Taiwanese Journal of Obstetrics & Gynecology 53 (2014) 276e278
Contents lists available at ScienceDirect
Taiwanese Journal of Obstetrics & Gynecology journal homepage: www.tjog-online.com
Research Letter
Delayed postpartum hemorrhage secondary to idiopathic rupture of right uterine artery: A case report and literature review Fan-Hlan Koo a, Shan-Tai Chao a, b, Peng-Hui Wang a, b, Hsing-I Wang c, d, e, Shu-Huei Shen f, Chih-Yao Chen a, b, c, *, Ming-Jie Yang a, b, Ming-Shyen Yen a, b, Kuan-Chong Chao a, b a
Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan Department of Obstetrics and Gynecology, National Yang-Ming University, School of Medicine, Taipei, Taiwan Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan d Taipei Mackay Memorial Hospital, Taipei, Taiwan e Mackay Medicine, Nursing and Management College, Taipei, Taiwan f Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan b c
a r t i c l e i n f o Article history: Accepted 8 April 2013
Secondary postpartum hemorrhage or late postpartum hemorrhage is defined as bleeding from 24 hours to 6 weeks after delivery [1]. Characteristics of delayed postpartum hemorrhage are heavy bleeding and signs of impending shock and anemia. Here, we present a rare case of Cesarean section (CS) with recurrent postpartum hemorrhage due to rupture of the right uterine artery. The 35-year-old woman, gravida 3, para 2, spontaneous abortion 1, gave two births by CS in 2008 and 2012, respectively. Her first male baby was delivered by CS due to dysfunctional labor, and the patient had an uneventful postoperative course. In 2012, she delivered her second child, a female, at 39 weeks of gestation, by repetitive CS. At this CS, a lower segment section was applied without complication, and a live female newborn weighing 2986 g was delivered with an Apgar score of 8 at 1 minute and of 9 at 5 minutes. The estimated blood loss was 700 mL. The patient also had an unremarkable postoperative course and was discharged home on the 5th postoperative day. She also received a postpartum visit 2 weeks after being discharged, and the transvaginal sonography disclosed no retained placenta or fetal membranes (Fig. 1). However, the patient experienced profuse vaginal bleeding on the 17th postoperative day and was in the status of impending shock with blood pressure at 54/39 mmHg and pulse rate 98/minute upon her arrival. Her hemoglobin was 9.7g/dL. She
* Corresponding author. Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, 201, Section 2, Shih-Pai Road, Taipei 112, Taiwan. E-mail address: [email protected] (C.-Y. Chen).
received a transfusion with four units of packed red blood cells (PRBC) in the emergency room. A uterotonic agent (oxytocin) was administered at the same time. The vaginal bleeding ceased the day after admission and the clinical presentation improved. Thus, she was discharged 2 days after admission and received a postpartum cervical Pap smear 1 week later. Unfortunately, she experienced recurrent vaginal bleeding on the 44th post CS day. She was sent to the emergency department, where vital signs included a blood pressure of 113/84 mmHg, pulse rate of 107/minute, respiratory rate (R.R.) of 20/minute, and a temperature of 37.8 C. She displayed pallor and weakness. Laboratory data showed hemoglobin at 10.3 g/dL, platelet at 306,000/mm3, international normalized ratio (INR) of 0.99, prothrombin time (PT) of 10.6, and activated partial thromboplastin time (APTT) of 26.7. The transvaginal sonography showed a large blood clot confined within the lower cervix and upper vagina (Fig. 2). Blood transfusion with PRBC was administered and oxytocin was prescribed in the ER. After attaining a stable condition, she was admitted for further management. She then underwent check bleeding in the operating room, and dilation and curettage (D&C) was performed. A 3-way Foley catheter (22 Fr) was inserted into the uterine cavity for balloon tamponade (with 100 mL normal saline inflation), and vaginal rolling gauze packing was also used to stop bleeding. Shock status followed as the bleeding seemed unstoppable, and intravenous fluid resuscitation was given. Blood components, including four units of PRBC, four units of frozen fresh plasma, and one unit of plateletpheresis, were transfused. Emergent transarterial angiography was arranged due to intractable bleeding. The angiography revealed contrast extravasation from the ascending branch of right uterine artery (Fig. 3), suggestive of active bleeding. A mixture of Lipiodol and N-butyl-2-cyanoacrylate (Histoacryl, Braun, Melsungen, Germany) tissue adhesive glue was used for embolization (Fig. 4). Tangles of small vessels from the left uterine artery were also found, and uterine artery embolization was
http://dx.doi.org/10.1016/j.tjog.2013.04.042 1028-4559/Copyright © 2014, Taiwan Association of Obstetrics & Gynecology. Published by Elsevier Taiwan LLC. All rights reserved.
F.-H. Koo et al. / Taiwanese Journal of Obstetrics & Gynecology 53 (2014) 276e278
277
Fig. 1. No retained placental tissue was noted within the endometrial cavity (arrow) 2 weeks after Cesarean section.
Fig. 4. Postembolization digital subtraction angiography of the right internal iliac artery (curved arrow) shows no more contrast extravasation.
Fig. 2. A large echogenic structure is confined within the lower cervix and upper vagina (arrow). Cx ¼ cervix; UB ¼ urinary bladder; UT ¼ uterus.
Fig. 3. Digital subtraction angiography shows contrast extravasation (arrow) from a branch of the right uterine artery.
performed with 500e710 um Contour polyvinyl alcohol (PVA) embolization particles and small cubes of gelfoam until sluggish flow was achieved. The bleeding gradually ceased. The patient received blood transfusion with 12 units of PRBC, six units of frozen fresh plasma, and four units of plateletpheresis in total at different times throughout this hospitalization period. The pathology sections of D&C showed blood clots and fibrinous materials admixed with acute inflammatory cells. Scattered unremarkable endometrial fragments were seen. Neither decidual tissue nor chorionic villi were identified. Serum beta-human chorionic gonadotropin was 0.16 mIU/mL. Significant improvement was seen in the patient after uterine arterial embolization, and she was discharged in a stable condition 6 days later. Postpartum hemorrhage is the leading cause of maternal death [1], accounting for at least 25% of maternal deaths worldwide. Postpartum hemorrhage is defined as an estimated blood loss > 500 mL for a vaginal delivery, or >1000 mL for a CS. It may occur immediately, several hours, days, or even weeks after delivery [1]. If the bleeding occurs for more than 24 hours and up to 6 weeks postpartum, it can be defined as delayed postpartum hemorrhage. This most commonly occurs between 8 days and 14 days postpartum [2] and tends to be associated with maternal morbidity rather than mortality [3]. The common causes of secondary postpartum hemorrhage include retained products of conception, infection, and subinvolution of the placental implantation site [3,4]. Pseudoaneurysm of uterine vessel, arteriovenous malformation, and choriocarcinoma are rare causes of secondary postpartum hemorrhage [2,5e7]. Sometimes, the cause cannot be determined. The patient presented here experienced two episodes of delayed postpartum hemorrhage on the 17th day and 44th day after CS. She received the embolization procedure on the second episode as the therapeutic goal [8,9]. The angiogram revealed contrast extravasation from a branch of the right uterine artery (Fig. 3), suggestive of active bleeding. The use of arterial embolization to control hemorrhage has a reported success rate of 90e95% [1]. Angiographic study assisted in localizing the bleeding site in the case of extravasation of iodinated contrast material [1]. As in our study case, the patient experienced massive bleeding repeatedly until she
278
F.-H. Koo et al. / Taiwanese Journal of Obstetrics & Gynecology 53 (2014) 276e278
received an angiogram to assess the bleeding site, prior to carrying on the embolization of the corresponding artery to achieve full control of bleeding [10]. Angiography remains the standard for diagnosis and may provide definite treatment [11]. In spite of the possibility of a few complications arising from arterial embolization (the most common event is low-grade postprocedural fever), it has distinct advantages, such as being a less invasive procedure, no need for general anesthesia in a potentially unstable patient, ease in identifying the source of bleeding, a tendency to achieve rapid control of the hemorrhage, a low incidence of rebleeding, and a high success rate [11]. Therefore, selective arterial embolization of the uterine arteries is an option in hemodynamically stable patients and is the treatment of choice [8,9,12]. Postpartum hemorrhage is an obstetrical emergency that can follow vaginal or CS delivery. Secondary postpartum hemorrhage affects 0.5e2% of women in developed countries. Delayed postpartum hemorrhage has been paid little attention, due to several factors: (1) it is underestimated because of the difficulties in evaluating blood loss by only visual observation; (2) it is associated with maternal morbidity rather than mortality; and (3) it occurs after hospital discharge [13]. Once late postpartum hemorrhage occurs, it is important to determine the diagnosis and provide management to prevent maternal sequelae. Prompt arterial embolization should be considered in the case of intractable bleeding. It may provide successful control of the bleeding situation, avoiding the ultimate therapeutic option, such as hysterectomy [1]. Conflicts of interest The authors declare no conflicts of interest.
References [1] Pelage JP, Soyer P, Repiquet D, Herbreteau D, Le Dref O, Houdart E, et al. Secondary post-partum hemorrhage: treatment with selective arterial embolization. Radiology 1999;212:385e9. [2] Cooper BC, Hocking-Brown M, Sorosky JI, Hansen WF. Pseudoaneurysm of the uterine artery requiring bilateral uterine artery embolization. J Perinatol 2004;24:560e2. [3] Khong TY, Khong TK. Delayed postpartum hemorrhage: a morphologic study of causes and their relation to other pregnancy disorders. Obstet Gynecol 1993;82:17e22. [4] Lausman AY, Ellis CA, Beecroft JR, Simons M, Shapiro JL. A rare etiology of delayed postpartum hemorrhage. J Obstet Gynaecol Can 2008;30:239e43. [5] Wald DA. Postpartum hemorrhage resulting from uterine artery pseudoaneurysm. J Emerg Med 2003;25:57e60. [6] Descargues G, Douvrin F, Gravier A, Lemoine JP, Marpeau L, Clavier E. False aneurysm of the uterine pedicle: an uncommon cause of post-partum hemorrhage after cesarean section treated with selective arterial embolization. Eur J Obstet Gynecol Reprod Biol 2001;97:26e9. [7] Zimon AE, Hwang JK, Principe DL, Bahado-Singh RO. Pseudoaneurysm of the uterine artery. Obstet Gynecol 1999;94(5 Pt 2):827e30. [8] Vegas G, Illescas T, Munoz M, Perez-Pinar A. Selective pelvic arterial embolization in the management of obstetric hemorrhage. Eur J Obstet Gynecol Reprod Biol 2006;127:68e72. [9] Tourne G, Collet F, Seffert P, Veyret C. Place of embolization of the uterine arteries in the management of post-partum hemorrhage: a study of 12 cases. Eur J Obstet Gynecol Reprod Biol 2003;110:29e34. [10] Brown BJ, Heaston DK, Poulson AM, Gabert HA, Mineau DE, Miller FJ. Uncontrollable postpartum bleeding: a new approach to hemostasis through angiographic arterial embolization. Obstet Gynecol 1979;54:361e5. [11] Yun SY, Lee DH, Cho KH, Lee HM, Choi YH. Delayed postpartum hemorrhage resulting from uterine artery pseudoaneurysm rupture. J Emerg Med 2011;42: e11e4. [12] Yi SW, Ahn JH. Secondary postpartum hemorrhage due to a pseudoaneurysm rupture at the fundal area of the uterus: a case treated with selective uterine arterial embolization. Fertil Steril 2010;93:2048e9. [13] Sumedha S, Usha G, Manisha K, Sanjay T, Neha T. Pseudoaneurysm as a cause of secondary postpartum hemorrhage: a case report and literature review. Anatolian J Obstet Gynecol 2011;4:3.
Contents lists available at ScienceDirect
Taiwanese Journal of Obstetrics & Gynecology journal homepage: www.tjog-online.com
Research Letter
Delayed postpartum hemorrhage secondary to idiopathic rupture of right uterine artery: A case report and literature review Fan-Hlan Koo a, Shan-Tai Chao a, b, Peng-Hui Wang a, b, Hsing-I Wang c, d, e, Shu-Huei Shen f, Chih-Yao Chen a, b, c, *, Ming-Jie Yang a, b, Ming-Shyen Yen a, b, Kuan-Chong Chao a, b a
Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan Department of Obstetrics and Gynecology, National Yang-Ming University, School of Medicine, Taipei, Taiwan Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan d Taipei Mackay Memorial Hospital, Taipei, Taiwan e Mackay Medicine, Nursing and Management College, Taipei, Taiwan f Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan b c
a r t i c l e i n f o Article history: Accepted 8 April 2013
Secondary postpartum hemorrhage or late postpartum hemorrhage is defined as bleeding from 24 hours to 6 weeks after delivery [1]. Characteristics of delayed postpartum hemorrhage are heavy bleeding and signs of impending shock and anemia. Here, we present a rare case of Cesarean section (CS) with recurrent postpartum hemorrhage due to rupture of the right uterine artery. The 35-year-old woman, gravida 3, para 2, spontaneous abortion 1, gave two births by CS in 2008 and 2012, respectively. Her first male baby was delivered by CS due to dysfunctional labor, and the patient had an uneventful postoperative course. In 2012, she delivered her second child, a female, at 39 weeks of gestation, by repetitive CS. At this CS, a lower segment section was applied without complication, and a live female newborn weighing 2986 g was delivered with an Apgar score of 8 at 1 minute and of 9 at 5 minutes. The estimated blood loss was 700 mL. The patient also had an unremarkable postoperative course and was discharged home on the 5th postoperative day. She also received a postpartum visit 2 weeks after being discharged, and the transvaginal sonography disclosed no retained placenta or fetal membranes (Fig. 1). However, the patient experienced profuse vaginal bleeding on the 17th postoperative day and was in the status of impending shock with blood pressure at 54/39 mmHg and pulse rate 98/minute upon her arrival. Her hemoglobin was 9.7g/dL. She
* Corresponding author. Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, 201, Section 2, Shih-Pai Road, Taipei 112, Taiwan. E-mail address: [email protected] (C.-Y. Chen).
received a transfusion with four units of packed red blood cells (PRBC) in the emergency room. A uterotonic agent (oxytocin) was administered at the same time. The vaginal bleeding ceased the day after admission and the clinical presentation improved. Thus, she was discharged 2 days after admission and received a postpartum cervical Pap smear 1 week later. Unfortunately, she experienced recurrent vaginal bleeding on the 44th post CS day. She was sent to the emergency department, where vital signs included a blood pressure of 113/84 mmHg, pulse rate of 107/minute, respiratory rate (R.R.) of 20/minute, and a temperature of 37.8 C. She displayed pallor and weakness. Laboratory data showed hemoglobin at 10.3 g/dL, platelet at 306,000/mm3, international normalized ratio (INR) of 0.99, prothrombin time (PT) of 10.6, and activated partial thromboplastin time (APTT) of 26.7. The transvaginal sonography showed a large blood clot confined within the lower cervix and upper vagina (Fig. 2). Blood transfusion with PRBC was administered and oxytocin was prescribed in the ER. After attaining a stable condition, she was admitted for further management. She then underwent check bleeding in the operating room, and dilation and curettage (D&C) was performed. A 3-way Foley catheter (22 Fr) was inserted into the uterine cavity for balloon tamponade (with 100 mL normal saline inflation), and vaginal rolling gauze packing was also used to stop bleeding. Shock status followed as the bleeding seemed unstoppable, and intravenous fluid resuscitation was given. Blood components, including four units of PRBC, four units of frozen fresh plasma, and one unit of plateletpheresis, were transfused. Emergent transarterial angiography was arranged due to intractable bleeding. The angiography revealed contrast extravasation from the ascending branch of right uterine artery (Fig. 3), suggestive of active bleeding. A mixture of Lipiodol and N-butyl-2-cyanoacrylate (Histoacryl, Braun, Melsungen, Germany) tissue adhesive glue was used for embolization (Fig. 4). Tangles of small vessels from the left uterine artery were also found, and uterine artery embolization was
http://dx.doi.org/10.1016/j.tjog.2013.04.042 1028-4559/Copyright © 2014, Taiwan Association of Obstetrics & Gynecology. Published by Elsevier Taiwan LLC. All rights reserved.
F.-H. Koo et al. / Taiwanese Journal of Obstetrics & Gynecology 53 (2014) 276e278
277
Fig. 1. No retained placental tissue was noted within the endometrial cavity (arrow) 2 weeks after Cesarean section.
Fig. 4. Postembolization digital subtraction angiography of the right internal iliac artery (curved arrow) shows no more contrast extravasation.
Fig. 2. A large echogenic structure is confined within the lower cervix and upper vagina (arrow). Cx ¼ cervix; UB ¼ urinary bladder; UT ¼ uterus.
Fig. 3. Digital subtraction angiography shows contrast extravasation (arrow) from a branch of the right uterine artery.
performed with 500e710 um Contour polyvinyl alcohol (PVA) embolization particles and small cubes of gelfoam until sluggish flow was achieved. The bleeding gradually ceased. The patient received blood transfusion with 12 units of PRBC, six units of frozen fresh plasma, and four units of plateletpheresis in total at different times throughout this hospitalization period. The pathology sections of D&C showed blood clots and fibrinous materials admixed with acute inflammatory cells. Scattered unremarkable endometrial fragments were seen. Neither decidual tissue nor chorionic villi were identified. Serum beta-human chorionic gonadotropin was 0.16 mIU/mL. Significant improvement was seen in the patient after uterine arterial embolization, and she was discharged in a stable condition 6 days later. Postpartum hemorrhage is the leading cause of maternal death [1], accounting for at least 25% of maternal deaths worldwide. Postpartum hemorrhage is defined as an estimated blood loss > 500 mL for a vaginal delivery, or >1000 mL for a CS. It may occur immediately, several hours, days, or even weeks after delivery [1]. If the bleeding occurs for more than 24 hours and up to 6 weeks postpartum, it can be defined as delayed postpartum hemorrhage. This most commonly occurs between 8 days and 14 days postpartum [2] and tends to be associated with maternal morbidity rather than mortality [3]. The common causes of secondary postpartum hemorrhage include retained products of conception, infection, and subinvolution of the placental implantation site [3,4]. Pseudoaneurysm of uterine vessel, arteriovenous malformation, and choriocarcinoma are rare causes of secondary postpartum hemorrhage [2,5e7]. Sometimes, the cause cannot be determined. The patient presented here experienced two episodes of delayed postpartum hemorrhage on the 17th day and 44th day after CS. She received the embolization procedure on the second episode as the therapeutic goal [8,9]. The angiogram revealed contrast extravasation from a branch of the right uterine artery (Fig. 3), suggestive of active bleeding. The use of arterial embolization to control hemorrhage has a reported success rate of 90e95% [1]. Angiographic study assisted in localizing the bleeding site in the case of extravasation of iodinated contrast material [1]. As in our study case, the patient experienced massive bleeding repeatedly until she
278
F.-H. Koo et al. / Taiwanese Journal of Obstetrics & Gynecology 53 (2014) 276e278
received an angiogram to assess the bleeding site, prior to carrying on the embolization of the corresponding artery to achieve full control of bleeding [10]. Angiography remains the standard for diagnosis and may provide definite treatment [11]. In spite of the possibility of a few complications arising from arterial embolization (the most common event is low-grade postprocedural fever), it has distinct advantages, such as being a less invasive procedure, no need for general anesthesia in a potentially unstable patient, ease in identifying the source of bleeding, a tendency to achieve rapid control of the hemorrhage, a low incidence of rebleeding, and a high success rate [11]. Therefore, selective arterial embolization of the uterine arteries is an option in hemodynamically stable patients and is the treatment of choice [8,9,12]. Postpartum hemorrhage is an obstetrical emergency that can follow vaginal or CS delivery. Secondary postpartum hemorrhage affects 0.5e2% of women in developed countries. Delayed postpartum hemorrhage has been paid little attention, due to several factors: (1) it is underestimated because of the difficulties in evaluating blood loss by only visual observation; (2) it is associated with maternal morbidity rather than mortality; and (3) it occurs after hospital discharge [13]. Once late postpartum hemorrhage occurs, it is important to determine the diagnosis and provide management to prevent maternal sequelae. Prompt arterial embolization should be considered in the case of intractable bleeding. It may provide successful control of the bleeding situation, avoiding the ultimate therapeutic option, such as hysterectomy [1]. Conflicts of interest The authors declare no conflicts of interest.
References [1] Pelage JP, Soyer P, Repiquet D, Herbreteau D, Le Dref O, Houdart E, et al. Secondary post-partum hemorrhage: treatment with selective arterial embolization. Radiology 1999;212:385e9. [2] Cooper BC, Hocking-Brown M, Sorosky JI, Hansen WF. Pseudoaneurysm of the uterine artery requiring bilateral uterine artery embolization. J Perinatol 2004;24:560e2. [3] Khong TY, Khong TK. Delayed postpartum hemorrhage: a morphologic study of causes and their relation to other pregnancy disorders. Obstet Gynecol 1993;82:17e22. [4] Lausman AY, Ellis CA, Beecroft JR, Simons M, Shapiro JL. A rare etiology of delayed postpartum hemorrhage. J Obstet Gynaecol Can 2008;30:239e43. [5] Wald DA. Postpartum hemorrhage resulting from uterine artery pseudoaneurysm. J Emerg Med 2003;25:57e60. [6] Descargues G, Douvrin F, Gravier A, Lemoine JP, Marpeau L, Clavier E. False aneurysm of the uterine pedicle: an uncommon cause of post-partum hemorrhage after cesarean section treated with selective arterial embolization. Eur J Obstet Gynecol Reprod Biol 2001;97:26e9. [7] Zimon AE, Hwang JK, Principe DL, Bahado-Singh RO. Pseudoaneurysm of the uterine artery. Obstet Gynecol 1999;94(5 Pt 2):827e30. [8] Vegas G, Illescas T, Munoz M, Perez-Pinar A. Selective pelvic arterial embolization in the management of obstetric hemorrhage. Eur J Obstet Gynecol Reprod Biol 2006;127:68e72. [9] Tourne G, Collet F, Seffert P, Veyret C. Place of embolization of the uterine arteries in the management of post-partum hemorrhage: a study of 12 cases. Eur J Obstet Gynecol Reprod Biol 2003;110:29e34. [10] Brown BJ, Heaston DK, Poulson AM, Gabert HA, Mineau DE, Miller FJ. Uncontrollable postpartum bleeding: a new approach to hemostasis through angiographic arterial embolization. Obstet Gynecol 1979;54:361e5. [11] Yun SY, Lee DH, Cho KH, Lee HM, Choi YH. Delayed postpartum hemorrhage resulting from uterine artery pseudoaneurysm rupture. J Emerg Med 2011;42: e11e4. [12] Yi SW, Ahn JH. Secondary postpartum hemorrhage due to a pseudoaneurysm rupture at the fundal area of the uterus: a case treated with selective uterine arterial embolization. Fertil Steril 2010;93:2048e9. [13] Sumedha S, Usha G, Manisha K, Sanjay T, Neha T. Pseudoaneurysm as a cause of secondary postpartum hemorrhage: a case report and literature review. Anatolian J Obstet Gynecol 2011;4:3.
