{"paper_id":"d289301e-3b00-4d20-8560-c40b4a4528dd","body_text":"Page 1 of  2\nA Special Case Report of Aggressive Hemorrhage in \nPosterior Vaginal Fornix DIE\nJunling Liu, Dan Tang, Ruxia Shi, Yunfen Jiang, Zhongfang Zhang and Jiming Chen*\nDepartment of Obstetrics and Gynecology, the Affiliated Changzhou NO. 2 People’s Hospital of Nanjing Medical University, Changzhou 213000, China\nIntroduction\nDeep infiltrating endometriosis (DIE) is defined by the presence \nof endometrial implants, fibrosis, and muscular hyperplasia below \nthe peritoneum, invading the tissue to a depth of more than 5 mm \n[1]. Deep endometriosis involves, in descending order of frequency, \nthe uterosacral ligaments (USL), the rectosigmoid colon, the vagina, \nand the bladder [2]. Pain and infertility are the main manifestations \nof DIE, including dysmenorrhea pain, chronic pelvic pain, \ndyspareunia, defecation pain, dysuria and back pain. DIE lesions \nare deep infiltration, severe pain symptoms, poor conservative \ntreatment, difficult surgery, pelvic adhesions, and high risk of \nsurgical accessory injury. It has been a difficult point in clinical \ntreatment of endometriosis and gynecological laparoscopic surgery, \nthere is no unified clinical type and treatment specifications [3-4]. \nThis paper reported a special case of recurrent vaginal hemorrhage \ncaused by posterior vaginal fornix DIE.\nCase Report\nFemale, 31-year-old, married, 1-0-1-1, hospitalized for “vaginal \nbleeding for 3 hours” . Regular menstruation, 7/30d, moderate \nmenstruation, no dysmenorrhea, normal leucorrhea, LMP:2017-10-\n1. At 9:00am on December 2, 2017, without obvious inducement, \nthere was massive vaginal hemorrhage, accompanied by blood \nclots. B ultrasound examination was done in Affiliated Changzhou \nNo.2 People’s Hospital of Nanjing Medical University finding \ninhomogeneous posterior cervical masses. It may be trophoblastic \ndisease. Cervical pregnancy remains to be checked. Gynecological \nexamination: vulva, married type; vagina: unimpeded, no excreta; \nuterine neck: smooth, no lift pain, a rupture, about 0.2cm in diameter, \nwas seen in the posterior cervical fornix, active hemorrhage; uterus: \nmeso-position, full, regular, no pressing pain; adnexa: there was no \nobvious abnormality in bilateral appendix area.\nThe patient was admitted to hospital for “cervical occupancy: \ncervical pregnancy?” We firstly used cotton ball to stop bleeding,  \n \nand then took anti-infective therapy and auxiliary examinations. \nA biopsy of the posterior vaginal fornix rupture showed chronic \ninflammation with hemorrhage. Blood HCG: 2.39mIU/ml, excluding \nthe possibility of cervical pregnancy. Cervical TCT showed atypical \nsquamous cells that could not be defined. Cervical HPV showed \nthat the HPV12 was positive and the others were negative, and the \npossibility of cervical cancer could not be excluded. Further cervical \nbiopsy is needed. \n The possibility of cervical tuberculosis was excluded \naccording to no previous tuberculosis history, physical signs, and \nauxiliary examinations after admission. After admission, uterine \narteriography was done thereby eliminating the possibility \nof vascular malformation. The patient finally underwent the \nlaparoscopic surgery including posterior vaginal fornix lesion \nresection, pelvic adhesion separation, intestinal adhesion \nseparation, cervical biopsy, and cervical tracheal scratch on \nDecember 14, 2017. The surgery was successful. Intraoperative \nrapid pathology indicated that there was chronic active \ninflammation with no malignant lesions in (cervical) mucosa. \nPostoperative routine pathology showed (cervical) mucosa chronic \nactive inflammation and amount of broken tissues: endometriosis. \nPathological findings of cervical biopsy: (3, 6, 9, 12 points) chronic \nactive inflammation, focal condyloma of squamous epithelium. \n(Cervical canal scratches) A small amount of broken cervical tissues \nand mucus showed chronic inflammation. It was finally diagnosed \nas deep endometriosis of posterior vaginal fornix.\nDiscussion\nEndometriosis is a condition in which the tissue of the \nendometrium (gland and stroma) appears outside the uterus. The \nectopic endometrium can invade any part of the whole body, but the \nvast majority is located in pelvic viscera and wall peritoneum, the \novary and uterosacral ligaments are the most common, followed \n*Corresponding author: Jiming Chen, Department of Obstetrics and Gynecology, \nthe Affiliated Changzhou No. 2 People’s Hospital of Nanjing Medical University, \nChangzhou 213000, Jiangsu Province, China.\nReceived Date: November 13, 2018\nPublished Date: November 27, 2018\nISSN: 2641-6247                                                                                                                           DOI: 10.33552/WJGWH.2018.01.000514\nWorld Journal of \nGynecology & Women’s Health\nCase Report Copyright © All rights are reserved by Jiming Chen\nThis work is licensed under Creative Commons Attribution 4.0 License  WJGWH.MS.ID.000514.\n\n\nWorld Journal of Gynecology & Women’s Health                                                                                                             Volume 1-Issue 3\nCitation: Junling Liu, Dan Tang, Ruxia Shi, Yunfen Jiang, Zhongfang Zhang and Jiming Chen. A Special Case Report of Aggressive Hemorrhage \nin Posterior Vaginal Fornix DIE. W J Gynecol Women’s Health. 1(3): 2018. WJGWH.MS.ID.000514. DOI: 10.33552/WJGWH.2018.01.000514.\nPage 2 of  2\nby uterus, visceral peritoneum, rectovaginal diaphragm, so it is \ncalled pelvic endometriosis [5]. Endometriosis shows a benign \nmorphological appearance, but it is similar to malignant tumor \nin clinical behaviors, such as implantation, invasion and distant \nmetastasis. Clinical manifestations mainly include lower abdominal \npain and dysmenorrhea, infertility, sexual discomfort and menstrual \nabnormality. When any part outside the pelvic cavity is implanted \nwith ectopic endometrial, periodic pain, hemorrhage and mass \ncan occur locally, and corresponding symptoms appear. DIE is a \ngroup of endometriosis lesions infiltrating below the peritoneum \nwith a depth of 5mm or more [1], which can be located anywhere \nin the pelvic cavity. Common DIE lesions include pelvic posterior \nendometriosis, cystopathia and ureteral endometriosis [6]. This \nkind of deep endometriosis with the main clinical manifestation of \nposterior cervical fornix rupture hemorrhage is also a rare case in \nclinical practice, which requires us to consider comprehensively. \nAfter the differential diagnosis of diseases with similar symptoms, \nthe possibility of DIE should be considered to avoid misdiagnosis \nand missed diagnosis.\nAcknowledgement\nNone.\nConflict of Interest\nNo Conflict of Interest.\nReferences\n1. Bazot M, Lafont C, Rouzier R, Roseau G, Thomassin-Naggara I, et al. \n(2009) Diagnostic accuracy of physical examination, transvaginal \nsonography, rectal endoscopic sonography, and magnetic resonance \nimaging to diagnose deep infiltrating endometriosis. Fertil Steril 92(6): \n1825-1833.\n2. Dai Y, Leng JH, Lang JH, Li XY, Zhang JJ (2012) Anatomical distribution \nof pelvic deep infiltrating endometriosis and its relationship with pain \nsymptoms. Chin Med 125(2): 209-213.\n3. Berkley KJ, Rapkin AJ, Papka RE (2005) The pains of endometriosis. \nScience 308(5728): 1587-1589.\n4. Valle RF, Sciarra JJ (2003) Endometriosis: treatment strategies. Ann N Y \nAcad Sci 997: 229-239.\n5. Dai Y, Leng JH, Lang JH, Liu ZF, Li XY, et al. (2010) Clinico-pathologic \ncharacteristics of posterior deeply infiltrating endometriosis lesions, \npain symptoms and its treatment using laparoscopic surgery. Zhonghua \nFu Chan Ke Za Zhi 45(2): 93-98.\n6.  Zhang J, Leng J, Dai Y, Lang J (2014) Significance of symptom and \nphysical sign to diagnosis of deeply infiltrating endometriosis. Zhonghua \nFu Chan Ke Za Zhi 49(8): 599-603.","source_license":"CC0","license_restricted":false}