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Death Due to Air Embolism During Sexual Intercourse in the Puerperium

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Death Due to Air Embolism During Sexual Intercourse in the Puerperium 612 Dutta anaerobic, capnophilic, and Gram-negative. C some birds as a commensal. Infection by the canimorsus is a normal resident of the canine organism has been identified in cases of mouth. Their growth in blood culture is slow Ludwig's angina, epiglottitis, and tonsillitis fol- Postgrad Med J: first published as 10.1136/pgmj.74.876.612 on 1 October 1998. Downloaded from but they may be isolated by Gram staining of a lowing animal bites. Fulminant infection buffy coat preparation. The correct diagnosis caused septicaemia and peritonitis in a cir- of infection with this organism in case 1 was rhotic cock trainer,9 and empyema in another possible when the microbiologist was alerted. patient.'0 These organisms have occasionally Usually, infection is associated with asplenism,' been isolated from throats of healthy humans hairy cell leukaemia,3 liver cirrhosis,4 and other with frequent exposure to animals. Invasive immune suppressive states. This organism, pasteurellosis may cause meningitis, pneumo- designated a Dysgonic Fermenter 2 (DF2) by the US Centers of Disease Control, has caused nia, and otitis media, due to the spread of fulminant bacillaemia and sepsis in some organisms from pre-existing colonies in the asplenic patients.5 6 Cutaneous infection caus- upper respiratory tract. In the present report, ing eschar formation and gangrene associated case 2 was effectively treated with cefotaxime, with DF2 septicaemia has also been although a cheaper drug like penicillin could reported.5 Infection by this microbe in healthy have controlled the infection but for his subjects is occasionally encountered.8 The sensitivity. In animal bite wounds initial child in this report had no known risk factors. therapy with penicillin is preferable unless con- Pasteurella multocida is a small non-motile, traindicated, as it can control infection with Gram-negative, bipolar coccobacillus which several microbes including Pasteurella and Cap- often inhabits the oropharynx of cats, dogs and nocytophaga species. 1 World Health Organisation (WHO). Expert committee on of the organisms from the patient's dog. Ann Intern Med rabies. Technical report series 824. Geneva: WHO, 1992. 1980;93:457-8. 2 Dire DJ, Hogan DE, Riggs MW. A prospective evaluation of 7 Kalb R, Kaplan MH, Fenenbaum MJ, Joachim GR, Samu- risk factors for infection from dog bite wounds. Acad Emerg els S. Cutaneous infection at dog bite wounds associated Med 1994;1:258-66. with fulminant DF2 septicaemia. Am J Med 1985;78:687- 3 Nodon JA. Capnocytophaga canimorsus septicaemia caused 90. by a dog bite in a hairy cell leukemia patient. J Clin Micro- 8 Hastson P, Gautier PF, Vekemans MC, et al. Fatal capnocy- biol 1992;30:211-13. tophaga canimorsus septicaemia in a previously healthy 4 Roblot P, Bazillou M, Grollier G, Beeg-Giraudon B, woman. Ann Emerg Med 1991;20:93-4. Fanchere JL. Septicaemia due to Capnocytophaga canimor- 9 Patton F, Dumas M, Cannon NJ. Pasteurella multicida sep- sus after a dog bite in a cirrhotic patient. EurJ Clin Microbiol ticemia and peritonitis in cirrhotic cock trainer with a pet Infect Dis 1993;12:302-3. pig. N Engl _J Med 1980;303:1126-7. 5 Findling JW, Pohlmann GP, Rose HD. Fulminant gram 10 Nelson SC, Hammert GS. Pasteurell multicida empyema: negative bacillemia (DF 2) following a dog bite in an case report and review of literature. Am J7Med Sci 198 1;281: asplenic woman. Am J Med 1980;68:154-6. 43. 6 Martone WJ, Zuehe RW, Minson GE, Scheld WM. Post splenectomy sepsis with DF 2: report of a case with isolation Death due to air embolism during sexual http://pmj.bmj.com/ intercourse in the puerperium P A Batman, J Thomlinson, V C Moore, R Sykes on September 30, 2021 by guest. Protected copyright. spontaneous vaginal delivery of their third Department of Summary Histopathology, We describe the cases oftwo young women child, when she collapsed suddenly and died, Bradford Hospitals who died due to air embolism during passing blood per vagina. Autopsy showed fea- NHS Trust, Bradford, sexual intercourse early in the puerper- tures of air embolism. Air bubbles were present BD9 6RJ, UK ium. in major vessels of organs inspected in situ, P A Batman including cerebral and coronary arteries. Keywords: air embolism; sexual intercourse; puerperium Frothy blood was detected between the Department of Obstetrics and trabeculae in the wall ofthe right ventricle. The Gynaecology, The review of maternal deaths covering the endometrial cavity contained blood clot and Dewsbury & District period 1967-1993 includes over 20 million fresh haemorrhage, and histological examina- Hospital, Dewsbury, tion of the placental bed showed few throm- WF13 4HS, UK pregnancies; 18 deaths were due to air embolism.' We describe two such cases occur- bosed blood vessels. Most vessels in the J Thomlinson placental bed myometrium contained fresh V C Moore ring within a 2-year period in a West Yorkshire town with approximately 2400 deliveries a blood and some showed organising luminal West Yorkshire year at the local hospital. thrombus. Post-mortem blood showed an Analytical Services, amphetamine concentration of 175 ng/ml. Wakefield, WF1 2TN, Case 1 UK R Sykes A 22-year-old woman was engaged in sexual Case 2 intercourse with her husband in a rear entry A 29-year-old woman died suddenly during Accepted 10 March 1998 (knee-chest) position 8 days following the sexual intercourse with her husband in the Air embolism during sexual intercourse 613 missionary position 5 days following the spon- thrombose and the endometrium regenerates taneous vaginal delivery of their fourth child. following parturition is not clearly defined, but Autopsy confirmed death due to air embolism. involution of the placental site is normally Postgrad Med J: first published as 10.1136/pgmj.74.876.612 on 1 October 1998. Downloaded from Bubbles were identified in major vessels, and complete within about 3 weeks. Delay in the air was released from the right atrium on open- physiological obliteration of the large vessels ing it under water. The lower uterine cavity underlying the placental site is not uncommon, contained blood clot, and histology of the pla- however, typically presenting as haemorrhage cental bed showed organising thrombus with in the first few weeks of the puerperium. blood in most vessels. No vessels with throm- In the two cases presented here, thrombotic botic luminal occlusion were identified. occlusion of the placental bed vasculature was not complete. The patency of these dilated ves- Discussion sels and the pumping action of intercourse forc- ing air into the uterine cavity would predispose Maternal deaths due to air embolism reported to massive air embolism. Circulating ampheta- to the Department of Health enquiry1 were mine in the first case, in addition to prolonging associated with abortion in seven cases and sexual with labour in five. One death followed activity, may have acted as an additional drainage of a lower segment Caesarean wound factor in encouraging air embolism via involut- abscess. In three cases embolism occurred dur- ing placental bed vessels by its action on heart ing sexual intercourse at 19 and 31 weeks ges- rate, blood pressure, and uterine muscle tone.67 tation and in the early puerperium. One death Non-fatal air embolism during Caesarean followed oral sex during foreplay. section may be more common than appreci- Death during sexual intercourse is fortu- ated. Precordial Doppler studies detected nately uncommon, most cases being attribut- venous air embolism in 52% of Caesarean sec- able to arrhythmias complicating ischaemic tions in one study,8 a finding which has subse- heart disease and heightened sympathetic quently been confirmed.9 0 Predisposing fac- stimulation of the myocardium in middle-aged tors at operation include the gradient created men.2 Maternal deaths due to air embolism between the position of the right side of the during pregnancy or labour have been de- heart and the uterine incision in the Trendelen- scribed following sexual intercourse, induced burg position, and exteriorising the uterus dur- abortion,3 oral sex, manual extraction of the ing lower segment repair.1 12 placenta, version and forceps delivery.4 During Cases of fatal air embolism in the puerper- the puerperium, air embolism is associated ium are rare. Most couples restart intercourse particularly with sexual activities in the knee- 5 or 6 weeks after delivery,'3 and mothers fre- chest position.4 This position elevates the quently seek advice about resumption of uterus above the level of the right atrium to sexual activity.'4 There are moves to give more create a pressure gradient which may draw air general guidelines about resuming intercourse into patent veins, while intercourse forces air than to persist in setting a postpartum sexual under pressure into the uterine cavity. abstinence period of 6 weeks.'5 However, Uterine spiral arteries during early preg- we feel it would be wise to warn mothers, nancy are converted by invading trophoblast without causing undue alarm, that intercourse http://pmj.bmj.com/ into distended uteroplacental arteries.5 The could be dangerous in the early days of the sequence of events by which these arteries puerperium. 1 Department of Health. Reports on confidential enquiries into 10 VR, Husain et al. Incidence of Karuparthy Downing JW, FJ, on September 30, 2021 by guest. Protected copyright. maternal deaths in the United Kingdom. London: HMSO. venous air embolism during Caesarean section is unchanged 2 Derogatis LR, King KM. The coital coronary: a reassess- by the use of a 5-10 degree head up tilt. Anaesth Analg ment of the concept. Arch Sex Behav 1981;10:325-35. 1989;69:620-3. 3 Silver MD, Evans TN. Air embolism. A discussion ofmater- 11 Maroon nal mortality with a report of 1 survivor. Obstet Gynecol JC, Goodman JM, Horner TG, Campbell RL.
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