Role of Uterine Artery Embolization in Pseudoaneurysm of Uterine Artery: A Rare Cause of Secondary Postpartum Hemorrhage

Imaging spectrum of acquired uterine vascular abnormalities with angiographic correlates, a pictorial review

Background

Acquired uterine arterial anomalies, including uterine artery pseudoaneurysms (UAP), arteriovenous malformations (AVMs) and arteriovenous fistulae (AFVs), are rare presenting causes of abnormal uterine bleeding. Timely diagnosis is essential for safe and effective treatment, avoiding life-threatening haemorrhage resulting from erroneous uterine curettage due to misdiagnosing these as other more common differentials.

Main text

This pictorial review discusses the ultrasound (USG), CT and MRI features of various acquired uterine vascular abnormalities with angiographic correlates.

Conclusion

Acquired uterine arteriovenous injuries are a fundamental cause of dysfunctional intractable bleeding recalcitrant to traditional conservative management. Endovascular transcatheter uterine artery embolisation is an increasingly popular and safe mode of treatment, especially in young patients desiring to have the option of future pregnancies, with lesser morbidity and in-hospital stay duration.

Modified sandwich embolization technique for postpartum hemorrhage caused by uterine artery pseudoaneurysm: a case series

PURPOSE

Uterine artery pseudoaneurysm (UAP) is rare but can cause life-threatening postpartum hemorrhage (PPH). To evaluate a novel sandwich embolization technique as a treatment for PPH caused by UAP.

METHODS

This retrospective study included 10 patients with PPH caused by UAP who were treated using a modified sandwich embolization technique at the Radiology Department, Third Affiliated Hospital of Guangzhou Medical University between April 2009 and September 2018. Baseline clinical characteristics, intraoperative data (including treatment effectiveness) and postoperative data (including re-bleeding events and complications) were extracted from the medical records.

RESULTS

Uterine arterial angiography showed cystic shadowing of the vascular wall during the arterial phase in all patients. Spraying of contrast agent into the pseudoaneurysm was observed for large UAPs, and the pseudoaneurysm disappeared in the venous phase. The pseudoaneurysm blood supply was from the uterine artery in 9 patients (90%) and the uterine, superior vesical, internal pudendal and nameless little arteries in 1 patient (10%). Bleeding symptoms were completely relieved in all patients after sandwich embolization. Eight patients experienced painful contractions in the perioperative period, but there were no other postoperative complications. During the 1-year postoperative follow-up, 9 patients (90%) had no re-bleeding symptoms/signs. One patient (10%), who had a pseudoaneurysm supplied by the uterine, superior vesical, internal pudendal and nameless little arteries, experienced re-bleeding 20 days after surgery and was treated by hysterectomy.

CONCLUSION

Modified sandwich embolization is an effective treatment for PPH caused by UAP.

Transcatheter Embolization of Ruptured Uterine Artery Pseudoaneurysm: A Case Report

A 30-years-old post-cesarean lady presented with a secondary post-partum hemorrhage for a week, complicated by anemia, which required blood transfusion. Despite conservative medical management, the bleeding persisted and ultrasonography demonstrated a ruptured left uterine artery pseudoaneurysm. Computed Tomography angiogram was performed for confirmation and planning for embolization. Transcatheter directed uterine artery pseudoaneurysm embolization was performed. Her bleeding was controlled with an uneventful post-procedure period and was discharged after two days. This case report summarizes the procedure of transcatheter embolization of uterine artery pseudoaneurysm in a tertiary care hospital in Nepal.

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.