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

Uterine artery pseudoaneurysm caused by hysteroscopic surgery: A case report

BACKGROUND

We report a case of uterine artery pseudoaneurysm (UAP) occurrence during hysteroscopic endometrial polypectomy and its treatment via uterine artery embolization (UAE).

CASE SUMMARY

A 48-year-old primigravid, primiparous patient was incidentally found to have an endometrial polyp during a health checkup, and underwent a hysteroscopic polypectomy at another hospital. Her cervix was dilated with a Laminken-R^® device. After the Laminken-R^® was withdrawn, a large amount of genital bleeding was observed. This bleeding persisted after the hysteroscopic polypectomy, and, as hemostasis became impossible, the patient was transferred to our hospital by ambulance. On arrival, transvaginal ultrasonography revealed a 3-cm hypoechoic mass with a swirling internal pulse on the right side of the uterus, and color Doppler ultrasonography showed feeder vessels penetrating the mass. Pelvic contrast-enhanced computed tomography (CT) confirmed the presence of a mass at this site, and vascular proliferation was observed within the uterine cavity. Consequently, UAP was diagnosed, and UAE was performed. The patient’s postoperative course was uneventful, and 6 mo post-UAE, no recurrence of blood flow to the UAP was observed.

CONCLUSION

When abnormal genital bleeding occurs during hysteroscopic surgery, ultrasonography and contrast-enhanced CT can assist in the detection of early UAPs.

A Case Report of a Patient with Spontaneously Resolving Unruptured Uterine Artery Pseudoaneurysm after Surgery for Miscarriage during the Early Stages of Pregnancy Using Manual Vacuum Aspiration

Uterine artery pseudoaneurysms are caused by damage to blood vessel walls from iatrogenic changes including cesarean section or cervical dilatation and uterine curettage. Manual vacuum aspiration (MVA) is becoming increasingly popular from the perspective of reducing the risk of endometrial injury. This is a case report of a 33-year-old primigravida female patient diagnosed with an unruptured uterine artery pseudoaneurysm that spontaneously resolved after surgery for miscarriage using MVA. The patient experienced a miscarriage at 10 weeks and 0 days of gestation and underwent surgery using MVA. Fourteen days after surgery, the patient was diagnosed with a uterine artery pseudoaneurysm by transvaginal ultrasound tomography and contrast computed tomography of the pelvic region. The patient received elective follow-up and was found to be completely thrombosed 2 months after surgery. MVA for miscarriage may cause uterine artery pseudoaneurysms. Elective therapy may be an option for unruptured uterine artery pseudoaneurysms.

How to minimize bleeding in laparoscopic myomectomy

PURPOSE OF REVIEW

Laparoscopic myomectomy is a common surgical procedure for symptomatic myomas. However, bleeding control during surgery may pose a challenge. Therefore, the aim of this study was to review recent evidence regarding interventions to control bleeding during laparoscopic myomectomy.

RECENT FINDINGS

The use of vasopressin resulted in less blood loss compared to placebo. Barbed sutures reduced blood loss compared to conventional sutures. Intravenous infusion of tranexamic acid (TXA) in the intraoperative period of large myomectomies showed no significant difference compared to placebo. Uterine artery occlusion (UAO) and emergency uterine artery embolization were reported to be feasible and may reduce and treat bleeding before conversion to laparotomy.

SUMMARY

Several methods can control bleeding during laparoscopic myomectomy. Vasopressin and barbed sutures resulted in decreased blood loss, and TXA did not have an impact on bleeding control. The use of UAO and emergency embolization techniques can contribute to the control of bleeding; however, further studies are needed to prove the efficacy of these and other agents.

Anatomic variations of the Uterine Artery. Review of the literature and their clinical significance

Uterine arteries are the main vessels supplying blood to the uterus. Mainly, they originate from the anterior trunk of the internal iliac artery. Uterine arteries play an important role in pregnancy as well as transcatheter arterial embolization for postpartum hemorrhage and uterine fibroid management. This is a review of the English literature in the PubMed database of the anatomic variety on the origin of uterine arteries and their clinical significance. Eleven studies describe the origin of the uterine arteries and their variations in the literature. In six studies, the uterine artery emerged from internal iliac artery in the majority of the cases, either as a separate branch, or as a bifurcation with the inferior gluteal artery, or trifurcation with superior and inferior gluteal artery. In two studies, the inferior gluteal artery manifested as the main source of the uterine artery, whereas in three studies, the umbilical artery posed as its main origin. Internal iliac artery is described as the most common vascular origin of uterine artery. However, this review highlights that the main vessels of origin for uterine arteries are internal iliac, umbilical and inferior gluteal artery. Nevertheless, classification and further research for this peculiar anatomic structure is fundamental in the future.

Postpartum hemorrhage from non-uterine arteries: clinical importance of their detection and the results of selective embolization

Background Identification of the source of postpartum hemorrhage (PPH) is important for embolization because PPH frequently originates from non-uterine arteries. Purpose To evaluate the clinical importance of identifying the non-uterine arteries causing the PPH and the results of their selective embolization. Material and Methods This retrospective study enrolled 59 patients who underwent embolization for PPH from June 2009 to July 2016. Angiographic findings and medical records were reviewed to determine whether non-uterine arteries contributed to PPH. Arteries showing extravasation or hypertrophy accompanying uterine hypervascular staining were regarded as sources of the PPH. The results of their embolization were analyzed. Results Of 59 patients, 19 (32.2%) underwent embolization of non-uterine arteries. These arteries were ovarian (n = 7), vaginal (n = 5), round ligament (n = 5), inferior epigastric (n = 3), cervical (n = 2), internal pudendal (n = 2), vesical (n = 1), and rectal (n = 1) arteries. The embolic materials used included n-butyl cyanoacrylate (n = 9), gelatin sponge particles (n = 8), gelatin sponge particles with microcoils (n = 1), and polyvinyl alcohol particles (n = 1). In 13 patients, bilateral uterine arterial embolization was performed. Re-embolization was performed in two patients with persistent bleeding. Hemostasis was achieved in 17 (89.5%) patients. Two patients underwent immediate hysterectomy due to persistent bleeding. One patient experienced a major complication due to pelvic organ ischemia. One patient underwent delayed hysterectomy for uterine infarction four months later. Conclusion Non-uterine arteries are major sources of PPH. Detection and selective embolization are important for successful hemostasis.