Epistaxis in Pregnancy-A Rare Case Report

Introduction

Pyogenic granuloma (also known as a “eruptive hemangioma”, “granulation tissue-type hemangioma”, “granuloma gravidarum”, “lobular capillary hemangioma”, “pregnancy tumor”, and “tumor of pregnancy” [1, 2] is a vascular lesion that occurs on both mucosa and skin, and appears as an overgrowth of tissue due irritation, physical trauma, hormonal factors [3, 4]. Lobular capillary hemangioma is microscopic proliferation of capillaries with lobular structure. Oral mucosa is the most common site. It is rapidly growing benign lesion. It was first described as human botryomycosis by Poncet and Dor in 1897. Causes of epistaxis: hereditary telangiectasia, trauma, neoplastic like juvenile nasoangiofibroma, capillary and cavernous hemangioma, hormonal like endometriosis, vicarious menstruation, systemic causes like hypertension (most common).

A 22 year old female patient came to our opd with 7 months of amenorrhoea with compalints of nasal bleeding and nasal obstruction since 2 months. There was no history of trauma or any recent infection. On anterior rhinoscopy, there was a mass in left nasal cavity which was smaller initially then rapidly increased in size to fill the left nasal cavity completely causing obstruction of left nasal cavity. It used to bleed on touch or otherwise also. On diagnostic nasal endoscopy, revealed a reddish hemorrhagic polypoid mass in left nasal cavity arising from nasal septum from postero-superior part. Patient was otherwise healthy. Her blood parameters were within normal limits. Bleeding was so profuse that we had to excise this nasal mass by endoscopic approach transnasally and excised mass sent for histopathology. Lesion composed of proliferation of small capillaries sized vessels lined by endothelium along with anastomizing channels. Areas of hemorrhagic and necrosis are seen.

Discussion

Pyogenic granuloma is acquired vascular tumour of benign etiology. It can occur at any age. It is more common in females than males of 20-30 years of age (3-5 times). In pregnant females it is more common in second and third trimester. It is presented as unilateral epitaxis, nasal obstruction with or without facial pain, headache. Our patient has similar complaints (left nasal obstruction, epistaxis). But these symptoms are not specific for pyogenic granuloma. Any mass in nasal cavity may present with similar complaints. Differential diagnosis are nasal polyp, menigocoele, sarcoidosis, hemangiosarcoma, wegener’s granulomatosis [5]. As pyogenic granuloma in pregnancy is due to hormonal changes, we can wait and watch till it regress es by itself after delivery. But if bleeding is so profuse then it might require intervention such as electrodessication (cauterisation) or excision by endoscopic approach. In our patient, we waited till 1 month; but symptoms were not relieved with conservative line of management ultimately we had to excise her nasal mass endoscopically and sent it for histopathological examination Prognosis is excellent; It may recur in 16% of the patients. There are least chances of its malignanr transformation.

Conclusion

Removal of pyogenic granuloma is indicated to treat any bleeding, discomfort, cosmetic distress, and diagnostic uncertainty. A number of malignant tumors may clinically mimic pyogenic granuloma, making histopathologic confirmation important if the presentation is atypical.