Shinshu M ed J, 64⑴ :35〜39, 2016

A Case of Vaginal Varices that Caused Massive Bleeding
after Vaginal Delivery
Norihiko KIKUCHI , Satoshi OHIRA , Ryoichi ASAKA
Akiko TAKATSU , Hisanori KOBARA , Hirofumi ANDO
Makoto KANAI , Tsutomu M IYAMOTO and Tanri SHIOZAWA
1) Department of Obstetrics and Gynecology, Shinshu University School of Medicine
2) Department of Family and Child Nursing, and Midwifery, Shinshu University School of Health Sciences

Vaginal varices are common during pregnancy and are rarely troublesome during the perinatal period.
However, we report a woman who presented with massive postpartum hemorrhage caused by the rupture ofprominent vaginal varices. A 35‑year‑old primigravida woman was found to have extensive vaginal varices
with a red color on the surface at 28 weeks of gestation.She delivered a healthy infant at term.Immediately
after the delivery, massive hemorrhage from the torn varices occurred. We ﬁrst tried surgical sutures, but
bleeding points could not be clearlyidentiﬁed because of the massive hemorrhage.We performed vaginal gauze
packing to reduce the bleeding.The estimated blood loss at delivery was 3,770 ml.Two days after the delivery
we removed the vaginal packing,but massive hemorrhage from the varices resumed immediately.The blood
loss was approximately 2,000 ml in a few minutes,and the vaginal packing was the only means to control thebleeding. Both seven and 21 days after the delivery, balloon occlusion of the bilateral common iliac arteries
was performed,but suﬃcient hemostasis was not achieved and vaginal packing was performed again.Because
vaginal hemorrhage slowly decreased during the packing,we started step‑wise removal of the vaginal packing
and performed complete removal on the 48th day of puerperium without notable hemorrhage.Although life‑
threatening postpartum hemorrhage caused by vaginal varices is very rare,the present case suggests the needfor an appropriate indication to avoid vaginal delivery. Shinshu Med J 64 : 35 ―39, 2016
(Received for publication September 24, 2015;accepted in revised form November 19, 2015)
Key words:vaginal varices, massive postpartum hemorrhage, vaginal packing

Introduction

such as those extending to the vaginal fornix
rupture and massive hemorrhage occurs, surgical

Varicose veins during pregnancy are common,

hemostasis is very diﬃcult. We report a case ofaﬀecting up to 15% of the population . In particu-varices associated with massive bleeding after vagi-lar, perineal and vaginal varices during pregnancy

nal delivery, for which vaginal packing was theare very common and usually do not lead to life‑

most eﬀective.

threatening obstetric hemorrhage. Therefore, vaginal varices generallyare not an indication for cesarean section. However, when large vaginal varices

Case Report
A 35‑year‑old primigravida woman with no complications visited our hospital at 11 weeks of gesta-Corresponding author:Tanri Shiozawa
Department of Obstetrics and Gynecology, Shinshu University School of Medicine, 3‑1‑1 Asahi, M atsumoto,tion for routine prenatal care. At 28 weeks ofgestation, vaginal examination revealed extensive

Nagano 390‑8621, Japanvaginal varices with a red color on the surface(Fig.

E‑mail:tanri＠shinshu‑u.ac.jp1).There was no complaint such as abnormal bleed-No. 1, 2016

35

Kikuchi.Ohira.Asaka et al.

Fig. 1

At 28 weeks of gestation, vaginal examination revealed extensive
vaginal varices with a red color on the surface (arrows).
A :vaginal introitus. B :inspection by vaginal speculum.

ing or pain until term. After the onset of labor,theBecause multiple bleeding sites could be roughly

progress of delivery was uneventful, and a 2,562‑g

identiﬁed this time, surgical suture was attempted.

male infant was delivered at 39 weeks of gestation.

However, a large amount of bleeding and the vul-

After the placenta was delivered, massive vaginal

nerable vaginal wall hampered observation andbleeding was noted. Because uterine contraction

suturing (Fig. 2).Therefore,gauze packing with thewas suﬃcient, the bleeding was considered to haveuse of tissue‑adhesive sheets containing ﬁbrinogenoriginated from the vaginal cavity. We thenwas performed again, and the bleeding markedly

identiﬁed multiple bleeding sites from the vaginalreduced. Although the patient temporarily devel-varices. We ﬁrst tried surgical sutures, but hemos-

oped disseminated intravascular coagulation due totasis was impossible because of the bloody, limited

the total blood loss of 3,200 ml, this was improved

operative ﬁeld and friable vaginal wall. During theby blood transfusion including fresh frozen plasma

massive vaginal bleeding, her blood pressure wasand platelet concentrate.

64/35 mmHg, and pulse was 168/min. Therefore,

At both seven and 21 days after the vaginalvaginal packing using approximately 30 pieces ofdelivery, the vaginal packing was removed. Before

gauze containing povidone iodine was performed,

the removal, interventional radiology, involving

and the bleeding was reduced.At this point in time,balloon occlusion of the bilateral common iliac

only conservative management was eﬀective.After

artery, was performed on both days. Just after thevaginal packing and blood transfusion, the blood

removal of the gauze,a moderate amount of bleed-pressure stabilized at 100‑120/60‑70 mmHg. Total

ing was observed. Surgical suture of the bleedingblood loss was 3,770 ml.The prophylactic antibiotic

points was possible up to the middle of the vaginalCefmetazole sodium was administered at a daily

cavity, but the suture of deeper sites near the vagi-

dose of 3 g.

nal fornix was impossible.Gauze packing was again

Two days after the vaginal delivery, the vaginal

performed and the bleeding stopped. This gauze

packing was removed since natural hemostasis wascontained terramycine ointment instead of povidone

expected. However, as soon as the packing was

iodine, because povidone iodine became dry andremoved, massive vaginal hemorrhage resumed.

adherent to the vaginal mucosa.

The estimated blood loss this time was as much as

As a result of these attempts,we considered that

2,000 ml within ﬁve minutes after the removal.

vaginal packing was the most eﬀective.The amount36

Shinshu M ed J Vol. 64M assive postpartum hemorrhage due to vaginal varices

Fig. 2A large amount ofvaginal bleeding and vulnerable vaginal wall hamper
observation and suturing.

of bleeding and number of pieces of gauze necessary

a case of successful vaginal birth with huge vulvar

for hemostasis were reduced on each subsequentand vaginal varicosities. They suggested that

hemostatic procedure. This was possibly due to a

women with vulvar varicosities could be allowed toreduced blood supply around the vagina in associa-attempt a vaginal birth regardless of their severitytion with involution of the uterus.

because varicose veins become compressed by theFrom thirty‑one days after the vaginal delivery,

fetal head from the inside and markedly diminish in

vaginal packing was gradually removed every day.

size during crowning and after delivery . Mean-

Seventeen days later,the vaginal packing had been

while, in an earlier reported case with extensive

removed completely and the patient was discharged

varices of the vulva and vagina ,an elective cesar-on the ﬁfty‑seventh postpartum day. At 18 months

ean section was performed for fear of their rupture

after childbirth, the vaginal wall was macros-during a vaginal delivery. In fact, we found no

copically normal without apparent varices.

report in the literature of massive postpartum hem-Discussion

orrhage due to the rupture of vaginal varices.
In the present case,surgical hemostasis,i.e.,band-

Perineal and/or vaginal varices during pregnancy

ing hemostasis of bleeding sites, was diﬃcult

are very common. The physical changes that havebecause marked, continuous bleeding impaired thebeen proposed as contributing to the development ofvisual ﬁeld.Bleeding points were multiple and locat-

varices during pregnancy include:1)venous disten-

ed at various sites in the vaginal wall, including

sion due to plasma volume expansion ;2)hormonal

near the vaginal fornix. In addition, most of thechanges; 3) increased intra‑abdominal pressure;vaginal wall was occupied by lacerated varices

and 4) compression of the inferior vena cava andafter vaginal delivery, and the mucosa was exces-

pelvic veins by the pregnant uterus . Vaginal var-

sively friable for suturing. Embolization of theices are usually not a cause of life‑threatening

common iliac artery was not eﬀective, because anpostpartum hemorrhage. Therefore, unless it is aactive bleeding point on an arteriogram could not bespecial case such as Klippel‑Trenaunay syndrome

detected and the main source of bleeding was a vein.

which is characterized by capillary and venous

In this case, we concluded that compression wasmalformations , they are generally not an indica-

the most eﬀective for hemostasis. Because the pel-tion for a cesarean section. Furuta et al. reported

vic veins and inferior vena cava were compressed

No. 1, 2016

37

Kikuchi.Ohira.Asaka et al.

by the enlarging pregnant uterus, vascular dilata-eﬀect in such a case with eﬀective vaginal pack-tion and increased venous pressure may have been

ing ;we therefore did not use it.

contributing factors in the development of vaginal

Evaluation of a hemorrhagic varicose vein isvarices. We considered that blood ﬂow around thediﬃcult.This case suggests that not only the size ofvagina would decrease with involution of the uterus.

varices but also the color may be important. Var-During the gauze tamponade,the risk of infection,icose veins of the vagina or perineum are usually

delayed wound healing due to decreased blood sup-blue‑purple in color, but they looked red in thisply, and the formation of a recto‑vaginal or vesicocase.In esophageal varices,the color of the surface‑vaginal ﬁstula were matters of concern.However,of varicose veins is indicative of bleeding ; a red

infection was not observed. Although the reason iscolor signiﬁes a state in which the small blood

unknown, the use of gauze containing povidone

vessels have been extended, suggesting the risk ofiodine or the antibiotic tetrramycine was eﬀective.

bleeding . M oreover, in the above‑mentioned case

Wound healing might have been delayed ;however,in which an elective cesarean section was perfor-

precise evaluation is diﬃcult because of the lack ofmed, the author stated that the vaginal varix

an appropriate comparison.Fortunately,ﬁstula for-assumed ʻa port‑wine colorʼ.We consider that themation did not occur, possibly because of suﬃcient

criterion of color in esophageal varices may be

blood supply even in the presence of compression.

applicable to vaginal varices.

We believe that the use of a tissue‑adhesive sheet

In conclusion, we encountered a patient withalleviated the hemostasis and promoted wound

ruptured extensive vaginal varices which caused

healing, but precise evaluation of the eﬀectivenessmassive postpartum hemorrhage. Gauze packing

was diﬃcult due to the lack of an appropiate con-

was the only eﬀective treatment. Vaginal delivery

trol.

should be avoided in the case of large vaginal

Recently, several reports have documented thevarices with a red‑colored surface.

use of recombinant activated factor VII (rFVIIa)in

Disclosure Statementcases of life‑threatening postpartum hemorrhage .
Because the bleeding source was mainly a vein inthis case,rFVIIa mayhave been eﬀective.However,The authors have no potential conﬂicts of interest
associated with this case report.

rFVIIa may induce a thrombus as a serious side
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