A PDF file should load here. If you do not see its contents
the file may be temporarily unavailable at the journal website
or you do not have a PDF plug-in installed and enabled in your browser.
Alternatively, you can download the file locally and open with any standalone PDF reader:
http://www.biomedcentral.com/content/pdf/1472-6874-14-89.pdf
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)