Very rare cause of vaginal mass in pregnancy:Cavernous hemangiomajog_1793 889..891

Fatih Celik, Dagistan Tolga Arioz, Gülengül N. Köken and Mehmet YilmazerDepartment of Obstetrics and Gynecology, Faculty of Medicine, Afyon Kocatepe University, Afyonkarahisar, Turkey

Abstract

Vaginal cavernous hemangioma is a considerably rare condition during pregnancy. There has only been onereported case to date. A multiparous, 24-year-old woman in the 32nd week of pregnancy was admitted witha mass prolapsed from the vagina, which had suddenly increased in size over the previous few days. A necroticmass obstructing the vaginal canal and originating from the posterior wall was observed in a pelvic physicalexamination and carefully excised. The patient had contractions after the intervention and was administeredtocolytic treatment with bed-rest and fluids. Her obstetric clinical status was stable after treatment and she gavebirth without complication at 37 weeks and 5 days from the vaginal canal. The main approach to these very raretumors of pregnancy, especially in the presence of necrosis, infection and/or obstruction, should be excision.But the potential for increased blood loss that may occur due to the hypervascular structure of the tumorshould be taken into account.Key words: cavernous hemangioma, pregnancy, vaginal mass.

Introduction

Cavernous hemangiomas are benign vascular tumors.Even though they are the most frequent benign tumorof the liver, they may occur in any site of body. They aremostly congenital and seen more frequently in pediat-ric age ranges, but may also occur later in life. Heman-giomas are generally harmless, but they may causesome complications. Rupture due to rapid growth andbleeding, as well as hematologic abnormalities pre-senting with thrombocytopenia, anemia and coagul-opathy are among the serious complications. Thesetumors are seen frequently in the liver,1 although caseswith tumors in the cervix,2 corpus uteri,3 fetus4 andvaginal epithelium5 have been reported. Only one caseof hemangioma of vaginal epithelial origin has beenreported. Histologically, these tumors without capsulescontain cavernous vascular structures and the connec-tive tissues they contain are divided by vascular canals.Thrombosis may develop in these vascular canals andthe mass may be obliterated.

Case Report

A multiparous, 24-year-old patient in the 32nd week ofpregnancy was admitted with a mass presenting in theprevious few days, which had grown and protrudedoutside the vagina. The necrotic appearing mass wasapproximately 4.5 cm in dimension, originating fromthe posterior vaginal wall, 1–2 cm over the level of thehymen, and protruding out from the introitus (Fig. 1).The mass obstructed the vaginal entrance but was notpainful. The possibility of a hematoma, tumor, rectocelewith fecal obstruction, pyogenic granuloma and benigncyst such as inclusion cyst or Gartner’s cyst were con-sidered in the differential diagnosis. No defects of therectovaginal septum were found in the rectal examina-tion. The patient was given regional anesthesia, with theintention of excising the mass. The mass was locatedsuperficially on the posterior vaginal wall mucosa. Sothat the mass could be clearly distinguished fromhealthy vaginal epithelium, the lateral border and depthof the mass was excised by establishing the edges at

Received: June 3 2011.Accepted: October 10 2011.Reprint request to: Dr Fatih Celik, SHCEK Kız Yurdu Lojmanlari Selcuklu Mah. No. 1 Merkez, 03200/Afyonkarahisar, Turkey.Email: drfatihcelik@yahoo.com

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doi:10.1111/j.1447-0756.2011.01793.x J. Obstet. Gynaecol. Res. Vol. 38, No. 5: 889–891, May 2012

© 2012 The Authors 889Journal of Obstetrics and Gynaecology Research © 2012 Japan Society of Obstetrics and Gynecology

least 0.5 cm from peripheral healthy tissue. In addition,the depth of the mass was assessed by rectal exam andrectovaginal tissue was observed as intact. As the benignnature of the mass was not certain, a deep dissection wasmade and the tumor was totally excised. Diathermy wasnot utilized due to its bearing a risk of damaging therectum with the heat effect during excision. Blood lossof approximately 400 mL occurred due to the hypervas-cular structure and easily fragmented nature of themass. Bleeding arteries on the lesion base were sutured.The defect left after excision was sewn continuouslywith 1-0 vicryl and the intervention was ended afterobtaining hemostasis. Pathologic examination results ofthe mass reported cavernous hemangioma, and tumortissues were not observed at the excision borders(Fig. 2). In the postoperative period, bed rest, hydrationand tocolysis with nifedipin were administered afteruterine contractions were detected in the patient. Treat-ment with i.v. iron were carried out as the hemoglobinlevel was detected at 7.5 g/dL on the first postoperativeday. On the second postoperative day, the patient wasdischarged after detecting no uterine contractions and aafter a reactive non-stress test. Bed rest was advised andnifedipin was prescribed (oral, 4 ¥ 1). The patient gavebirth by the vaginal route with right mediolateral epi-siotomy after a pregnancy of 37 weeks and 5 days,without complications and was discharged from thehospital on the first postpartum day. In the sixth post-partum week, the vaginal epithelium had completely

recovered. In addition, any residual hemangioma tissuewas not observed in the vaginal wall.

Discussion

As cavernous hemangiomas are considerably rare inpregnancy, they deserve to be the topic of a report. Theonly previous case reported in the literature was in1997 by Rezvani.5 Although that case had similar fea-tures, the hemangioma was infected in appearance.The present case had no history of vaginal trauma orcoital activity in the history, and surgical interventioninstead of conservative treatment was mandatorybecause of obstruction of the vaginal introitus and thenecrotic appearance of the mass. Additionally, becausethe mass demonstrated a significant protrusion fromthe vaginal wall, it was located in a visible area and itsborders were easily distinguishable, magnetic reso-nance imaging and ultrasonographic evaluation werenot deemed necessary. For this reason the mass wasexcised. The intraoperative blood loss was more thanexpected because of the natural hypervascular charac-teristic of the tumor.6

Blood loss during dissection of the mass from theposterior vaginal wall was more than expected becauseof caution against damage to the rectovaginal fascia andrectum. To lessen the bleeding, excision was accom-plished after placing clamps at the base of the mass.Further, although embolization would decrease bloodloss, this type of treatment was not implemented as thepatient requested a short treatment period and thuspreferred surgical treatment.

Figure 1 Vaginal mass with necrotic appearanceobstructing the vaginal introitus.

Figure 2 Multiple dilated and congested vascular struc-tures under a multi-layered flat epithelium.

F. Celik et al.

890 © 2012 The AuthorsJournal of Obstetrics and Gynaecology Research © 2012 Japan Society of Obstetrics and Gynecology

Kasabach and Merritt reported a syndrome pre-senting with thrombocytopenia, consumption coa-gulopathy and cavernous hemangioma in 1940.7

Kasabach–Merritt syndrome is an illness that should beconsidered in such cases, but there was no thrombocy-topenia or coagulation problem in the present case.

The preference for a conservative or surgicalapproach towards such hemangiomas during preg-nancy depends upon the localization, dimensions andpresence or absence of infected or necrotic appearance,and should be individualized according to its features.Surgical excision may be preferred in tumors causingvaginal canal obstruction, having a necrotic or infectedappearance and tumors with excessive growth due tointra-tumoral bleeding. In other cases, embolization isa preferable treatment as it causes less blood loss.8

Extra attention is warranted in pregnant patients atterm to decrease loss of blood due to the hypervascularnature of the mass. Also, the surgical borders should bebroad as the benign nature of the tumor is not clearlyknown. Another point that should be given attention isthe investigation of thrombocyte counts and the coagu-lation profile preoperatively in cases in which the massis suspected to be a hemangioma.

Disclosure

None declared.

References

1. Sharara FI, Khoury AN. Prenatal diagnosis of a giant cavern-ous hemangioma in association with nonimmune hydrops: Acase report. J Reprod Med 1994; 39: 547–549.

2. Jackson J. Natural history of a cervical cavernous hemangiomathrough two pregnancies. J Am Board Fam Pract 1993; 6: 283–287.

3. Weissman A, Tamon R, Jakobi P. Cavernous hemangioma ofthe uterus in a pregnant woman. Obstet Gynecol 1993; 81: 825–827.

4. Graham E, Cohen AW, Soulen M, Faye R. Symptomatic liverhemangioma with intra-tumor hemorrhage treated by angiog-raphy and embolization during pregnancy. Obstet Gynecol1993; 81: 813–816.

5. Rezvani FF. Vaginal cavernous hemangioma in pregnancy.Obstet Gynecol 1997; 89: 5-824–5-825.

6. Robbins SL, Cotran RS. Pathologic Basis of a Disease, 2nd edn.Philadelphia, PA: WB Saunders, 1979; 634–636. 1063, 1428–1429.

7. Kasabach HH, Merritt KK. Capillary hemangioma with exten-sive purpura: Report a case. Am J Dis Child 1940; 59: 1063–1070.

8. Giavroglou C, Economou H, Ioannidis I. Arterial embolizationof giant hepatic hemangiomas. Cardiovasc Intervent Radiol 2003;26: 92–96.

Cavernous hemangioma in the vagina

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