Figure 1
Ultrasonography
Uterine artery pseudoaneurysm: A rare life-threatening cause of secondary post partum haemorrhage
SectionInterventional radiology
Case TypeClinical Cases
AuthorsMinu Mohandas1, Sreeraj Nadarajan2, Sara Ammu Chacko1, Nita H1, Manish Kumar Yadav2.
Connected authors
26 years, female
Clinical History
A 26-year-old female who delivered a 2800g male baby was admitted with excessive bleeding per vaginum. She underwent elective C-section 5 weeks before. O/E she was hypotensive, anaemic (Hb 3.8), abdomen was soft with healthy scar. Uterus bulky, os closed. Blood clots ~ 100g were removed from the vagina.
Imaging Findings
Transabdominal colour Doppler US revealed a well-defined rounded cystic lesion with colour filling and aliasing, measuring 1.3 cm × 1 cm in anterior wall of lower uterine segment (Fig. 1a). Spectral Doppler showed marked turbulence and biphasic pattern (Fig. 1b).
CT angiogram showed a well-circumscribed globular contrast-filled lesion in left anterior myometrium of uterus suggestive of a pseudoaneurysm (Fig. 2a, 2b).
Transcatheter arterial embolization of pseudoaneurysm was planned and DSA was done. Left iliac arteriogram revealed a pseudoaneurysm from the terminal part of the left uterine artery (Fig. 3a, 3b). Superselection of terminal branch of left uterine artery was done using a microcatheter and was embolized with N-butyl cyanoacrylate (Fig. 4a). The right uterine artery was embolized with gel foam. Post embolization angiography showed no evidence of pseudoaneurysm (Fig. 4b). Follow-up colour Doppler US showed aneurysmal cavity filled with echogenic content with no evidence of blood flow.
CT angiogram showed a well-circumscribed globular contrast-filled lesion in left anterior myometrium of uterus suggestive of a pseudoaneurysm (Fig. 2a, 2b).
Transcatheter arterial embolization of pseudoaneurysm was planned and DSA was done. Left iliac arteriogram revealed a pseudoaneurysm from the terminal part of the left uterine artery (Fig. 3a, 3b). Superselection of terminal branch of left uterine artery was done using a microcatheter and was embolized with N-butyl cyanoacrylate (Fig. 4a). The right uterine artery was embolized with gel foam. Post embolization angiography showed no evidence of pseudoaneurysm (Fig. 4b). Follow-up colour Doppler US showed aneurysmal cavity filled with echogenic content with no evidence of blood flow.
Discussion
Secondary postpartum haemorrhage is defined as excessive bleeding starting any time from 24 hours after delivery to 6 weeks postpartum. Common causes of secondary postpartum haemorrhage are retained products of conception, sub-involution of the uterus and placental bed, and endometritis [1]. Vascular causes include uterine pseudoaneurysms, arteriovenous malformations, and direct vessel rupture.
Uterine artery pseudoaneurysm is a rare life-threatening cause of secondary postpartum haemorrhage [2]. Extended uterine incision, additional haemostatic suture and repeated caesarean sections are the risk factors associated with the occurrence of pseudoaneurysm after caesarean section [3]. Rupture of pseudoaneurysm causes severe haemorrhage.
Color Doppler US and Computed Tomography are being used more frequently as initial diagnostic modalities [4]. On US, pseudoaneurysm appears as an anechoic sac which shows turbulent arterial flow on Doppler [5, 6]. Doppler demonstrates to-and-fro sign in the neck and yin yang sign in the body of pseudoaneurysm with a narrow neck [7, 8]. Computed Tomography can confirm the diagnosis and help rule out other causes of delayed postpartum haemorrhage. Angiography remains the gold standard in confirming the diagnosis.
Treatment options include hysterectomy, surgical ligation of uterine arteries and transarterial embolisation of uterine artery (TAE). Many studies have documented the safety and effectiveness of TAE for secondary PPH and reported clinical success rates >90% [9]. Angiographic embolization of pseudoaneurysm has the advantages of low morbidity, easy localization of bleeder, more distal occlusion than surgical ligation, and preservation of fertility compared to hysterectomy.
Redistribution of blood or neovascularization may allow bleeding to occur from the contralateral side after unilateral embolisation. Hence, bilateral uterine artery embolization is safe than unilateral embolisation [10]. Embolisation of anterior divisions of both internal iliac arteries should be considered when the uterine artery could not be easily accessed or when vaginal bleeding continues in spite of embolisation of both uterine arteries [9]. The cervicovaginal branch should be spared during embolisation [11].
Take home message - In a woman with unexplained vaginal bleeding after caesarean section delivery, pseudoaneurysm is a potentially life-threatening complication and should be considered as a differential diagnosis.
Uterine artery pseudoaneurysm is a rare life-threatening cause of secondary postpartum haemorrhage [2]. Extended uterine incision, additional haemostatic suture and repeated caesarean sections are the risk factors associated with the occurrence of pseudoaneurysm after caesarean section [3]. Rupture of pseudoaneurysm causes severe haemorrhage.
Color Doppler US and Computed Tomography are being used more frequently as initial diagnostic modalities [4]. On US, pseudoaneurysm appears as an anechoic sac which shows turbulent arterial flow on Doppler [5, 6]. Doppler demonstrates to-and-fro sign in the neck and yin yang sign in the body of pseudoaneurysm with a narrow neck [7, 8]. Computed Tomography can confirm the diagnosis and help rule out other causes of delayed postpartum haemorrhage. Angiography remains the gold standard in confirming the diagnosis.
Treatment options include hysterectomy, surgical ligation of uterine arteries and transarterial embolisation of uterine artery (TAE). Many studies have documented the safety and effectiveness of TAE for secondary PPH and reported clinical success rates >90% [9]. Angiographic embolization of pseudoaneurysm has the advantages of low morbidity, easy localization of bleeder, more distal occlusion than surgical ligation, and preservation of fertility compared to hysterectomy.
Redistribution of blood or neovascularization may allow bleeding to occur from the contralateral side after unilateral embolisation. Hence, bilateral uterine artery embolization is safe than unilateral embolisation [10]. Embolisation of anterior divisions of both internal iliac arteries should be considered when the uterine artery could not be easily accessed or when vaginal bleeding continues in spite of embolisation of both uterine arteries [9]. The cervicovaginal branch should be spared during embolisation [11].
Take home message - In a woman with unexplained vaginal bleeding after caesarean section delivery, pseudoaneurysm is a potentially life-threatening complication and should be considered as a differential diagnosis.
Differential Diagnosis List
Left uterine artery pseudoaneurysm
Arteriovenous malformation
Direct vessel rupture
Final Diagnosis
Left uterine artery pseudoaneurysm
References
[1] T. Y. Khong and T. K. Khong (1993) Delayed postpartum hemorrhage: a morphologic study of causes and their relation to other pregnancy disorders. Obstetrics and Gynecology vol. 82, no. 1, pp. 17–22 (PMID: 8515920)
[2] G. Descargues, F. Douvrin, A. Gravier, J. P. Lemoine, L. Marpeau, and E. Clavier (2001) False aneurysm of the uterine pedicle: an uncommon cause of post-partum haemorrhage after caesarean section treated with selective arterial embolization. European Journal of Obstetrics Gynecology and Reproductive Biology vol. 97, no. 1, pp. 26–29 (PMID: 11435004)
[3] T. Kuwata, S. Matsubara, Y. Kaneko, A. Izumi, M. Nakata, and M. Suzuki (2010) Asymptomatic uterine artery pseudoaneurysm after cesarean section. Journal of Obstetrics and Gynaecology Research vol. 36, no. 2, pp. 405–410 (PMID: 20492396)
[4] Grivell M, Reid M, Mellor A (2005) Uterine arteriovenous malformations: a review of current literature. Obstet Gynecol Surg 60(11):761-767 (PMID: 16250925)
[5] Mou et al. (2014) Giant uterine artery pseudoaneurysm after a missed miscarriage termination in a cesarean scar pregnancy. BMC Women's Health 14:89 (PMID: 25070087)
[6] Huang MW, Muradali D, ThurstonWA, Burns PN,Wilson SR (1998) Uterine arteriovenous malformations: gray-scale and Doppler US features with MR imaging correlation. Radiology 206:115-23 (PMID: 9423660)
[7] N. Butori, L. Coulange, L. Filipuzzi, D. Krausé, and R. Loffroy (2009) Pseudoaneurysm of the uterine artery after cesarean delivery: management with superselective arterial embolization. Obstetrics and Gynecology vol. 113, no. 2, pp. 540–543 (PMID: 19155949)
[8] P. Polat, S. Suma, M. Kantarcý, F. Alper, and A. Levent (2002) Color Doppler US in the evaluation of uterine vascular abnormalities. Radiographics vol. 22, no. 1, pp. 47–53 (PMID: 11796897)
[9] Park, H. sun, Shin, J. H., Yoon, H.-K., Kim, J. H., Gwon, D.-I., Ko, G.-Y., & Sung, K.-B (2016) Transcatheter Arterial Embolization for Secondary Postpartum Hemorrhage: Outcome in 52 Patients at a Single Tertiary Referral Center. Journal of Vascular and Interventional Radiology 25(11), 1751–1757 (PMID: 24985718)
[10] J. H. Kwon and G. S. Kim (2002) Obstetric iatrogenic arterial injuries of the uterus: diagnosis with US and treatment with transcatheter arterial embolization. Radiographics vol. 22, no. 1, pp. 35–46 (PMID: 11796896)
[11] Osher, M., Semaan, D., & Esq, D. O (2016) The uterine arteries, anatomic variation and the implications pertaining to uterine artery embolization. Journal of Vascular and Interventional Radiology 25(3), S143
Case information
| URL: | https://www.eurorad.org/case/13699 |
| DOI: | 10.1594/EURORAD/CASE.13699 |
| ISSN: | 1563-4086 |
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Ultrasonography
Sagittal sonogram of uterus (B&W) showing well-defined rounded cystic lesion with colour filling in anterior myometrium.
Nita H, Department of Radiology, Dr. SMCSI Medical College, Karakonam
Nita H, Department of Radiology, Dr. SMCSI Medical College, Karakonam
Spectral Doppler showing marked turbulence in the lesion.
Nita H, Department of Radiology, Dr. SMCSI Medical College, Karakonam
Nita H, Department of Radiology, Dr. SMCSI Medical College, Karakonam
CT angiography
CT axial section showing a well-circumscribed globular contrast filled lesion in left anterior myometrium of uterus suggestive of pseudoaneurysm.
Nita H, Department of Radiology, Dr. SMCSI Medical College, Karakonam
Nita H, Department of Radiology, Dr. SMCSI Medical College, Karakonam
CT coronal section showing the pseudoaneurysm in left anterior myometrium of uterus.
Nita H, Department of Radiology, Dr. SMCSI Medical College, Karakonam
Nita H, Department of Radiology, Dr. SMCSI Medical College, Karakonam