Giant uterine artery pseudoaneurysm after a missed miscarriage termination in a cesarean scar pregnancy

BMC Women's Health, Jul 2014

Background Uterine artery pseudoaneurysms are dangerous and can lead to severe hemorrhage. We report an uncommon cause of a giant pseudoaneurysm in a missed miscarriage in a woman with a cesarean scar pregnancy. Case presentation The patient was a 25-year-old Chinese woman with a missed miscarriage in a cesarean scar pregnancy. Curettage was performed under ultrasound monitoring. A uterine artery pseudoaneurysm measuring 71 × 44 × 39 mm was detected the next day by Doppler ultrasonography. While waiting for admittance to an advanced institution to undergo embolization treatment, the pseudoaneurysm ruptured spontaneously. The subsequent severe hemorrhage necessitated hysterectomy. Conclusion A delay in diagnosis of uterine artery pseudoaneurysms may result from a long period between the curettage and follow-up examination. Ultrasound and Doppler ultrasonography should be performed repeatedly at short intervals to rule out them, especially in cesarean scar pregnancies. For a giant uterine artery pseudoaneurysm, interventional embolization might be the first treatment choice. If time allows, intra-operative ligation of the feeding vessels should be attempted before any decision to perform a hysterectomy is made. However, hysterectomy remains a possibility when severe bleeding occurs.

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Giant uterine artery pseudoaneurysm after a missed miscarriage termination in a cesarean scar pregnancy

BMC Women's Health Giant uterine artery pseudoaneurysm after a missed miscarriage termination in a cesarean scar pregnancy Yun Mou 0 Yuezhen Xu 1 Ying Hu 0 Tianan Jiang 0 0 Department of Ultrasound, the First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou , P. R. China 1 Department of Ultrasound, Zhejiang Xinan Hospital , Jiaxing , P.R. China Background: Uterine artery pseudoaneurysms are dangerous and can lead to severe hemorrhage. We report an uncommon cause of a giant pseudoaneurysm in a missed miscarriage in a woman with a cesarean scar pregnancy. Case presentation: The patient was a 25-year-old Chinese woman with a missed miscarriage in a cesarean scar pregnancy. Curettage was performed under ultrasound monitoring. A uterine artery pseudoaneurysm measuring 71 44 39 mm was detected the next day by Doppler ultrasonography. While waiting for admittance to an advanced institution to undergo embolization treatment, the pseudoaneurysm ruptured spontaneously. The subsequent severe hemorrhage necessitated hysterectomy. Conclusion: A delay in diagnosis of uterine artery pseudoaneurysms may result from a long period between the curettage and follow-up examination. Ultrasound and Doppler ultrasonography should be performed repeatedly at short intervals to rule out them, especially in cesarean scar pregnancies. For a giant uterine artery pseudoaneurysm, interventional embolization might be the first treatment choice. If time allows, intra-operative ligation of the feeding vessels should be attempted before any decision to perform a hysterectomy is made. However, hysterectomy remains a possibility when severe bleeding occurs. Uterus; Pseudoaneurysm; Ultrasound; Missed miscarriage; Cesarean scar pregnancy - Background Uterine artery pseudoaneurysms are rare complications that can arise after repeated curettage, abortions, cesarean sections, uncomplicated vaginal deliveries or reproductive tract infections. They are dangerous and can lead to severe hemorrhage. The interval from pelvic surgery to the onset of symptoms is typically 1 week to 3 months [1-4]. This delay is supposed to be caused by a gradual increase in the size of the pseudoaneurysm caused by a characteristic pressure increment. The blood flow into the pseudoaneurysm is greater during systole than diastole. This leads to a gradual pressure build up and eventual rupture. It can be treated with hysterectomy with or without hypogastric artery ligation. In recent years, uterine artery embolization has become an accepted treatment method for this condition. The option depends on the patients reproductive desires and hemodynamic situation. A literature search found three case reports of cesarean scar pregnancies complicated with a uterine artery pseudoaneurysm [5-7]. Here, it occurred in a patient with a missed miscarriage during a cesarean scar pregnancy and the lesion was the largest reported to date. Case presentation The 25-year-old Chinese female patient had been amenorrheic for 2 months and was referred to the hospital because of painless vaginal bleeding that had lasted for 15 days. Four years ago she had a missed miscarriage at 9 weeks of gestation, which was managed by surgical curettage. Two years prior to presentation she had delivered a baby by elective cesarean. Twenty days before presenting at the hospital she had been diagnosed as 40 days pregnant based on elevated urinary levels of beta human chorionic gonadotropin (-hCG). The study was approved by the Institutional Review Board at the First Affiliated Hospital, College of medicine, Zhejiang University. The procedures were conducted according to the principles of the Helsinki Declaration. On presentation the vaginal bleeding was scanty and her serum -hCG level was 1200 mIU/mL. Transvaginal ultrasonography showed that the uterus measured 106 64 60 mm. There was an echo-free area above the inner cervical os, measuring 43 23 mm, without any blood flow signal, yolk sac or embryo present. A mixed echo mass measuring 29 15 mm was detected in the uterine cavity but no blood flow signal could be found in it. The patient was diagnosed as having had a missed miscarriage in the cesarean scar region of the uterus and curettage was performed with ultrasound monitoring. During the procedure, massive bleeding (~600 mL) occurred but this was stopped with an intravenous injection of oxytocin and uterine massage. Chorionic tissue was aspirated and proven as such by histopathology. When the curettage was finished, the uterine cavity was revealed as a clear thin line by ultrasound and was considered normal. Vaginal packing was performed subsequently. At 18 hours after curettage, the serum -hCG level was 1164 mIU/mL. A cystic lesion with an uneven wall in the lower part of the uterus measuring 71 44 39 mm was detected with gray-scale ultrasonography (Figure 1). Color Doppler ultrasonography showed a swirl of colors in the cystic lesion (Figure 2), which was connected to (...truncated)


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Yun Mou, Yuezhen Xu, Ying Hu, Tianan Jiang. Giant uterine artery pseudoaneurysm after a missed miscarriage termination in a cesarean scar pregnancy, BMC Women's Health, 2014, pp. 89, 14, DOI: 10.1186/1472-6874-14-89