Spontaneous massive vulvar edema is not usual during pregnancy, but its presence possesses management challenges with significant PT anxiety and discomfort (1,2).
The cause of massive vulvar edema has been described associated with multiparty, diabetes, hypoproteinemia, preeclampsia, tocolytic therapy, volvovagintis and severe anemia (1-5).
In one study, vulvar edema was seen in seropositive syphilis in pregnancy in a Mozambican woman (6).
Vulvar edema was also reported after infection, neoplasms, and congenital lymphatic anomalies, truma, inflammatory and metabolic disorders (1,5).
In this case report we described a cause of spontaneous massive vulvar edema after treatment of Bronchitis and influenza at 17 weeks of gestation.
A 22 years old woman was admitted with complaint of prolonged influenza and Bronchitis. Her prenatal care was done completed in gynocology clinic and her lab data such as Hemoglobin, syphilis, Bacteriuria, glucose uria and protein uria was NL. She didn’t have HTN. She had positive hx of convulsion since 4 years old and used Depakin and lamotrigin daily. She had no positive history of allergy. When she was admitted she had respiratory symptoms and she was stable and had well general condition. But she was febrile (T: 38 oral).
Blood pressure was detected 110/70 and pulse rate was 92/min. The height of fundus was about the umbilical level. On pelvic examination no vulvar or vaginal edema was seen. Influenza and Bronchitis was diagnosed for her and oseltamivir 75 mg/ per daily was started for 5 days. After 5 days of admission and AB therapy she got better and discharged without respiratory symptoms, fever and without sign of edema. At the same day, in the evening she developed edema that rapidly progressed in 4 hours (Figure 1). So, she returned to hospital and was admitted. She didn’t have urinary problem but she had pain and on pelvic examination severe vulvar edema was detected. However, no tenderness, warmness or redness was seen in the vulve.
Albumin level was NL (Alb=4). Her WBC was NL (9000) without shift to left. Other lab data was NL. The fluid of vulvar edema was sent for culture which was NL.
Cefazolin was started with a dose of 1 g QID which she received for 2 days, but it was not effective and Dexamothazone 8 mg daily was started for her. The vulvar edema decreased gradually in 3 days after prescribing Dexamthazone and the patient was discharged form hospital at day 6 from hospital.
Figure 1. The vulvar edema in day 1.
Figure 2. The vulvar edema in day 5.
Figure 3. The vulvar edema after 2 weeks
In this care report we described a case of massive vulvar edema after influenza and receiving oseltamivir. Vulvar edema is an unusual situation during pregnancy that generally can occure with multiparity, preeclamsia, hypothermia, diabetes, Tocoloytic therapy and volvovaginitis and severe anemia and also seropositive syphilis in pregnancy (1-6). In this case, it is still a hypothesis that edema might have occurred after using oseltamivir.
Oseltamivir is a prescription medical for influenza treatment in adult and children. It can have different side effects and the usual ones include nausea and vomiting that both occurred within 2 days of treatment; but it can also have other side effects such as pain, headache, nose bleeding, fatigue, allergic skin rash, hives and blister, itching, difficulty breathing and swelling of tongue and face (7).
In one case report after using oseltamivir a 29-year-old woman presented with tongue and lip swelling and angioedema (7,8).
Allergic reactions were seen after using oseltamivir such as skin reaction, angioedema and Steven-Johnson syndrome (7-9); but it needs further evaluation and studies to confirm if it can cause also vulvar edema.
In this case report other causes of vulvar edema was excluded.
This is not a definite way of management of vulvar edema since it is rare and there are few case reports about it (2,1).
In some cases, mechanical drainage and puncturing was preferred (10) while another patient was treated by conservative management (11).
It is so important to find the underlying cause of vulvar edema and treat it effectively (3).
In some studies, the vulvar edema was treated spontaneously after delivery (1). In this case the patient was cured with corticosteroid. In our point of view, due to difficulties in urination and routine physical activities which are disturbed by the vulvar edema, a straightforward management is mandatory, even if the main cause is not found during the first evaluation.
Vulvar edema is a critical situation during pregnancy that needs attention and should be treated carefully since it can cause pain and discomfort for the pregnant woman. Our experience in this case was treatment by corticosteroid that had good response.
The authors would like to thank all those who helped them writing this paper.
Conflicts of Interest
Authors declared no conflict of interests.