Uterine artery pseudoaneurysm: not a rare condition occurring after non-traumatic delivery or non-traumatic abortion

Secondary Postpregnancy Hemorrhage: Guide for Diagnosis and Management

Secondary postpregnancy hemorrhage (PPH) is increasing in incidence, especially in developed countries such as the United States. PPH occurs after 24 hours and up to 12 weeks in the postpregnancy period and may be associated with significant maternal morbidity. Common causes of secondary PPH are subinvolution of the placental site (SIPS) and retained or residual products of conception (RPOC). Other less common and rare causes include bleeding diathesis, endo(myo)metritis, gestational trophoblastic disease, and vascular anomalies such as congenital arteriovenous malformation (AVM), iatrogenic arteriovenous fistula, or pseudoaneurysm. A common finding encountered during imaging evaluation of secondary PPH is increased vascularity in the myometrium deep to an implantation site, termed enhanced myometrial vascularity (EMV). EMV typically represents the physiologic reversion of the uterus back to its prepregnancy state. The appearance of EMV varies from mild to marked and is also associated with SIPS and RPOC. Interpretation or reporting of EMV as an AVM or other rare uterine vascular anomaly may lead to unnecessary testing and overtreatment. The authors review placental physiology, describe the causes of secondary PPH and their imaging appearances, and present an algorithm to assist the radiologist in diagnosis of this important condition and management options. ©RSNA, 2025 Supplemental material is available for this article. See the invited commentary by Gomez in this issue.

Differential diagnosis of uterine vascular anomalies: Uterine pseudoaneurysm as a cause of massive hemorrhage

In this article, we comment on the paper by Kakinuma et al published recently. We focus specifically on the diagnosis of uterine pseudoaneurysm, but we also review other uterine vascular anomalies that may be the cause of life-threating hemorrhage and the different causes of uterine pseudoaneurysms. Uterine artery pseudoaneurysm is a complication of both surgical gynecological and non-traumatic procedures. Massive hemorrhage is the consequence of the rupture of the pseudoaneurysm. Uterine artery pseudoaneurysm can develop after obstetric or gynecological procedures, being the most frequent after cesarean or vaginal deliveries, curettage and even during pregnancy. However, there are several cases described unrelated to pregnancy, such as after conization, hysteroscopic surgery or laparoscopic myomectomy. Hemorrhage is the clinical manifestation and it can be life-threatening so suspicion of this vascular lesion is essential for early diagnosis and treatment. However, there are other uterine vascular anomalies that may be the cause of severe hemorrhage, which must be taken into account in the differential diagnosis. Computed tomography angiography and embolization is supposed to be the first therapeutic option in most of them.

Fatal risk in hysteroscopic surgery that should not be overlooked: Uterine artery pseudoaneurysm

This article provides a detailed account of the diagnosis and treatment of a case involving a uterine artery pseudoaneurysm (UAP), as well as an analysis of UAP etiology. This finding emphasizes that UAP should be considered in patients presenting with abnormal genital bleeding after hysteroscopy and offers valuable insights and lessons for gynecologists in hysteroscopic procedures. The patient underwent timely relevant examinations to confirm the diagnosis, allowing for crucial time required for her treatment. In this study, the primary cause of UAP formation in the patient was attributed to a prior hysteroscopic surgical procedure conducted at another medical facility, suggesting that the selection and implementation of dilatation catheters are some of the predisposing factors for UAP. In conclusion, this case study offers a comprehensive analysis of the etiology of UAP and effectively provides timely diagnosis and treatment, offering valuable insights for the clinical diagnosis and management of UAP.

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.

Postpartum hemoperitoneum - A rare case of uterine artery pseudoaneurysm rupture after uncomplicated vaginal delivery

OBJECTIVE

Our aim is to demonstrate a rare cause of hemoperitoneum without vaginal bleeding resulting from the rupture of a uterine artery pseudoaneurysm after uncomplicated vaginal delivery.

CASE REPORT

A 39-year-old woman who had experienced a normal vaginal delivery 8 days previously to being seen in our hospital, was presented to the emergency room with hypovolemic shock. Computed tomography angiography (CTA) showed massive internal bleeding and a ruptured pseudoaneurysm arising from the left uterine artery. The patient was successfully treated through transcatheter arterial embolization (TAE).

CONCLUSION

A pseudoaneurysm is a rare disease which can occur during an uncomplicated vaginal delivery. The clinical presentation can vary from asymptomatic, vaginal bleeding or hemoperitoneum. The diagnosis can be made by using Doppler sonography, CTA or Magnetic Resonance Imaging. The use of TAE is now the most common treatment option and possesses a high success rate.

A Case of Ruptured Exophytic Uterine Artery Pseudoaneurysm without Specific Risk Factors That Manifested Seven Days after Vaginal Delivery

A uterine artery pseudoaneurysm (UAP) is a life-threatening complication during pregnancy and postpartum. Early diagnosis of exophytic UAP rupture is difficult due to the absence of vaginal bleeding. This study reports the case of a 31-year-old postpartum woman who presented with abdominal pain and fever seven days after vaginal delivery, without symptoms of maternal shock. Ultrasonography revealed a ruptured exophytic UAP with hemoperitoneum, which was confirmed using computed tomography. Interventional radiology confirmed that the site of the pseudoaneurysm was at the level of the uterine artery bifurcation, and embolization was performed immediately after diagnosis using a coil and n-butyl-2-cyanoacrylate. The patient's symptoms were relieved, and she was discharged 12 days after the embolization. At eight months postpartum, the UAP was not visible on transvaginal ultrasonography. Exophytic UAP can occur even in the absence of specific risk factors such as cesarean section or endometriosis, and the UAP may not necessarily rupture immediately after delivery. Obstetricians must remain aware of the possibility of exophytic UAP rupture manifesting as abdominal pain with postpartum fever, rather than as unstable vital signs. This is the first report of an exophytic UAP that occurred at the level of the uterine artery bifurcation. Identification of the sites where exophytic UAP can occur can aid in the early diagnosis of the condition.

Uterine disorders and iron deficiency anemia

Abnormal uterine bleeding (AUB) is a clinical entity which can lead to iron deficiency anemia. Classification according to the acronym PALM-COEIN (polyp, adenomyosis, leiomyoma, malignancy, and hyperplasia; coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not otherwise classified) provides a structured approach to establish the cause of AUB. The goal of this review is to discuss the different mechanisms and the relationship between uterine disorders and AUB. Heavy menstrual bleeding, a subgroup of AUB, is more closely related to the presence of uterine fibroids. The relationship between heavy menstrual bleeding and uterine fibroids remains poorly characterized, particularly the understanding of endometrial function in women with structural myometrial features such as leiomyomas. A number of theories have been proposed in the literature and are discussed in this review. Uterine adenomyosis is also a frequent cause of AUB, and its pathogenesis is still far from being fully elucidated. The mechanisms contributing to its development are multifactorial. Many theories lean toward invasion of the myometrium by endometrial cells. Both clinical and basic studies favor the theory of direct invasion, although de novo development of adenomyosis from Müllerian rests or stem cells has not been ruled out. Development of adenomyotic lesions involves repeated tissue injury and repair. In addition, this review describes the other causes of AUB such as endometrial polyps, cesarean scar defects, and uterine vascular abnormalities. Endometrial polyps are often asymptomatic, but approximately 68% of women have concomitant AUB. Histologic alterations in the lower uterine segment in patients who had undergone cesarean sections were identified and may explain the cause of AUB.

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.

Diagnosis and treatment of uterine artery pseudoaneurysm: Case series and literature review

BACKGROUND

Uterine artery pseudoaneurysm (UAP) is a rare but potentially life-threatening cause of hemorrhage. Nonetheless, its knowledge could be insufficient among obstetricians, gynecologists, and radiologists. We aimed to clarify the clinical characteristics, management, and outcomes of UAP.

METHODS

We retrospectively analyzed nine female patients diagnosed with UAP at our institute between 2013 and 2020.

RESULTS

Seven cases presented with a history of traumatic surgery including cesarean section, dilation and curettage, laparoscopic myomectomy, and cervical conization. Two cases occurred after spontaneous vaginal delivery and second-trimester pregnancy termination. The main symptom was heavy/massive/prolonged vaginal bleeding. All patients were first evaluated by color Doppler ultrasonography and three cases were confirmed by magnetic resonance imaging. Severn patients underwent transarterial embolization (TAE) of the uterine arteries, and two were managed conservatively. All patients had good outcomes.

CONCLUSIONS

UAP can develop after traumatic pelvic operations and non-traumatic delivery/abortion. It may be more common than previously considered. The risk of rupture may be correlated with multiple factors other than the mass size. TAE of the uterine artery could be an effective management strategy for ruptured UAP. However, some cases can resolve spontaneously without TAE, suggesting that conservative management can be employed in some women.

Pseudoaneurysm of the uterine artery with presentation of haematuria; a rare case report

Introduction

Pseudoaneurysm of the uterine artery is a condition in which extra luminal collection of blood with a turbulent flow that communicates with flowing blood of uterine artery through a defect in its arterial wall. As per literature uterine artery pseudoaneurysm is a very rare condition and its incidence is 2–3/1000 deliveries. Clinical diagnosis is very challenging and in the index case haematuria was the presenting complaint which in fact is the extremely rare presenting complaint. Angioembolization is the ideal treatment modality for such a rare condition.

Case presentation

A 25-year old female presented in a shock state with history of massive haematuria two months after delivering a baby. She was resuscitated with fluid, blood and blood products. A computed tomography angiogram was done which showed a large pseudoaneurysm of the left uterine artery so consequently angioembolization was done with n-butyl cyanoacrylate (NBCA) and lipoid mixture. Serial assessment of biochemical and clinical parameters depicted improvement in the clinical status of the patient. She was doing well at 6 months of follow up.

Discussion

A post-partum massive haematuria could be due to pseudo aneurysm of uterine artery. The presentation of haematuria may occur due to communication of aneurysm with urinary bladder and which further get ruptured. Aggressive resuscitation and angioembolization of the pseudoaneurysm is employed to treat such patients.

Conclusion

Pseudoaneurysm of uterine artery is rare condition which may present as haematuria. Once clinical diagnosis is suspected it's better to first resuscitate and plan for angioembolization for better outcome.

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Pseudoaneurysm of uterine artery presented with haematuria is the first case to be reported in the leterature.

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Clinically the pseudoaneurysm of uterine artery should be considered in mind in patients with massive haematuria after caesarean/normal deliveries.

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Aggressive resuscitation and definitive management with embolization is the ideal treatment for such cases.

Uterine pseudoaneurysm on the basis of deep infiltrating endometriosis during pregnancy-a case report

Background

Pseudoaneurysm of the uterine artery (UPA) is a rare cause of potentially life-threatening hemorrhage during pregnancy and puerperium. It is an uncommon condition that mainly occurs after traumatic injury to a vessel following pelvic surgical intervention, but also has been reported based on underlying endometriosis. There is an increased risk of developing UPA during pregnancy. Diagnosis includes clinical symptoms, with severe abdominal pain and is confirmed by sonographic or magnetic resonance imaging (MRI). Due to its potential risk of rupture, with a subsequent hypovolemic maternal shock and high fetal mortality, an interdisciplinary treatment should be considered expeditiously.

Case presentation

We present the case of a 34-year old pregnant symptomatic patient, where a large UPA was detected at 26 weeks, based on deep infiltrating endometriosis (DIE). The UPA was successfully treated by selective arterial embolization. After embolization, the pain decreased but the woman still required intravenous analgesics during follow-up. At 37 weeks she developed a sepsis from the intravenous catheter which led to a cesarean section and delivery of a healthy boy. She was discharged 10 days postpartum.

Conclusions

UPA should be considered in pregnant women with severe abdominal and pelvic pain, once other obstetrical factors have been excluded. DIE might be the underlying diagnosis. It is a rare but potentially life-threatening condition for mother and fetus.

ACR Appropriateness Criteria® Postpartum Hemorrhage

Postpartum hemorrhage (PPH) can be categorized as primary or early if occurring in the first 24 hours after delivery, whereas late or delayed PPH occurs between 24 hours and 6 weeks. Most of the causes of PPH can be diagnosed clinically, but imaging plays an important role in the diagnosis of many causes of PPH. Pelvic ultrasound (transabdominal and transvaginal with Doppler) is the imaging modality of choice for the initial evaluation of PPH. Contrast-enhanced CT of the abdomen and pelvis and CT angiogram of the abdomen and pelvis may be appropriate to determine if active ongoing hemorrhage is present, to localize the bleeding, and to identify the source of bleeding. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

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.

Uterine Artery Pseudoaneurysm: A Case Report

Pseudoaneurysm is an extraluminal collection of blood with a turbulent flow that communicates with flowing arterial blood through a defect in the arterial wall. Uterine artery pseudoaneurysm (UAP) is considered a rare case that occurs in 2–3/1,000 deliveries. A 33-year-old pregnant woman was admitted for a planned caesarian section. After a successful delivery, the patient experienced a postpartum vaginal bleeding 3 days later. Sonography revealed a suspected right UAP, and the diagnosis was confirmed by angiography. The defect was treated by uterine artery embolization.

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.

Uterine Artery Pseudoaneurysm: A Life-Threatening Cause of Vaginal Bleeding in the Emergency Department

BACKGROUND

Vaginal bleeding is a common presenting complaint in the emergency department (ED); life-threatening hemorrhage is rare. Uterine artery pseudoaneurysm (UAP) is an uncommon but potentially life-threatening cause of vaginal bleeding that is most likely to present primarily to EDs, given its delayed postpartum or postoperative presentation.

CASE REPORT

A 25-year-old female gravida two, para one, who was 19 days post dilation and evacuation for an elective termination of a pregnancy at 20 weeks, presented to the ED with profuse vaginal bleeding. She was hypotensive and tachycardic at presentation, requiring resuscitation with 0.9% normal saline and transfusions of packed red blood cells. Transvaginal ultrasound completed in the ED demonstrated a pulsatile mass in the cervix with internal "ying-yang" flow on Doppler images, suggestive of a uterine artery pseudoaneurysm within the cervix. The patient underwent emergent uterine artery embolization with resolution of bleeding and improvement in her hemodynamic status. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: UAP is an uncommon cause of vaginal bleeding, but UAP rupture can be life-threatening. UAP is an important differential diagnosis for vaginal bleeding, particularly in the postpartum or postoperative setting. Delaying diagnosis may worsen bleeding in the setting of a ruptured UAP if treatment is pursued for alternative diagnosis; for example, treating retained products of conception with a dilation and curettage. Being aware of UAP and how to diagnose it will allow early proper treatment and more favorable patient outcomes.

True Aneurysm of the Uterine Artery in a Young Nulliparous Female: An Extremely Rare Vascular Entity

We present the first case of a large true uterine artery aneurysm, with a 5-cm diameter, in a 35-year-old nulliparous woman who presented with lower abdominal pain and dyspareunia. She underwent successful ligation and excision of the aneurysm using the Pfannenstiel approach. The diagnostic modalities and treatment option for such a case is discussed herein.

Long-term uterine balloon tamponade for treatment and obliteration of ruptured uterine pseudoaneurysm

OBJECTIVE

Rupture of uterine artery pseudoaneurysm (UAP) is a life-threatening event after childbirth. Hysterectomy or uterine arterial embolization was often needed for hemostasis. However, such procedures may cause severe morbidities for these women. To estimate the efficacy of uterine balloon tamponade (UBT) for controlling ruptured UAP bleeding, a retrospective analysis in a single teaching hospital was performed.

MATERIALS AND METHODS

We reviewed the medical record of Juntendo University Hospital in 2015. All the women diagnosed with UAP were recruited to this study and management for UAP was investigated.

RESULTS

Three women were treated with UBT for ruptured UAP. All cases achieved hemostasis. One case had recurrent UAP after 24 h of UBT, and was retreated with UBT for a longer duration. The UAP was obliterated after more than 2 days of UBT in all cases.

CONCLUSION

UBT has potential as a therapeutic technique not only for treatment of a ruptured UAP but also for obliteration of a UAP.

Hypervascular retained product of conception: Characteristic magnetic resonance imaging and possible relationship to placental polyp and pseudoaneurysm

The cases of two patients who developed myometrial vascularization following dilatation and curettage are described. In case 1, pathological diagnosis was possible with the resected specimens. This patient had hypervascular retained products of conception (RPOC). In case 2, the natural course of this pathological condition was observed, confirming a process of regression during repeated withdrawal bleeding. The three principal magnetic resonance imaging (MRI) findings in these cases were: (i) presence of a remnant; (ii) breaking of the junctional zone in contact with the remnant; and (iii) vascularization/flow voids infiltrating into the myometrium from the broken junctional zone. These three MRI findings differed in degree and varied in combination in each case of RPOC. Uterine artery pseudoaneurysms have been reported as intrauterine vascularization after abortion or delivery with subsequent spontaneous regression. These reports may include cases of hypervascular RPOC.

Delayed postpartum hemoperitoneum due to uterine artery pseudoaneurysm rupture

A 30-year-old woman experienced severe abdominal pain 8 days after vaginal delivery. The patient was diagnosed with hemoperitoneum due to rupture of the left uterine artery pseudoaneurysm, which was confirmed via ultrasound with color Doppler and computed tomography scans. This patient was treated with bilateral uterine artery embolization to maintain fertility. A uterine artery pseudoaneurysm that causes delayed postpartum hemorrhage can occur after cesarean section or vaginal delivery. A uterine artery pseudoaneurysm can be fatal, so its detection and diagnosis are critical. Herein, we report a case of delayed postpartum hemoperitoneum due to uterine artery pseudoaneurysm rupture.

Antepartum hemorrhage from previous-cesarean-sectioned uterus as a potential sign of uterine artery pseudoaneurysm

Postpartum hemorrhage (PPH), a leading cause of maternal mortality, can occur within 24 h of delivery (primary PPH), or during the period from 24 h after delivery to Week 6 of puerperium (secondary PPH). It requires health professionals to be alert to the symptoms to ensure prompt diagnosis and treatment, especially in the case of rupture of a uterine artery pseudoaneurysm (UAP) due to its life-threatening consequence (Baba et al., 2014). Most of the published case reports or case serials describe UAP as a possible cause of delayed PPH after traumatic procedures during delivery or pregnancy termination, including cesarean section (CS), manual removal of the placenta, or dilation and curettage (D&C) (Wald, 2003). Herein, we report a case of prior CS-related UAP manifesting as primary PPH after an uncomplicated vaginal delivery. This case required emergency embolization and is notable for several reasons. Antepartum hemorrhage of the previously scarred uterus was a potential sign of the ruptured UAP, and color Doppler sonography sometimes deceived the physician as the characteristic features of UAP did not appear to be present.

Embolization of iatrogenic uterine pseudoaneurysm

Uterine artery pseudoaneurysms (UAPs) are rare vascular lesions that may be life threatening if not diagnosed and properly treated. The clinical presentation of UAPs includes a spectrum of symptoms that are often associated with other and more frequent gynecologic/obstetric pathologies, both with and without vaginal bleeding, and may span from postpartum hemorrhage to the absence of symptoms. We report cases of two patients with UAP, both of whom were diagnosed with ultrasonography and contrast-enhanced computed tomography and successfully treated with transcatheter embolization. The first patient presented delayed hypovolemic shock following surgery for endometriosis, whereas the second patient suffered from postpartum hemorrhage after cesarean section. Diagnosis of UAPs relies on noninvasive imaging; transcatheter arterial embolization is an effective treatment to control bleeding in both hemodynamically stable and unstable patients.

Rupture of uterine artery pseudoaneurysm: role of ultrasonography in postpartum hemorrhage management

Uterine artery pseudoaneurysm (UAP) rupture should be considered in case of late genital bleeding without obvious cause and lead to perform a sonographic examination with Doppler-scan. We report two cases of late post-partum hemorrhage from UAP diagnosed as such using color Doppler US. In order to avert life-threatening bleeding, prompt and accurate diagnosis should be made using color Doppler US since the latter plays a significant role in demonstrating the vascular nature of this anechoic uterine lesion.

Management of uterine artery pseudoaneurysm: advanced ultrasonography imaging and laparoscopic surgery as an alternative method to angio-computed tomography and transarterial embolization

Uterine artery pseudoaneurysms (UAP) are rare but potentially life-threatening lesions. They may occur after traumatic deliveries, cesarean sections, and other interventions. We present a case of a 39-year-old woman with a UAP. The patient was accurately diagnosed using ultrasound imaging, with subsequent diagnostic hysteroscopy and laparoscopic excision of the UAP. In the present case, a ligation of the artery branch was performed to provide accurate hemostasis during UAP dissection. The vascular lesion was partially enucleated and removed, followed by recreation of the previous uterine shape. Power Doppler with HD flow and 3D ultrasound are accurate methods in the diagnosis of UAP. We are of the opinion that laparoscopic surgery can be on a par with transarterial embolization. During laparoscopy, the surgeon can either close the feeding vessel or remove the pathological tissue. In our opinion, this method solves the problem permanently and, after a successful case series with long-term follow-up, might be applied in other centers as well.

Uterine artery pseudoaneurysm caused by a uterine manipulator

A uterine artery pseudoaneurysm (UAP) can occur after a traumatic event to the uterus, and cause massive bleeding. A uterine manipulator has been widely used for gynecologic laparoscopic surgery as basically an atraumatic instrument. We describe here a woman with a UAP caused by a uterine manipulator. She underwent laparoscopic ovarian cystectomy with a uterine manipulator due to torsion of a left ovarian cyst. Eleven days later, she came to our hospital with massive vaginal bleeding. Transvaginal Color Doppler ultrasound showed an intrauterine cystic mass with swirling blood flow, and three-dimensional arterial imaging from computed tomography revealed a UAP on the left side. Selective uterine artery angiography demonstrated a pseudoaneurysm in the distal portion of the left uterine artery, and embolization was performed successfully. A UAP should be taken into consideration in uterine bleeding after the use of a uterine manipulator.

Uterine artery pseudoaneurysm: its occurrence after non-traumatic events, and possibility of "without embolization" strategy

OBJECTIVES

Uterine artery pseudoaneurysm (UAP) has been considered to occur very rarely after traumatic delivery/abortion, and is usually detected after its rupture, yielding massive bleeding. Our hypothesis is: some UAP may be undetected without massive bleeding and may spontaneously resolve, and, thus, may not require transarterial embolization (TAE). We attempted: (1) to detect both ruptured and non-ruptured UAP, thereby characterizing candidates of spontaneously resolving UAP, and (2) to confirm that UAP is not rare and not always associated with traumatic events.

STUDY DESIGN

This was a retrospective observational study of 50 women with angiographically confirmed UAP and treated by TAE. Angiograms and medical charts were retrieved to examine the associations among symptoms, ultrasound findings, and extravasation. Gray-scale ultrasound was performed for all women after delivery or abortion as our routine practice.

RESULTS

UAP occurred in 3-6/1000 deliveries and 40% occurred after non-traumatic deliveries/abortion. While 36% had active vaginal bleeding at admission, 64% did not. While 100% of patients with current active bleeding showed extravasation from the pseudoaneurysmal sac, patients without it showed a varied incidence of extravasation depending on the bleeding pattern/history and ultrasound findings. Interestingly, all patients with current bleeding (-), bleeding history (+), and ultrasound-discernable-intrauterine low echoic mass (-) were devoid of extravasation, suggesting that UAP may show progression to thrombosis and, thus, resolve spontaneously.

CONCLUSIONS

UAP may not be so rare and not associated with traumatic delivery/abortion. Some UAP may resolve, and, thus, may not require TAE, at least immediately.

Spontaneous resolution of post-delivery or post-abortion uterine artery pseudoaneurysm: A report of three cases

Post-delivery/-abortion uterine artery pseudoaneurysm (UAP) sometimes causes life-threatening bleeding, requiring transarterial embolization (TAE). It is unclear whether some UAP resolve spontaneously. In three patients, UAP resolved spontaneously without TAE. Case 1 was after vacuum delivery with slight bleeding: at day 5 post-partum, a yin-yang sign on Color Doppler and an enhanced intrauterine sac-like structure were observed, leading to the diagnosis of UAP, which disappeared at 4 weeks post-partum. Case 2 was after vacuum delivery with manual placental removal and was asymptomatic: a hypoechoic intrauterine mass with a yin-yang sign were observed during a post-partum routine check-up and the intrauterine flow disappeared at 4 weeks post-partum. Case 3 was after dilatation and curettage in the first trimester with slight bleeding: UAP was detected at 4 weeks post-abortion, which disappeared at 6 weeks post-abortion. All three cases had a small UAP (diameter: 10-15 mm) and low-level or no symptoms. Some UAP may resolve spontaneously and, thus, may not require TAE.

An exceptional outcome from a rare cause of postpartum haemodynamic collapse

We present a case of a 26-year-old woman presenting with haemorrhagic shock without any overt bleeding on postpartum day 2. Work up revealed intra-abdominal haemorrhage from an unclear source in the pelvis. She was intubated, resuscitated with mostly crystalloids, and started on norepinephrine and dopamine, in a rural hospital with limited resources. She was then transferred to the closest tertiary care centre 3 h away by air. On arrival, she was hypothermic (34.9°C) and had developed severe metabolic acidosis (pH 6.89). A massive transfusion protocol was initiated. She underwent an emergency laparotomy and the origin of the active bleeding was believed to be a branch of the right internal iliac artery. Haemostasis was achieved with packing. She was subsequently taken to interventional radiology for angioembolisation of the right uterine artery as an alternative to haemostatic hysterectomy. Her final diagnosis was rupture of an extrauterine uterine artery pseudoaneurysm.

Severe Postcoital Bleeding From a Uterine Artery Pseudoaneurysm 4 Months After Cesarean Delivery

BACKGROUND

Uterine artery pseudoaneurysm is considered a rare complication of gynecologic and obstetric procedures. The delayed diagnosis of this condition may result in life-threatening hemorrhage.

CASE

A 34-year-old woman underwent an urgent cesarean delivery for labor dystocia. The procedure was complicated with hemorrhage from the uterine incision angles requiring extra hemostatic suture. She presented with secondary postpartum hemorrhage on day 14 and again with life-threatening postcoital vaginal bleeding 4 months after cesarean delivery. Magnetic resonance imaging and angiography revealed a uterine artery Pseudoaneurysm, which was treated with uterine artery embolization.

CONCLUSION

Uterine artery pseudoaneurysm should be considered as a differential diagnosis in patients presenting with postpartum hemorrhage, especially if bleeding is significant and recurrent, particularly after an operative delivery. The diagnosis of a pseudoaneurysm can be made by color Doppler ultrasonography, computed tomography, magnetic resonance imaging, and angiography.

Post-partum hemoperitoneum: Do not miss false aneurysm as a cause of bleeding

A 27-year-old woman underwent a first vaginal delivery at our institution. She returned four days after delivery, presenting with abdominal pain and an unexplained drop in her hemoglobin value, without external bleeding. The initial computed tomography abdominal scan revealed an isolated diffuse hemoperitoneum. A laparoscopy did not find the cause of bleeding. A second computed tomography scan, performed 15 days later, revealed hemoperitoneum associated with a false aneurysm of the right uterine artery. Treatment consisted of embolization of the uterine arteries, with clinical success. False aneurysms are a rare cause of intra-abdominal non-exteriorized bleeding in late post-partum hemorrhage.

Novel pathophysiological cause for post-partum hemorrhage: Case report of post-partum hemorrhage with occult abnormal artery diagnosed on pelvic angiography

To the best of our knowledge, this is the first report of post-partum hemorrhage (PPH) caused by an occult abnormal artery detected shortly after delivery on pelvic angiography (PAG). Initially, a diagnosis of uterine atony was made because the apparent cause of hemorrhage was not detected via the usual obstetrical examination. An abnormal artery, however, was suspected on PAG and confirmed on pathology. This case suggests a novel cause of persistent PPH resistant to obstetric management. Obstetricians should be aware that an abnormal artery may cause PPH, and that radiology may be required for diagnosis.