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

Kakinuma K., Kakinuma T., Ueyama K., Okamoto R., Yanagida K., Takeshima N., Ohwada M.

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 After the Laminken-R® was withdrawn, a large amount of genital bleeding was observed.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.

Jennings L., Presley B., Krywko D.

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.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.

Ludwin A., Martins W.P., Ludwin I.

A pseudoaneurysm is a blood-filled cavity communicating with the lumen of the artery and surrounding perivascular tissue creates a wall of pseudoaneurysm. Uterine artery pseudoaneurysm (UAP) after myomectomy is considered a rare and potentially life-threatening event1.

Ciebiera M., Słabuszewska-Jóźwiak A., Zaręba K., Jakiel G.

Kanao S., Miyatake T., Tanaka A., Takeda M., Miyoshi A., Mimura M., Nagamatsu M., Yokoi T.

Baba Y., Matsubara S., Kuwata T., Ohkuchi A., Usui R., Saruyama M., Nakata M., Suzuki M.

Uterine artery pseudoaneurysm (UAP) is considered a rare disorder after traumatic delivery or traumatic pregnancy termination such as cesarean section or dilatation and curettage, initially manifesting as genital hemorrhage. Our clinical impression contradicts these three assumptions; after traumatic delivery/termination, hemorrhage, and its rarity. Thus, we attempted to clarify these three issues. We retrospectively analyzed 22 UAP cases treated at our institute over a 6-year period. Uterine artery pseudoaneurysm occurred in 2–3/1,000 deliveries. Of 22 cases, half occurred after non-traumatic deliveries or non-traumatic pregnancy termination. Fifty-five percent (12/22) showed no hemorrhage; ultrasound or color Doppler revealed UAP. Thus, half of UAP occurred after non-traumatic deliveries or non-traumatic pregnancy termination and showed no hemorrhage at the time of their diagnoses. All patients received transarterial embolization, which stopped blood flow into UAP or achieved hemostasis. We must be aware that UAP may not be so rare and it may be present in patients after non-traumatic deliveries/pregnancy termination and without postpartum or postabortal hemorrhage.

Kwon J.H., Kim G.S.

Uterine curettage or surgical trauma can cause uterine vascular abnormalities, including pseudoaneurysms, acquired arteriovenous malformations (AVMs), arteriovenous fistulas, and rupture of vessels. Recognition of these abnormalities as the cause of hemorrhage is important, since these abnormalities can be treated safely and effectively with transcatheter arterial embolization but may be worsened by uterine curettage, precipitating massive uterine bleeding. Ultrasonography (US) is the most commonly performed initial imaging examination for evaluation of abnormal uterine bleeding. Color and duplex Doppler US allows convincing detection and diagnosis of these vascular abnormalities and helps differentiate vascular abnormalities that require embolization from nonvascular abnormalities. In cases of pseudoaneurysms, color and duplex Doppler US shows a blood-filled cystic structure with swirling arterial flow. In cases of AVMs, color Doppler US shows an intense vascular tangle, whereas duplex Doppler US shows low-resistance, high-velocity arterial flow. Cases of an AVM combined with a pseudoaneurysm demonstrate the findings of both AVMs and pseudoaneurysms. Transcatheter arterial embolization after angiography is the therapy of choice for these vascular abnormalities, with the advantage of retained reproductive capacity. Routine use of color and duplex Doppler US during examination of abnormal uterine bleeding is recommended to identify and characterize the vascular abnormality.

Kuwata T., Matsubara S., Kaneko Y., Izumi A., Nakata M., Suzuki M.

Uterine artery pseudoaneurysm is a rare but important complication of cesarean section (CS). If treated inadequately, it may cause profuse life-threatening postpartum hemorrhage. We report an asymptomatic postpartum woman with uterine artery pseudoaneurysm after CS. We also provide a review of published reports of pseudoaneurysm after CS. A 31-year-old Japanese woman underwent CS, in which the uterine incision was extended laterally. Routine postoperative evaluation with vaginal ultrasound on postpartum day 6 revealed a parauterine mass with a maximum diameter of 49 mm with swirling flow. Selective angiography confirmed this mass as a uterine artery pseudoaneurysm. Uterine artery embolization was performed with success. Uterine artery pseudoaneurysm should be listed as a differential diagnosis of pelvic mass after CS.

Lee W.K., Roche C.J., Duddalwar V.A., Buckley A.R., Morris D.C.

Uterine artery pseudoaneurysm is a rare but serious complication of pelvic surgery. Radiology has an important role in its diagnosis and primary management. We believe that this complication and its management are of importance to those assessing for complications following pelvic surgery.

Langer J.E., Cope C.

The development of an arterial pseudoaneurysm is a rare but reported complication of pelvic surgery. Typically the lesion is discovered because the patient has symptoms related to delayed rupture of the pseudoaneurysm, causing hemorrhage. We report a case in which an uterine artery pseudoaneurysm was detected 14 days after vaginal hysterectomy by TVUS, which was performed prior to a transvaginal drainage procedure to treat an infected pelvic hematoma.