Iris Publishers_World Journal of Gynecology & Womens Health (WJGWH)

Death from Acute Hyponatremia Following Uneventful Abdominal Hysterectomy: Lessons from a Case Report

Abstract

A 38-year-old woman underwent a routine/uneventful abdominal hysterectomy for abnormal uterine bleeding (AUB) and uterine fibroids. Approximately 24 hours later, she developed severe hyponatremia (Na = 118 mEq/L), brain edema and coma, and she died 3 days later. The mechanism of hyponatremia was, likely, due to excessive and/or inappropriate fluid infusion of 2/3:1/3 solution. The inability to regulate her fluids and electrolytes (Na and K), was, likely, related to addback estrogen therapy given for 3 months preoperatively in conjunction with a GnRH agonist to optimize the patient’s hemoglobin and shrink the uterus/fibroids. It has been known that postmenopausal women and men can regulate excessive hyponatremic fluid absorption and electrolytes better than premenopausal women implicating an estrogen role. Estrogen has been found to inhibit the Na/K-ATPase pump in a variety of tissues/organs including the brain. This woman’s pathology of the endometrium was reported as proliferative indicating that enough estrogen may have been available to inhibit her Na/K-ATPase pump resulting in inability to regulate her fluids and electrolytes leading to her death.
Keywords: Hysterectomy; Hyponatremia; Death; GnRH agonist; Addback therapy

Introduction

Hysterectomy is the most frequently performed gynecologic procedure worldwide with a lifetime risk for hysterectomy in the US of 45% [1]. Uterine fibroids, abnormal uterine bleeding (AUB) and chronic pelvic pain with or without endometriosis are the three major indications for hysterectomy and together, they account for 55% - 85% of all hysterectomies [2].
However, in spite of its common practice and advancements in techniques and technologies, hysterectomy is still associated with considerable risks and complications resulting in significant morbidity (15%-30%) and mortality (0.03%-0.04%) [3]. In 2018, a population-based, retrospective cohort study of 93 059 adult women who underwent abdominal hysterectomy from April 1, 2003, to October 1, 2014, in Ontario, Canada, reported a 30-day mortality of 59 (0.06%) [4].
Although the cause of death was not specified in any of the above studies, the most frequent associated morbidities listed were wound complications, venous thromboembolism (VTE), urinary tract infection (UTI), sepsis and blood transfusion. Herein we present a unique case of uneventful abdominal hysterectomy for AUB and uterine fibroins who died from acute dilutional hyponatremia.

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