Acute rectal ischemia following failed uterine artery embolization and emergency hysterectomy for postpartum hemorrhage

Acute rectal ischemia is rare. The rectum is often spared in cases of ischemic colitis owing to its abundant collateral blood supply [1]. Uterine artery embolization is an effective second-line therapy used to control massive postpartum hemorrhage when medical treatment has failed to stop the bleeding [2,3]. However, the transitory subischemic conditions induced by embolotherapywhen a patient is in hemorrhagic shock may disturb the pelvic arterial blood flow. The present case describes an acute full-thickness ischemic proctitis following failed uterine artery embolization and subsequent emergency hysterectomy for postpartum hemorrhage. A 34-year-old patient (G3,P2) was admitted in November 2013 in spontaneous labor at 41 weeks of pregnancy and delivered vaginally four hours later. The patient had no significant personal or family history of disease. Immediately after delivery the patient suffered uterine atony and a postpartum hemorrhage of greater than 500 mL of blood,which necessitated promptmedicalmanagement (active resuscitation, manual exploration of the uterine cavity, and administration of the uterotonic drugs oxytocin and sulprostone), which was unsuccessful at controlling the bleeding. The uterine arteries were selectively catheterized and bilateral uterine artery embolization was performed— two hours after the hemorrhage had begun—using a semi-gelatin sponge on each side (Gelita-Spon, Gelita Medical GmbH, Eberbach, Germany), but without success. Uterine bleeding remained uncontrollable and the patient’s vital signs were unstable; therefore, total hysterectomy with blood transfusion was performed. Postoperative recovery was uneventful. Nine days after surgery the patient experienced diarrhea and pelvic pain. MRI showed full-thickness rectal necrosis associated with a voluminous left ischiorectal abscess and a transsphincteric fistula between the abscess and the rectum (Fig. 1). Endoscopic examination of the anal canal and lower rectum under general anesthesia confirmed acute ischemic proctitis extending 15 cm proximally from the dentate line, and a left ischiorectal abscess that was treated by excision and drainage. Laparoscopic sigmoid colostomy was performed to maintain a clean environment for healing. Testing for Clostridiumdifficile colitis was negative. A repeat lower endoscopy at day 24 after delivery showed a low transsphincteric rectovaginal fistula, which was drained using a loose seton stitch. Postoperative recovery was uneventful, and the patient was discharged 30 days after delivery. Six months later, healthy rectal tissue was present; however, the anal sphincter remained inefficient. Acute ischemic colitis commonly occurs in the splenic, descending, and sigmoid colon. The rectum is involved in less than 2% of all cases [1]. Ischemic proctitis is most commonly described in 70year-old men (75%) and secondary to radiotherapy, severe aortoiliac occlusive disease, tumor encasement of the rectum, or prior vascular surgery with interruption of the collateral blood supply [1,4]. In the present case, the transitory subischemic conditions in the pelvic area induced by embolotherapy in a patient with hypotension and in hemorrhagic shock may explain the occurrence of acute ischemic proctitis. Diagnosis of acute ischemic proctitis may be indicated by pelvic pain associated with diarrhea and lax or absent anal sphincter tone in a patient with a major illness or hemodynamic disturbance [1,4]. It requires pelvic imaging (computerized tomography, color flow Doppler imaging, angiography, or MRI) and a definitive diagnosis is obtained by proctosigmoidoscopy [1]. Adequate management of acute ischemic proctitis is controversial, depends on the clinical status of the patient, and on the assessment of the degree of ischemia at proctosigmoidoscopy. Conservative management with antibiotics is appropriate for uncomplicated acute ischemic proctitis. Patients with more severe degrees of rectal ischemia may develop bowel perforation necessitating a proctectomy or colonic diversion [1,4]. Acute ischemic proctitis is an exceptional complication of transitory subischemic conditions in the pelvic area following failed uterine artery embolization for postpartum hemorrhage. Hypotension and hemorrhagic shock should be controlled in patients with massive postpartum hemorrhage to prevent low pelvic arterial flow.