Pseudoaneurysm of the Uterine Artery Requiring Bilateral Uterine Artery Embolization
Uterine artery embolization is an effective method of treating delayed
postpartum hemorrhage secondary to a pseudoaneurysm of the uterine
Journal of Perinatology
Pseudoaneurysm of the Uterine Artery Requiring Bilateral Uterine Artery Embolization
Brian C. Cooper 0 1
Michelle Hocking-Brown 0 1
Joel I. Sorosky 0 1
Wendy F. Hansen 0 1
0 and Gynecology, University of Vermont College of Medicine , 89 Beaumont Ave., Given Bldg. C-254, Burlington, VT 05405 , USA
1 Department of Obstetrics and Gynecology , Roy J. and Lucille A. Carver College of Medicine, University of Iowa Hospitals and Clinics , Iowa City, IA , USA
32-year-old G2 P1 female. CASE PRESENTATION
To report a case of uterine artery pseudoaneurysm which initially failed
unilateral uterine artery embolization that subsequently responded to
A case report.
Left uterine artery embolization followed by right uterine artery
embolization 1 day later.
MAIN OUTCOME MEASURE(S):
Vaginal bleeding, hemoglobin.
Unilateral uterine artery embolization failed to control vaginal bleeding.
Repeat embolization of the contralateral side was successful.
Pseudoaneurysm of the uterine artery is an uncommon cause of
delayed postpartum hemorrhage following cesarean or vaginal
delivery.1 – 3 A uterine artery pseudoaneurysm develops when the
uterine artery is lacerated or injured. While maintaining contact
with the parent vessel, extravasating blood dissects through tissues,
finally establishing a connection with the uterine cavity, causing a
delayed hemorrhage. The boundaries of a false aneurysm are
constituted by thrombus, as opposed to the three arterial layers as
in a true aneurysm. Although Doppler ultrasound can aid in the
assessment,4 uterine artery angiography is necessary to make the
diagnosis and provides the subsequent means for embolization. We
present a case of a uterine artery pseudoaneurysm presenting as
delayed postpartum hemorrhage.
A 32-year-old gravida 2, para 1 was emergently transferred to our
institution on postpartum day 17 for postpartum hemorrhage
unresponsive to local measures. Prior to transfer she had been
transfused a total of nine units of packed red blood cells. She
underwent a primary low transverse cesarean delivery for failure to
progress beyond 8 cm. Her postoperative course was uncomplicated.
On postoperative day 12, she was readmitted locally for
management of a delayed postpartum hemorrhage. She was
hypotensive with a hemoglobin of 5 g/dl. After stabilization with
four units of packed red blood cells, an exploratory laparotomy
showed a 16-week size uterus with a small hysterotomy hematoma.
No intra-abdominal source of bleeding was seen. A dilatation and
curettage was then performed and tissue sent to pathology. The
bleeding stopped, and she was discharged home on hospital day #3.
Pathology showed no evidence of retained pregnancy products.
After 2 days, on postpartum day 17, she again experienced heavy
vaginal bleeding and presented locally. Her hemoglobin was 8 g/dl.
An ultrasound showed blood versus retained products of conception
within the uterus. A second dilatation and curettage was performed.
The bleeding persisted and was unresponsive to oxytocin,
methylergonovine maleate, and carboprost tromethamine. After
hemodynamic stabilization with 5 units of packed red blood cells
and uterine packing, she was transferred to our institution. On
arrival her coagulation factors were normal, hemoglobin was 9 g/
dl, and quantitative hCG was less than 2. Her abdomen was soft
with a superficial Pfannenstiel wound separation. Her uterus was
20-week size and nontender. There was no evidence of vaginal
lacerations. Ultrasound revealed a uterus with minimal clot.
Interventional radiology was consulted, as the patient desired
future fertility. Pelvic angiography demonstrated a left uterine
artery pseudoaneurysm with extravasation of contrast into a pocket
that connected to the uterine cavity (Figure 1). This false aneurysm
was located almost midline and cephalad within the myometrium
of the uterus. The left uterine artery was embolized. The right
uterine artery was identified, and no abnormal bleeding was seen.
The patient was transferred to the surgical intensive care unit and
received two more units of packed red blood cells, raising her
hemoglobin to 9.6 g/dl. The uterine pack was removed on
postembolization day 1. Vaginal hemorrhage recurred 12 hours
later. Her hemoglobin dropped to 7.5 g/dl, and her partial
thromboplastin time rose to 70 seconds. She received two more
units of packed red blood cells and two units of fresh frozen
plasma. Given her strong desire to maintain fertility, a second
pelvic angiogram was performed. The left uterine artery was still
hemostatic; however, now a branch of the right uterine artery was
bleeding into the pseudoaneurysm (Figure 2). Embolization was
performed, and the bleeding stopped. The remainder of the hospital
course was uncomplicated. She was discharged on hospital day #5
with a hemoglobin of 9.9 g/dl. At her 6-week follow-up
examination, her uterus was normal size and her vaginal bleeding
Delayed postpartum hemorrhage is defined as excessive bleeding
occurring 24 hours after delivery until 6 weeks postpartum and
most commonly occurs between 8 and 14 days postpartum.
Common causes established by pathologic examination of uterine
contents include retained products of conception, subinvolution or
involution of the placental bed, and less commonly endometritis.5
Rare causes include pseudoaneurysm of a uterine vessel,
arteriovenous malformations, and choriocarcinoma. When the
more common causes have been excluded, pelvic angiography may
be performed. Uterine artery embolization can be carried out to
control hemorrhage, sparing fertility. In 1979, Brown et al.6
reported the first case of selective arterial embolization used
successfully to treat an extrauterine pelvic hematoma after three
failed surgical attempts to control the bleeding. Since that time,
arterial embolization has been used successfully to control
postpartum bleeding from atony, placenta accreta, extrauterine
pregnancies, and vulvar and vaginal hematomas. Uterine artery
pseudoaneurysm, although a rare cause of postpartum
hemorrhage, can also be successfully diagnosed and treated with
angiography and subsequent embolization.
Via computerized search of medical database using terms
‘‘pseudoaneurysm,’’ ‘‘postpartum hemorrhage,’’ ‘‘pregnancy,’’ and
‘‘interventional radiology,’’ we identified two authors who described
successful vascular embolization of pseudoaneurysms in women
presenting with delayed postpartum hemorrhage.1–3 In these
reports (for a total of six women), a single embolization achieved
hemostasis in four patients. Two patients underwent bilateral
embolization prophylactically.2,3 Unlike previous reports, our
patient developed recurrent vaginal bleeding after embolization.
Rebleeding did not signify a failed embolization but rather bleeding
from a branch of the contralateral uterine artery feeding this same
false aneurysm. It is possible that the redistribution and redirection
of blood or hypoxia-induced neovascularization to allow bleeding
to occur from the contralateral side after the initial embolization.
Burchell7 demonstrated that bilateral internal iliac artery ligation
was more effective in reducing the pulse pressure than unilateral
ligation. Unilateral embolization was also found to be less effective
in the treatment of cervical pregnancy.8 Therefore, careful
evaluation of the patient over time is essential.
Hysterotomy can be avoided in patients with delayed postpartum
hemorrhage caused by pseudoaneurysm of the uterine artery who
wish to preserve fertility. In a small case series of women who
underwent embolotherapy for obstetric hemorrhage, all three
women who attempted conception after embolization were
successful.9 Two of the three patients had undergone bilateral
uterine artery embolization. Although data are scant, bilateral
uterine artery embolization for obstetric hemorrhage appears to
have no increased deleterious effect on future fertility when
compared to unilateral embolization.
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