Pseudoaneurysm of the Uterine Artery Requiring Bilateral Uterine Artery Embolization

Journal of Perinatology, Aug 2004

OBJECTIVE: To report a case of uterine artery pseudoaneurysm which initially failed unilateral uterine artery embolization that subsequently responded to bilateral embolization. DESIGN: A case report. SETTING: University hospital. PATIENT(S): 32-year-old G2 P1 female. INTERVENTION(S): Left uterine artery embolization followed by right uterine artery embolization 1 day later. MAIN OUTCOME MEASURE(S): Vaginal bleeding, hemoglobin. RESULTS: Unilateral uterine artery embolization failed to control vaginal bleeding. Repeat embolization of the contralateral side was successful. CONCLUSIONS: Uterine artery embolization is an effective method of treating delayed postpartum hemorrhage secondary to a pseudoaneurysm of the uterine artery.

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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 artery. 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 - OBJECTIVE: To report a case of uterine artery pseudoaneurysm which initially failed unilateral uterine artery embolization that subsequently responded to bilateral embolization. DESIGN: A case report. SETTING: PATIENT(S): INTERVENTION(S): Left uterine artery embolization followed by right uterine artery embolization 1 day later. MAIN OUTCOME MEASURE(S): Vaginal bleeding, hemoglobin. RESULTS: Unilateral uterine artery embolization failed to control vaginal bleeding. Repeat embolization of the contralateral side was successful. CONCLUSIONS: INTRODUCTION 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 had stopped. DISCUSSION 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. 1. Descargues G , Douvrin F , Gravier A , Lemoine JP , Marpeau L , Clavier E. False aneurysm of the uterine pedicle: an uncommon cause of post-partum haemorrhage after cesarean section treated with selective arterial embolization . Eur J Obstet Gynecol Reprod Biol 2001 ; 97 : 26 - 9 . 2. Pelage JP , Soyer P , Repiquet D , et al. Secondary post-partum hemorrhage: treatment with selective arterial embolization . Radiology 1999 ; 212 : 385 - 9 . 3. Ho SP , Ong CL , Tan BS . A case of uterine artery pseudoaneurysms . Singapore Med J 2002 ; 43 ( 4 ): 202 - 4 . 4. Wiebe ER , Switzer P . Arteriovenous malformations of the uterus associated with medical abortion . Int J Gynecol Obstet 2000 ; 71 : 155 - 8 . 5. Khong TY , Khong TK . Delayed postpartum hemorrhage: a morphologic study of causes and their relation to other pregnancy disorders . Obstet Gynecol 1993 ; 82 : 17 - 22 . 6. Brown BJ , Heaston DK , Poulson AM , Gabert HA , Mineau DE , Miller Jr FJ . Uncontrollable postpartum bleeding: a new approach to hemostasis through angiographic arterial embolization . Obstet Gynecol 1979 ; 54 : 361 - 5 . 7. Burchell RC . Internal iliac artery ligation: hemodynamics . Obstet Gynecol 1964 ; 24 : 737 - 9 . 8. Simon PH , Donner C , Delcour C , Kirkpatrick C , Rodesch F. Selective artery embolization in the treatment of cervical pregnancy: two case reports . Eur J Obstet Gynecol Reprod Biol 1991 ; 40 : 159 - 61 . 9. Stancato-Pasik A , Mitty HA , Richard III HM , Eshkar N. Obstetric embolotherapy: effect on menses and pregnancy . Radiology 1997 ; 204 ( 3 ): 791 - 3 .


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Brian C Cooper, Michelle Hocking-Brown, Joel I Sorosky, Wendy F Hansen. Pseudoaneurysm of the Uterine Artery Requiring Bilateral Uterine Artery Embolization, Journal of Perinatology, 2004, 560-562, DOI: 10.1038/sj.jp.7211119