Postpartum hemorrhage: is angiographically detectable "sac" mandatory for diagnosis of ruptured pseudoaneurysm?

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.

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.