infarction, and eventual necrosis. leiomyoma After the procedure, patients typically have pelvic pain due to fibroid necrosis and inflammation; the pain is usually worst in the first 24 hours and can be associated with fever, nausea, and malaise (ie, postembolization syndrome). Because these symptoms are related to inflammation, they are usually self-limiting. In the weeks to months following uterine artery embolization, patients may also develop watery, blood-tinged vaginal discharge (due to on-going tissue sloughing). Patients with excessive discharge may be evaluated for infection, including a complete blood count and wet mount microscopy; a wet mount microscopy positive for leukocytes is a normal finding and consistent with postprocedural inflammation. Therefore, this patient's vaginal discharge is benign, and she can receive expectant management. (Choices A, B, and C) In contrast to this patient, some (<1%) who undergo uterine artery embolization develop an infection. This complication likely occurs because tissue infarction and necrosis associated with the procedure can make the uterus a nidus for ascending bacterial infection. Infection onset is typically delayed (ie, weeks) due to the gradual accumulation of purulent fluid within the slowly necrosing fibroids. Patients typically have high fever, severe pelvic pain, purulent vaginal discharge, and leukocytosis. Patients with these symptoms require further evaluation (eg, CT scan of the abdomen and pelvis, blood and endometrial cultures) and are usually started on broad-spectrum antibiotics. (Choice D) Emergency hysterectomy may be indicated in patients with complete uterine necrosis after uterine artery embolization. This patient has an appropriate pain level, hemoglobin level, and leukocyte count; therefore, emergency hysterectomy is not indicated. Educational objective: Uterine artery embolization can be used to treat symptomatic uterine fibroids. The procedure causes fibroid infarction and necrosis, which can lead to pelvic pain and profuse, blood-tinged vaginal discharge. Patients with no signs of infection (eg, fever, purulent discharge, leukocytosis) receive expectant management. References: Uterine necrosis after uterine artery embolization for symptomatic fibroids. (http://www.ncbi.nlm.nih.gov/pubmed/29998027) Pyomyoma after uterine artery embolization: A case report. (http://www.ncbi.nlm.nih.gov/pubmed/32181148)

A 39-Year-Old Woman Comes to the Office for Evaluation of Vaginal