Kulkarni A*, Parulekar SV**.
(* First Year Resident ** Professor and Head, Obstetrics and Gynaecology, Seth G S Medical College and K E M Hospital, Mumbai, India.)
Labial edema is not only a cause of severe discomfort to a woman, but also a cause for concern because it can be due to a number of serious conditions. When it occurs related to a pregnancy, it is usually in the antenatal period. There are very few cases of postpartum labial edema in literature. We present a curious case of a 19-year-old primipara who developed acute labial edema in the immediate postpartum period.
Edema is found in 8-10% gravidas. But it is found in the lower limbs, hands and face. Isolated edema of the vulva is uncommon. The vulva includes structures that are visible externally from the symphysis pubis to perineum, viz. the mons pubis, clitoris, labia majora and minora, hymen, vestibule, vestibular glands and paraurethral glands. Vulvar edema can be due to a number of conditions like infection, lymphatic obstruction, preeclampsia, diabetes mellitus, hypoproteinemia, anemia and tocolytic therapy.[1-4] It is important to determine the cause of labial edema, so that appropriate treatment can be given.
A 19-year-old primigravida presented to the obstetric emergency room in labor at term. She was our registered patient and had been attending the antenatal clinic as per schedule. Her antenatal period had been uneventful. She had taken all medications and vaccines as prescribed. Her vital parameters were in normal limits. Her general and systemic examination revealed no abnormality. The uterus was full term size. There was a single fetus in vertex presentation, with normal heart rate. Local examination of the vulva and speculum examination of the vagina revealed no abnormality. Her hemogram, plasma sugar levels, renal, liver and thyroid function tests, and serological tests for syphilis, HIV, hepatitis B and C were normal. Her medical and surgical history was not contributory. She progressed in labor spontaneously and delivered uneventfully vaginally a female child weighing 2.4 kg. A left mediolateral episiotomy was taken under local anesthesia for assisting childbirth. It was sutured in layers under all aseptic precautions with polyglactin No. 0. Her fourth stage of labor was normal and the episiotomy was healthy. She was transferred to the postnatal ward.
The patient complained of some pain at the episiotomy site 6 hours after delivery. She was afebrile and her pulse rate, respiratory rate and blood pressure were in normal limits. On local inspection there was an edematous swelling of both labia minora, more on the left side. It was not tender and its temperature was not raised. There was no erythema or pus locally. No vesicles or ulcers were seen. No lymphadenopathy was present. Per vaginal examination showed no evidence of infection and no other abnormality. The episiotomy was healthy. Her hemogram, random plasma sugar, liver and renal function tests were repeated and the results were normal.
She was given oral amoxicillin plus clavulanate, warm sitz baths and magnesium sulfate dressing twice a day. The edema subsided over the next 7 days. No other active management was done since the edema was subsiding. She no longer complained of pain. On day 7 the edema had completely resolved. The episiotomy healed well. She was reassured, explained about perineal hygiene, advised local application of antibiotic ointment and was discharged. At the follow-up examination after 15 days, no abnormality was found on her general and systemic examination as well local examination of the genital tract.
There is loose connective tissue in the labia minora, in which edema fluid can collect. That explains involvement of labia minora more than other vulvar structures in development of edema. However labial edema does not develop as often as can be expected. When a preeclamptic woman or a nonpregnant woman with a systemic disease presents with generalized edema, the labia minora are not involved as a rule. Acute appearance of labial edema in pregnancy can be seen in severe preeclampsia with renal failure.[5-7] Our patient was normotensive during antenatal period, labor and puerperium. This it was not due o preeclampsia. Edematous and dry vagina and edematous vulva can be found in prolonged labor with obstruction. Our patient had normal progress of labor and timely delivery.
When edema develops in response to inflammation, it is at the site of inflammation. There are local signs of inflammation, like erythema, warmth and tenderness. These features were absent in our case. There was no lymphatic obstruction, because no other vulvar structure was involved and the edema resolved after 7 days, which would not occur with lymphatic obstruction. She had no systemic disease like renal failure, anemia or hypoproteinemia. A local allergic reaction was a possibility, such as use of povidone-iodine scrub and solution for skin preparation, lignocaine for local anesthesia and polylactin for suturing the episiotomy. It could not have been povidone iodine, as no other adjacent skin covered area was involved. It was found in the right labium minus too, the side opposite to that of the episiotomy. Furthermore the local anesthetic had not been given into the labia and polyglactin suture did not pass through the labia too. These facts combined with an absence of erythema or vesicles ruled out allergic dermatitis.
The only etiological possibility in this case was local abrasion/contusion of the delicate labia minora and compression of their lymphatics by the fetal head during childbirth. Resultant tissue swelling would have blocked the lymphatics temporarily and caused edema of the labia minora. It would have probably resolved with conservative local treatment alone, in the form of warm sitz baths and magnesium sulfate compresses. We administered antibiotic as an additional safety measure and also for preventing infection of the episiotomy.
Labial edema is generally not treated by surgical decompression, though there are some reports of the same.[8,9] The edema in our case was not severe enough to warrant such a treatment, and it resolved successfully with conservative treatment. We have presented this case only to make clinicians aware that acute labial swelling can occur postpartum without any obvious cause and it resolves well.
We thank Dr Sarika Solanke for taking clinical photograph.
- Owa OO, Aderoba AA, Akintan AL. Spontaneous massive vulva swelling in pregnancy: a case report. Tropical Journal of Obstetrics and Gynaecology 2015;32:157–160.
- Brittain C, Carlson JW, Gehlbach DL, Robertson AW. A case report of massive vulvar edema during tocolysis for preterm labor. Am J Obstet Gynecol 1991;165:420–422.
- Trice L, Bennert H, Stubblefield PG. Massive vulvar edema complicating tocolysis in a patient with twins. A case report. J Reprod Med 1996;41:121–124.
- Mizock G, Siegel I. Acute edema of the vulva in pregnancy. Am J American Journal of Obstet Gynecol 1963;86:483-484.
- Gerdhzhikov B, Kozovski G. Massive vulvar edema in severe preeclampsia. Akush Ginecol. 2005;44:44.
- Daponte A, Skentou H, Dimopoulos KD, Kallitsaris A, Messinis IE. Massive vulvar edema in a patient with preeclampsia. J Reprod Med. 2007;52:1067–1069.
- Moulin B, Hertig A, Rondeau E. Kidney and preeclampsia. Ann Fr Anesth Reamin. 2010;29:83–90.
- Bracero LA, Didomenico A. Massive vulvar edema complicating preeclampsia: a management dilemma. J Perinatol 1991;11:122–125.
- Deren O, Bildirici I, Al A. Massive vulvar edema complicating a diabetic pregnancy. European Journal of Obstetrics Gynecology and Reproductive Biology 2000;93:209–211.
Kulkarni A, Parulekar SV. Postpartum Acute Labial Edema. JPGO 2019. Vol 6 No. 6. Available from: https://www.jpgo.org/2019/06/postpartum-acute-labial-edema.html