A Case of Strange Arterial Embolism After Uterine Curettage

Introduction

Hysteroscopy is important for patients with endometrial disease.¹ Uterine curettage is also helpful in the diagnosis of endometrial cancer, especially in the case of reproductive needs, early diagnosis and treatment are very important.^2,3 The safety and effectiveness of uterus curettage in clinical application have been verified. However, complications such as bleeding and thrombosis occurred in some patients after uterine curettage. Thrombus in the arterial system is rare in patients after uterus curettage, and thromboembolism in both organs is even rarer.

Case Presentation

This case involves a 50-year-old female with presenting symptom of increased menstrual volume for 9 months and irregular vaginal bleeding for 27 days. After 9 months of outpatient treatment with dydrogestrel and norethindrone, irregular vaginal bleeding continued. Transvaginal ultrasonography revealed a low echo area (about 27×16mm in size) in the left lateral wall of the uterus. Interwall myoma was considered. The endometrial line was centered and the endometrial thickness was about 9mm. Hysteroscopy was performed and endometrial polypoid hyperplasia was found in the right anterior wall and right posterior wall of the uterine cavity. The bleeding point was scattered in the local endometrium. The whole uterine cavity was scraped with a scraper, and the endometrium was thickened by unipolar electric incision. The histopathological diagnosis of excision was endometrial polyps and secreted endometrium (Figure 1). Four hours after curettage, upper abdominal pain and left lumbar distension occurred. Electrocardiogram indicated ST segment elevation of the lower wall lead, emergency coronary angiography indicated thromboembolism in the distal left posterior ventricular branch of the right coronary artery, and renal angiography indicated left renal artery branch thromboembolism. Heparin was administered with 100IU/kg anticoagulant therapy. Twenty minutes later, coronary angiography and renal angiography showed that the thrombus disappeared. Coronary and renal arteriography images are shown in Figure 1. ANA series, dsDNA, immunoglobulin and tumor index screening showed no abnormalities. Color ultrasound of lower extremity vein showed no thrombus. Rivaroxaban was subsequently given anticoagulation for 3 months and then discontinued. During 6 months of follow-up, the irregular vaginal bleeding and thromboembolism disappeared without any discomfort.

Figure 1 Multiposition coronary angiography revealed no stenosis of the left coronary artery. Histopathologic was performed to diagnose endometrial polyps and secretory endometrium. Coronary angiography indicated thromboembolism in the distal left posterior ventricular branch of the right coronary artery, and renal angiography indicated left renal artery branch thromboembolism. Repeat coronary angiography and renal angiography showed the disappearance of thrombus.

Discussion

The common complications of hysteroscopic local endometrial resection and curettage include uterine perforation, massive bleeding, injury of incomplete curettage, postoperative uterine adhesion and infection, occasional venous thrombosis and a small number of reported uterine arteriovenous malformations.

A recent report has shown that acquired uterine arteriovenous malformation following dilation and curettage.⁴ However, arterial embolism is rare. Both coronary artery and left renal artery embolism were present in this case. Baik et al had reported that venous thrombus may enter the left atrium through patent foramen ovale and cause arterial embolism.⁵ Transesophageal atrial color ultrasonography did not reveal the condition of patent foramen ovale in this case. Since the thrombe disappeared immediately after heparinization, we believe that the change of coagulation function after curettage resulted in blood hypercoagulation and thrombosis of distal coronary artery and small branch of renal artery. The change of coagulation function is its pathogenesis. The coagulation function of this patient may be easily affected by surgery, and thromboembolism in similar patients should be vigilant, not only venous thromboembolism, but also the arterial system may occur, which is a rare condition.

Arterial embolism after hysteroscopic local endometrial resection and curettage is rare. This case suggests that coagulation function should be monitored after curettage, and the use of heparin should be considered in patients with hypercoagulable state and high risk of thrombosis. Arterial embolization should be ruled out for postoperative discomfort.