Case notes

A 29-year-old woman, para 0010, sustained a second-degree perineal laceration during a spontaneous vaginal delivery that was repaired. However, during the immediate postpartum period, the patient had extensive vulvar edema, a spinal headache that required a blood patch and prolonged bed rest, and a sensation of vaginal tightness.

Despite these sequelae, she was breastfeeding successfully. She had a history of irritable bowel syndrome and anxiety; in particular, she expressed concern throughout the pregnancy at her ability to deliver a healthy child vaginally. She was also anxious about her ability be a successful mother, but she denied any previous psychiatric treatment.

At the 6-week visit, a 1-cm area of labial conglutination was clearly visible ( Figure ). The patient admitted to obsessive cleaning of the perineum with various antiseptics, local anesthetic gel, frequent sitz baths, and an excessive use of soap. She was offered a trial of local estrogen cream but preferred to try coconut oil. At another visit 3 weeks later, complete epithelization of the area was evident.

Obvious labial conglutination at the first postpartum visit

Baxi. Closure: an unusual postpartum problem. Am J Obstet Gynecol 2011 .

Conclusions

Labial adhesions are seen commonly in children and postmenopausal women, caused by hypoestrogenism. Postpartum labial adhesions in the absence of female circumcision rarely are described in the literature, with approximately 10 reported cases. It has been hypothesized that, as with patients at other stages in life, hypoestrogenism contributes to the development of postpartum labial adhesions; in breastfeeding women, it is caused by high prolactin levels. Inflammatory processes also may be involved. To date, all documented cases have required definitive surgical repair. Failed trials of topical estrogen, which have been reported in several cases, challenge the theory of hypoestrogenism as the sole cause.

Other factors that likely contributed to the labial adhesion seen in our patient’s case were perineal trauma, edema that pushes the labia together and facilitates fusion, and immobilization after spinal headache, because conglutination seems most likely when the legs are in the adducted position. Although lack of hygiene has been described as a risk factor for adhesions, our patient obsessively cleaned the perineal area, which triggered dryness and possibly chemical irritation. Both might have been components in adhesion formation. Indeed, a case of caustic postpartum conglutination, which was caused by the use of topical ferric subsulfate for hemostasis, has been reported previously. An inflammatory response, which was associated with her irritable bowel syndrome, could have been an additional culprit.

Labial conglutination in the postpartum period is an uncommon complication. The underlying cause is probably multifactorial, with trauma, edema, prolonged immobilization, and hypoestrogenism serving as contributing elements. Although data are insufficient for the development of strong preventive recommendations, the avoidance of excessive chemical irritation to the area seems intuitive. A temporary period of vaginal packing would likely be helpful, but the rarity of this complication makes widespread packing an impracticable solution. Nonetheless, practitioners should maintain suspicion when women have been exposed to multiple reported risk factors, such as prolonged immobilization after extensive perineal trauma.

It is highly likely that patients with postpartum labial adhesions will require definitive surgical repair. Successful treatment with topical estrogen alone has not been reported, although only a handful of reports describe a trial of estrogen therapy for this condition. Local application of estrogen after surgical repair might, however, reduce the incidence of recurrence.

Once epithelization of the area was noted, our patient agreed to undergo definitive treatment with pencil cautery and postsurgical local estrogen cream in the office under local anesthetic. One week later, the area was healed completely, with no residual skin bridge, and the patient had no discomfort. Several months later, she is doing well. As her confidence in being a mother has improved, so has her obsessive behavior.