Torrential epistaxis in the third trimester: a management conundrum

Abstract

SUMMARYAlthough epistaxis is common during pregnancy, large volume epistaxis is rare. Many standard epistaxis management options are limited in pregnancy due to absolute or relative contraindications. Ear, nose and throat surgeons need to be aware of what options can be used safely and effectively. We present a case of a 32-year-old woman, 32 weeks pregnant, who was admitted with heavy epistaxis refractive to conservative management. Several potential interventions including bismuth iodoform paraffin paste (BIPP) and Floseal were contraindicated or involved additional risk in pregnancy necessitating unorthodox management. This challenging case highlights suitable alternatives for managing large volume epistaxis during pregnancy, as well as discussing the differential diagnosis and relevant investigations. BACKGROUND

Management of Severe Epistaxis during Pregnancy: A Case Report and Review of the Literature

“…Few cases of severe epistaxis during pregnancy were described in literature [2–8, 12] (Table 1). We excluded cases of epistaxis associated with nasal lesions, like granuloma gravidarum [9] and nasal polyp [13], or clotting disorders [14].…”

The way a nose could affect pregnancy: severe and recurrent epistaxis

“…Estrogens could also have indirect effects on vascular wall by regulating NO signaling pathway (i.e. VEGF, VEGFR-2) [8]. Meanwhile progesterone provokes an increase of blood volume, which could cause an augmentation of vascular changes with severe epistaxis, in the absence of coagulative disorders or organic nasal abnormalities (polyps).…”

“…Last but not least immunological changes could lead to nasal hypersensitivity [11]. When severe epistaxis occurs in pregnancy a multidisciplinary approach is recommended, by obstetricians, ENT specialists [8]. The management could be conservative or surgical.…”

“…However, when it occurs in the third trimester it could become life-threatening and a severe deal for obstetricians. Operative ENT (ear, nose, throat) management is generally requested, even if there is limited evidence regarding the correct approach of severe epistaxis in pregnancy, complicated by the evidence that certain products are contraindicated (bismuth iodophorm paraffine gauzes, soaked ribbon gauzes) (Table 2) [8]. When termination of epistaxis is achieved, the further management depends on gestational age.…”

Severe epistaxis in pregnancy due to nasal pyogenic granuloma: A case report

“…Maternal safety needs to be prioritized with conservative measures being the first-line treatment(s). 10 As described by Crunkhorn et al., chemical cautery with silver nitrate is safe in mild cases, as is anterior and posterior nasal packing(s); however, the use of bismuth iodoform paraffin paste-soaked ribbon gauze for nasal packing is contraindicated. If epistaxis is severe and conservative management fails, surgical intervention, such as vessel ligation, is feasible with consideration of the risks of general anaesthesia in pregnancy.…”