Spontaneous cessation and recurrence of massive uterine bleeding can occur in uterine artery pseudoaneurysm after laparoscopically assisted myomectomy

Spontaneous Uterine Vessel Rupture During Pregnancy or in the Puerperium: A Review of the Literature

Importance

Spontaneous perinatal rupture of a uterine vessel is a rare occurrence that may lead to severe hemorrhage and requires prompt identification and management.

Objective

The aim of this study was to examine the etiologies, locations, diagnostic tools, treatment options, and risks in subsequent pregnancies when spontaneous rupture of a uterine vessel occurs in pregnancy.

Evidence Acquisition

A literature search was performed by university research librarians using the PubMed, CINAHL, and Web of Science search engines. Identified were 78 cases of perinatal spontaneous uterine vessel rupture and formed the basis for this review.

Results

Increased uterine blood flow during pregnancy may alter the integrity of pelvic vessels leading to increased risk of spontaneous rupture. The uterine artery is the most common site of vessel rupture; the second most common site is the uterine-ovarian plexus. The most common presentation is abdominal or pelvic pain, maternal vital sign abnormalities, and an absence of vaginal bleeding. Exploratory laparotomy and embolization (interventional radiology) have been reported as management options.

Conclusions

Spontaneous rupture of uterine vessels is a rare but potentially life-threatening complication of pregnancy that should be included in the differential diagnosis of pregnant patients presenting with an acute abdomen.

Relevance

Our aim is to increase the awareness of spontaneous vessel rupture during pregnancy to improve detection, management, and perinatal outcomes.

Ultrasound Imaging of Acquired Myometrial Pseudoaneurysm: The Role of Manipulators as an Unusual Cause during Laparoscopic Surgery

An acquired uterine artery myometrial pseudoaneurysm can occur due to inflammation, trauma, or iatrogenic causes, such as surgical procedures, and can lead to profuse bleeding. The efficacy of uterine manipulators in gynecological surgery, particularly as a cause of a pseudoaneurysm, has been poorly discussed in the literature. In this paper, we discuss a case of a 39-year-old woman with profuse uterine bleeding that occurred seven days after operative laparoscopic surgery for endometriosis. The color Doppler ultrasound better evoked the arterial-like turbulent blood flow inside this cavity. These sonographic features were highly suggestive of uterine artery pseudoaneurysm, presumably related to a secondary trauma caused by the manipulator. The diagnosis was subsequently re-confirmed by angiography, and the patient was treated conservatively with uterine artery embolization. Ultrasound has been shown to be a valuable and safe tool for imaging pseudoaneurysm and guiding subsequent interventional procedures. Accordingly, we briefly review the most suitable manipulators used in benign gynecological surgeries to verify if the different types in use can guide the surgeon towards the correct choice according to surgical needs and thus prevent potentially dangerous trauma.

Postpartum Pseudoaneurysm After Cesarean Delivery

Uterine artery pseudoaneurysm is an uncommon vascular lesion that can be life threatening. A ruptured uterine artery pseudoaneurysm can cause acute massive hemorrhaging, creating a true emergency for the postpartum patient. The etiology is more commonly seen with traumatic procedures such as cesarean delivery or curettage. This case report is of a patient with a history of HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome who presented with heavy bleeding after a cesarean delivery. Sonography was primarily used to diagnose the uterine artery pseudoaneurysm. Because of the massive hemorrhaging in this case, a hysterectomy was performed.

Post-operative hemorrhage after myomectomy: safety and efficacy of transcatheter uterine artery embolization

Objective

To evaluate the safety and clinical efficacy of transcatheter uterine artery embolization (UAE) for post-myomectomy hemorrhage.

Materials and Methods

We identified eight female patients (age ranged from 29 to 51 years and with a median age of 37) in two regional hospitals who suffered from post-myomectomy hemorrhage requiring UAE during the time period from 2004 to 2012. A retrospective review of the patients' clinical data, uterine artery angiographic findings, embolization details, and clinical outcomes was conducted.

Results

The pelvic angiography findings were as follows: hypervascular staining without bleeding focus (n = 5); active contrast extravasation from the uterine artery (n = 2); and pseudoaneurysm in the uterus (n = 1). Gelatin sponge particle was used in bilateral uterine arteries of all eight patients, acting as an empirical or therapeutic embolization agent for the various angiographic findings. N-butyl-2-cyanoacrylate was administered to the target bleeding uterine arteries in the two patients with active contrast extravasation. Technical and clinical success were achieved in all patients (100%) with bleeding cessation and no further related surgical intervention or embolization procedure was required for hemorrhage control. Uterine artery dissection occurred in one patient as a minor complication. Normal menstrual cycles were restored in all patients.

Conclusion

Uterine artery embolization is a safe, minimally invasive, and effective management option for controlling post-myomectomy hemorrhage without the need for hysterectomy.