Author Information
Ansari Munira,* Samant PY**, Parulekar SV ***
(*Assistant
Professor, ** Additional Professor, *** Professor and Head of Department,
Department of Obstetrics and Gynecology, Seth G. S. Medical college and KEM
hospital, Mumbai, India)
Abstract
Uterine
artery pseudoaneurysm is a rare cause of secondary postpartum hemorrhage
occurring due to vascular trauma and inflammation of during cesarean section,
vaginal delivery, curettage or hysterotomy.[1-4] We present a case
of cesarean section who underwent curettage for postpartum hemorrhage and
developed uterine artery pseudoaneurysm.
Introduction
Pseudoaneurysm results with
extraluminal collection of blood with turbulent flow communicating with lumen
of the parent vessel through a defect caused by trauma, and when connected with
the uterine cavity, it causes recurrent hemorrhage.[1] If it is surrounded by
myometrium, painful hematoma results.. The 3 layers of arterial wall are absent
and surrounding tissues comprise the wall.[5] The pseudoaneurysm is prone to
unpredictable rupture, and may cause fatal exsanguination.[2]
Case Report
Twenty two
years old P3L2D1 underwent cesarean section in a private hospital and had
severe primary postpartum hemorrhage. An emergency curettage was done. On day
17, bleeding recurred and the patient was transferred to another hospital in a
state of shock. Sonography indicated retained products. Blood transfusions were
started and curettage was repeated. A few placental bits were removed. On day
23, the patient had profuse vaginal bleeding. She was transfused blood and
transferred to tertiary hospital. The patient was pale and febrile. She had a
healed Pfannenstiel scar, bulky and soft uterus with minimal bleeding. Blood
and vaginal swab and were collected for microbiologic study. Broad spectrum
antibiotics were started. Her platelet count and coagulation profile were
normal. Ultrasonography (USG) revealed bulky uterus with blood clots within.
Antibiotics were changed as per culture report, blood was transfused. Pelvic computerized
tomography (CT) scan revealed a pseudoaneurysm in the distal branch of right
uterine artery and blood clots in the endometrial cavity ( figures 1 and 2).
Because of strong indication of infection, obstetric hysterectomy was
undertaken. On laparotomy, adhesions between the uterus and parietal peritoneum
as well as surrounding viscera were noted. Due to bowel adhesions posteriorly
and laterally, subtotal hysterectomy was done rather than total hysterectomy and
internal iliac artery ligation was deferred. In spite of appropriate
transfusions and antibiotic treatment, postoperatively the patient succumbed to
septic shock.
Discussion
A pseudoaneurysm forms due to surgical trauma, inflammation, neoplasia, and infarction; with leakage of blood from an artery into the surrounding tissue with a continuing communication and is a cause of secondary postpartum hemorrhage. Common causes of secondary postpartum hemorrhage include retained
products of conception, subinvolution of the uterus and hence of the placental
bed, and endometritis.[6] Vascular causes include uterine vascular
pseudoaneurysms, acquired arteriovenous malformations, and direct vessel
rupture, usually following uterine curettage, cesarean section, hysterotomy and
traumatic vaginal delivery.
Acquired
arteriovenous malformations occur following surgical trauma and consist of
multiple small arteriovenous fistulas between intramural arterial branches and
the venous plexus. On these appear focally or asymmetrically distributed
multiple small anechoic spaces in the myometrium or endometrium with low-resistance rapid currents
seen on Doppler. On USG pseudoaneurysm appears as an
anechoic sac which shows turbulent arterial flow on Doppler.[3,7]. Doppler
demonstrates to-and-fro sign in the neck of the pseudoaneurysm and yin yang
sign in the body of the pseudoaneurysm which is
diagnostic of pseudoaneurysm with a narrow neck. During systole, with higher
arterial pressure, there is influx of blood into the pseudoaneurysm. In
diastole the pressure in the artery drops and blood flows back through the pseudoaneurysm neck. This Doppler sign at the neck of the pseudoaneurym together with
turbulent flow helps to confirm the diagnosis.[2] Pseudoaneurysm of uterine artery after cesarean section
diagnosed sonographically has been reported by Henrich et al.[8]
Accurate diagnosis of vascular etiology
of delayed postpartum hemorrhage helps avoid unnecessary curettage for
suspected retained products of conception and may avoid catastrophic bleeding.
With the introduction of modern imaging modalities, the diagnosis of uterine
artery pseudoaneurysm has become easier.[1,2,4,5] USG,
CT and magnetic resonance imaging are being used more frequently as initial
diagnostic modalities.[9] Angiography remains the gold standard in
diagnosing and treating vascular malformations. Brown et al reported an early
case of selective arterial embolization used successfully to treat an extra
uterine pelvic haematoma after three failed surgical attempts.[10]
The success rate following embolization is around 97%.[11] In a study of efficacy of uterine artery
embolisation, Young Ho Choi reported 90% overall success rate, the least being with secondary PPH and
10% complications.[12] The reported success rates for internal iliac artery
ligation vary from 42%-100% because of the extensive pelvic collateral
circulation.[13] Dasari et al reported a case of hemorrhage on the 23rd
day due to pseudoaneurysm after cesarean section treated by bilateral internal
artery ligation.[14] Embolization of a uterine arteriovenous pseudo
aneurysm following arteriovenous fistula in a case of hysterectomy has been
reported by Ferguson et al.[15]
AV malformation including pseudoaneurysm should be suspected
in intractable or recurrent delayed postpartum hemorrhage. Angiographic
embolization of pseudoaneurysm has the advantage of low morbidity, easy bleeder
localization, more distal occlusion than ligation, and preservation of
fertility. Timely diagnosis and appropriate intervention can prevent infection
related morbidity.
References
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Citation
Ansari Munira, Samant PY, Parulekar SV.
Uterine Artery
Psuedoaneurysm. JPGO 2014 Volume 1 Number 12 Available from: http://www.jpgo.org/2014/12/uterine-artery-psuedoaneurysm.html