Novel Insights from Clinical Practice Gynecol Obstet Invest 2014;78:136–140 DOI: 10.1159/000363742
Received: April 18, 2013 Accepted after revision: May 18, 2014 Published online: July 9, 2014
Uterine Artery Pseudoaneurysm Manifesting as Delayed Postpartum Hemorrhage after Precipitous Delivery: Three Case Reports Jong Woon Kim a Yoon Ha Kim a Chul Hong Kim a Moon Kyoung Cho a Woo Dae Kang a Seok Mo Kim a Nam Yeol Yim b Tae-Bok Song a Departments of a Obstetrics and Gynecology and b Radiology, Chonnam National University Medical School, Gwangju, Korea
Established Facts • Precipitous delivery leads to serious maternal and neonatal complications. • Uterine artery pseudoaneurysm (UAP) is one of the causes of delayed postpartum hemorrhage.
Novel Insights • Precipitous delivery may lead to UAP. • UAP can be manifested as a mass protruding through the cervix. Management should include gentle physical examination and ultrasonographic evaluation using color Doppler.
Key Words Precipitous delivery · Uterine artery pseudoaneurysm · Delayed postpartum hemorrhage
sonogram and pelvic angiography revealed the UAP in each case and uterine artery embolization was performed. UAP may be a complication of precipitous delivery. © 2014 S. Karger AG, Basel
Abstract Precipitous delivery may lead to serious maternal and neonatal complications. Uterine artery pseudoaneurysm (UAP) is one of the causes of delayed postpartum hemorrhage. Here we describe 3 cases of UAP manifesting as delayed postpartum hemorrhage after precipitous delivery. The duration of the second stage of labor in cases 1, 2, and 3 was 15, 15, and 60 min, respectively. Excessive vaginal bleeding occurred 10, 9, and 31 days after delivery, respectively. Ultra-
© 2014 S. Karger AG, Basel 0378–7346/14/0782–0136$39.50/0 E-Mail [email protected] www.karger.com/goi
Introduction
Uterine artery pseudoaneurysm (UAP) has emerged as a possible cause of delayed postpartum hemorrhage. Pseudoaneurysm is an extraluminal collection of blood with turbulent flow that communicates with flowing arterial blood through a defect in the arterial wall. Such a defect is usually a consequence of a local trauma with vasYoon Ha Kim, MD, PhD Department of Obstetrics and Gynecology Chonnam National University Medical School 8 Hakdong, Donggu, Gwangju 501-190 (Korea) E-Mail kimyh @ jnu.ac.kr
Table 1. Summary of the cases
Parameters
Case 1
Case 2
Case 3
Age Delivery mode Gestational age on delivery, weeks Duration of labor, min Birth weight, g Immediate postpartum hemorrhage Birth canal laceration Oxytocin induction or augmentation Vacuum or forceps delivery Hysterectomy Timing of first embolization, postpartum day Times of embolization Embolization materials
37 SD 301/7 15 1,450 no no yes no no 31 1 gelatin sponge
28 SD 282/7 15 1,020 no no no no no 9 4 gelatin sponge (1st and 2nd) PVA particles (3rd and 4th) microcoils (4th)
28 SD 38 60 3,050 no no no no no 32 1 gelatin sponge
The duration of labor indicates the time interval between the active phase and delivery. Gelatin sponge: Cutanplast® (Mascia Brunelli SpA, Milan, Italy). PVA particles: Contour® (Boston Scientific, Natick, Mass., USA). Microcoils: VortX® (Boston Scientific); Tornado® (Cook, Bloomington, Ind., USA). SD = Spontaneous vaginal delivery.
cular injury. UAP is associated with a previously performed surgical procedure, such as cesarean section, dilatation and curettage, hysterectomy, or myomectomy [1]. Precipitous labor terminates in expulsion of the fetus in less than 3 h and represented 2% of all recorded births in the United States in 2006 [2]. Precipitous labor and delivery may be accompanied by serious maternal complication. Vigorous uterine contractions combined with a long, firm cervix and a noncompliant birth canal may lead to uterine rupture or birth canal laceration [3]. In this report, we present the clinical presentation and management of 3 cases of UAP manifesting as delayed postpartum hemorrhage after precipitous delivery. Case Series (table 1)
min) on electrical monitoring. Since clinical chorioamnionitis was suspected, tocolytics were stopped. There were no uterine contractions, so oxytocin augmentation was started. As the patient proceeded to the active phase of labor, and her cervix dilated to 4 cm in diameter, oxytocin was stopped. Just 15 min later, the cervix dilated fully and a 1,450-g female infant was delivered. Although it was a precipitous delivery, the patient was discharged from hospital 2 days after delivery without any complications. Eight days later, the patient visited our hospital with vaginal bleeding. On physical examination, a 4-cm-sized necrotic mass was found protruding from the external os (fig. 1a). Ultrasonographic examination included a check for UAP with turbulent flow on color Doppler imaging (fig. 2). Due to constant bleeding for 3 weeks, a pelvic angiography was performed which revealed a pseudoaneurysm connected to the right uterine artery. Selective right uterine arteriography and embolization with gelatin sponge were performed successfully. The patient recovered uneventfully following embolization and was discharged. An outpatient examination conducted 10 days later revealed no cervical necrotic mass on pelvic examination (fig. 1b).
Case 1 A 37-year-old woman, gravida 3 para 2 at 28 weeks of gestation, visited our hospital with watery vaginal discharge and regular uterine contractions. She was diagnosed with preterm labor with preterm premature rupture of membranes. There were no fever and chills or uterine tenderness. She was treated with tocolytic agents, corticosteroid, and antibiotics. Nine days later, she complained of febrile sensation. The body temperature was 37.8 ° C, white blood cell count was 17.3 × 103/mm3, and high-sensitivity C-reactive protein was 12.8 mg/dl. There was fetal tachycardia (170 beats/
Case 2 A 28-year-old woman, primipara at 26 weeks of gestation, visited our hospital with watery vaginal discharge and was diagnosed with preterm premature rupture of membranes. She was treated with tocolytic agents, corticosteroids, and antibiotics. Twelve days later, she complained of regular uterine contractions. Her cervix was dilated to 4 cm in diameter, so tocolytics were stopped. Fifteen minutes later, her cervix dilated fully and she delivered a 1,020-g female infant. She was discharged from hospital 2 days after delivery without any complications. Seven days later, she visited our
UAP Manifesting as Delayed Postpartum Hemorrhage after Precipitous Delivery
Gynecol Obstet Invest 2014;78:136–140 DOI: 10.1159/000363742
137
Color version available online
Fig. 1. Results of speculum examination in case 1. a On the first visit, a 4-cm-sized ne-
a
b
a
b
Color version available online
crotic mass was revealed protruding from the cervix (arrow). b Ten days after uterine arterial embolization, there was no mass lesion.
Fig. 2. Ultrasonographic examination in
case 3 revealing an echocomplex mass (arrows) of the uterine cervix with turbulent flow on color Doppler.
Fig. 3. Fourth embolization due to failed hemorrhage control in case 2. a A selective
right uterine artery angiogram demonstrates an engorged and tortuous uterine artery. An active extravasation into the uterine cavity is also seen (arrow). The right uterine artery was embolized with 344–500 μm contour PVA particles and fibered microcoils. b A selective right internal iliac artery angiogram obtained after embolization confirmed no further extravasation and complete exclusion of the right uterine artery. Note evidence of coil embolization of the left uterine artery (arrowhead).
138
Gynecol Obstet Invest 2014;78:136–140 DOI: 10.1159/000363742
Kim /Kim /Kim /Cho /Kang /Kim /Yim / Song
hospital with vaginal bleeding. On physical examination, a 3-cmsized necrotic mass was found protruding from the external os. She was diagnosed as having an UAP by ultrasonogram and pelvic angiogram. Uterine artery embolization was performed. She experienced vaginal bleeding again several days later. Additional embolization was performed three times (fig. 3). Twenty days later (80 days after delivery), she visited the outpatient department. No cervical necrotic mass was evident on pelvic examination. Case 3 A 28-year-old woman, gravida 1 para 1 at 38 weeks of gestation, visited our hospital with regular uterine contractions. The time interval between active phase and delivery was 60 min. She delivered a 3,050-g male infant. She was discharged from hospital 1 day after delivery without any complications. Thirty days later, she visited our hospital with vaginal bleeding. An ultrasonographic examination showed an echocomplex mass in the endometrium and UAP was diagnosed on color Doppler imaging. A pelvic angiogram and uterine artery embolization were performed the next day. She recovered uneventfully following embolization and was discharged. Ten days later, she visited the outpatient department. At her follow-up visit (after 34 days) there was no lesion on ultrasonographic examination.
Discussion
In this case series, we observed that UAP manifested as delayed postpartum hemorrhage after precipitous delivery. UAP is a rare complication of obstetric and gynecologic procedures, such as cesarean section, myomectomy, hysterectomy, and abortion [4, 5]. A pseudoaneurysm is a blood-filled space resulting from an incomplete sealing of the arterial lumen due to a deficiency of one or more layers of the arterial wall [6]. A pseudoaneurysm differs from a true aneurysm in that the former partly consists of the peripheral thrombus and the latter is surrounded by three arterial layers [7]. Injuries to the arterial vessel are more likely during a cesarean section, which could subsequently give rise to UAP [8]. Considering the strong forces in precipitous labor, the uterine arterial wall may be damaged and form a pseudoaneurysm after precipitous delivery. No report has mentioned the relationship between precipitous delivery and UAP so far. In the past, the majority of UAPs were treated with hysterectomy, with or without hypogastric artery ligation [7]. The efficacy and safety of selective arterial embolization of the uterine artery have also been improved in women with delayed postpartum hemorrhage. The success rate following embolization is 97–100% [9, 10]. Gelatin sponge and metallic coils are effective for the treatment of ruptured pseudoaneurysms [11]. As spontaneous UAP Manifesting as Delayed Postpartum Hemorrhage after Precipitous Delivery
resolution or separation after embolization is possible, as in the currently described cases, embolization should be the first-line treatment when the vital signs are stable. A necrotic mass protruding through the cervix was seen in cases 1 and 2. This is unusual for pseudoaneurysm, and differential diagnosis should include retained placenta, pedunculated myoma, uterine inversion, cervical prolapse, and cervix cancer. Ultrasonographic examination of a pseudoaneurysm shows the turbulent flow on color Doppler. Periodic assessment of vaginal bleeding and ultrasonographic examination should be performed after embolization. In cases 1 and 3, vaginal bleeding was stopped, and there was no turbulent flow on color Doppler. As in case 2, if vaginal bleeding and turbulent flow on color Doppler still remain, additional therapeutic options including embolization can be performed, and repeat embolization is frequently successful [12]. UAP may lead to massive bleeding upon manipulation and even soft touch. The bleeding risk increases when the pseudoaneurysm protrudes from the cervix, as occurred in 2 of the present cases. Careful and thorough postpartum management is therefore essential in women who had a precipitous delivery. Management should include gentle physical examination and ultrasonographic evaluation using color Doppler. According to our experience, UAP may be a complication of precipitous delivery.
Disclosure Statement The authors have no conflicts of interest to disclose.
References
1 Mahon TR, Chazotte C, Cohen WR: Short labor: characteristics and outcome. Obstet Gynecol 1994;84:47–51. 2 Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F, Kirmeyer S, Mathews TJ: Births: Final data for 2006. National vital statistics reports from the Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System 2009;57:1–104. 3 Kovo M, Behar DJ, Friedman V, Malinger G: Pelvic arterial pseudoaneurysm – a rare complication of cesarean section: diagnosis and novel treatment. Ultrasound Obstet Gynecol 2007;30:783–785. 4 Kim YA, Han YH, Jun KC, Jeon MK, Lee ES: Uterine artery pseudoaneurysm manifesting delayed postabortal bleeding. Fertil Steril 2008;90:849.
Gynecol Obstet Invest 2014;78:136–140 DOI: 10.1159/000363742
139
5 Lee WK, Roche CJ, Duddalwar VA, Buckley AR, Morris DC: Pseudoaneurysm of the uterine artery after abdominal hysterectomy: radiologic diagnosis and management. Am J Obstet Gynecol 2001;185:1269–1272. 6 Zimon AE, Hwang JK, Principe DL, BahadoSingh RO: Pseudoaneurysm of the uterine artery. Obstet Gynecol 1999;94:827–830. 7 Descargues G, Douvrin F, Gravier A, Lemoine JP, Marpeau L, Clavier E: False aneurysm of the uterine pedicle: an uncommon cause of post-partum haemorrhage after caesarean section treated with selective arterial embolization. Eur J Obstet Gynecol Reprod Biol 2001;97:26–29.
140
8 Chitra TV, Panicker S: Pseudoaneurysm of uterine artery: a rare cause of secondary postpartum hemorrhage. J Obstet Gynaecol India 2011;61:641–644. 9 Vedantham S, Goodwin SC, McLucas B, Mohr G: Uterine artery embolization: an underused method of controlling pelvic hemorrhage. Am J Obstet Gynecol 1997; 176: 938– 948. 10 Soyer P, Fargeaudou Y, Morel O, Boudiaf M, Le Dref O, Rymer R: Severe postpartum haemorrhage from ruptured pseudoaneurysm: successful treatment with transcatheter arterial embolization. Eur Radiol 2008;18: 1181–1187.
Gynecol Obstet Invest 2014;78:136–140 DOI: 10.1159/000363742
11 Dohan A, Soyer P, Subhani A, Hequet D, Fargeaudou Y, Morel O, Boudiaf M, Gayat E, Barranger E, Le Dref O, Sirol M: Postpartum hemorrhage resulting from pelvic pseudoaneurysm: a retrospective analysis of 588 consecutive cases treated by arterial embolization. Cardiovasc Intervent Radiol 2013; 36: 1247–1255. 12 Kirby JM, Kachura JR, Rajan DK, Sniderman KW, Simons ME, Windrim RC, Kingdom JC: Arterial embolization for primary postpartum hemorrhage. J Vasc Interv Radiol 2009; 20:1036–1045.
Kim /Kim /Kim /Cho /Kang /Kim /Yim / Song
Copyright: S. Karger AG, Basel 2014. Reproduced with the permission of S. Karger AG, Basel. Further reproduction or distribution (electronic or otherwise) is prohibited without permission from the copyright holder.
Received: April 18, 2013 Accepted after revision: May 18, 2014 Published online: July 9, 2014
Uterine Artery Pseudoaneurysm Manifesting as Delayed Postpartum Hemorrhage after Precipitous Delivery: Three Case Reports Jong Woon Kim a Yoon Ha Kim a Chul Hong Kim a Moon Kyoung Cho a Woo Dae Kang a Seok Mo Kim a Nam Yeol Yim b Tae-Bok Song a Departments of a Obstetrics and Gynecology and b Radiology, Chonnam National University Medical School, Gwangju, Korea
Established Facts • Precipitous delivery leads to serious maternal and neonatal complications. • Uterine artery pseudoaneurysm (UAP) is one of the causes of delayed postpartum hemorrhage.
Novel Insights • Precipitous delivery may lead to UAP. • UAP can be manifested as a mass protruding through the cervix. Management should include gentle physical examination and ultrasonographic evaluation using color Doppler.
Key Words Precipitous delivery · Uterine artery pseudoaneurysm · Delayed postpartum hemorrhage
sonogram and pelvic angiography revealed the UAP in each case and uterine artery embolization was performed. UAP may be a complication of precipitous delivery. © 2014 S. Karger AG, Basel
Abstract Precipitous delivery may lead to serious maternal and neonatal complications. Uterine artery pseudoaneurysm (UAP) is one of the causes of delayed postpartum hemorrhage. Here we describe 3 cases of UAP manifesting as delayed postpartum hemorrhage after precipitous delivery. The duration of the second stage of labor in cases 1, 2, and 3 was 15, 15, and 60 min, respectively. Excessive vaginal bleeding occurred 10, 9, and 31 days after delivery, respectively. Ultra-
© 2014 S. Karger AG, Basel 0378–7346/14/0782–0136$39.50/0 E-Mail [email protected] www.karger.com/goi
Introduction
Uterine artery pseudoaneurysm (UAP) has emerged as a possible cause of delayed postpartum hemorrhage. Pseudoaneurysm is an extraluminal collection of blood with turbulent flow that communicates with flowing arterial blood through a defect in the arterial wall. Such a defect is usually a consequence of a local trauma with vasYoon Ha Kim, MD, PhD Department of Obstetrics and Gynecology Chonnam National University Medical School 8 Hakdong, Donggu, Gwangju 501-190 (Korea) E-Mail kimyh @ jnu.ac.kr
Table 1. Summary of the cases
Parameters
Case 1
Case 2
Case 3
Age Delivery mode Gestational age on delivery, weeks Duration of labor, min Birth weight, g Immediate postpartum hemorrhage Birth canal laceration Oxytocin induction or augmentation Vacuum or forceps delivery Hysterectomy Timing of first embolization, postpartum day Times of embolization Embolization materials
37 SD 301/7 15 1,450 no no yes no no 31 1 gelatin sponge
28 SD 282/7 15 1,020 no no no no no 9 4 gelatin sponge (1st and 2nd) PVA particles (3rd and 4th) microcoils (4th)
28 SD 38 60 3,050 no no no no no 32 1 gelatin sponge
The duration of labor indicates the time interval between the active phase and delivery. Gelatin sponge: Cutanplast® (Mascia Brunelli SpA, Milan, Italy). PVA particles: Contour® (Boston Scientific, Natick, Mass., USA). Microcoils: VortX® (Boston Scientific); Tornado® (Cook, Bloomington, Ind., USA). SD = Spontaneous vaginal delivery.
cular injury. UAP is associated with a previously performed surgical procedure, such as cesarean section, dilatation and curettage, hysterectomy, or myomectomy [1]. Precipitous labor terminates in expulsion of the fetus in less than 3 h and represented 2% of all recorded births in the United States in 2006 [2]. Precipitous labor and delivery may be accompanied by serious maternal complication. Vigorous uterine contractions combined with a long, firm cervix and a noncompliant birth canal may lead to uterine rupture or birth canal laceration [3]. In this report, we present the clinical presentation and management of 3 cases of UAP manifesting as delayed postpartum hemorrhage after precipitous delivery. Case Series (table 1)
min) on electrical monitoring. Since clinical chorioamnionitis was suspected, tocolytics were stopped. There were no uterine contractions, so oxytocin augmentation was started. As the patient proceeded to the active phase of labor, and her cervix dilated to 4 cm in diameter, oxytocin was stopped. Just 15 min later, the cervix dilated fully and a 1,450-g female infant was delivered. Although it was a precipitous delivery, the patient was discharged from hospital 2 days after delivery without any complications. Eight days later, the patient visited our hospital with vaginal bleeding. On physical examination, a 4-cm-sized necrotic mass was found protruding from the external os (fig. 1a). Ultrasonographic examination included a check for UAP with turbulent flow on color Doppler imaging (fig. 2). Due to constant bleeding for 3 weeks, a pelvic angiography was performed which revealed a pseudoaneurysm connected to the right uterine artery. Selective right uterine arteriography and embolization with gelatin sponge were performed successfully. The patient recovered uneventfully following embolization and was discharged. An outpatient examination conducted 10 days later revealed no cervical necrotic mass on pelvic examination (fig. 1b).
Case 1 A 37-year-old woman, gravida 3 para 2 at 28 weeks of gestation, visited our hospital with watery vaginal discharge and regular uterine contractions. She was diagnosed with preterm labor with preterm premature rupture of membranes. There were no fever and chills or uterine tenderness. She was treated with tocolytic agents, corticosteroid, and antibiotics. Nine days later, she complained of febrile sensation. The body temperature was 37.8 ° C, white blood cell count was 17.3 × 103/mm3, and high-sensitivity C-reactive protein was 12.8 mg/dl. There was fetal tachycardia (170 beats/
Case 2 A 28-year-old woman, primipara at 26 weeks of gestation, visited our hospital with watery vaginal discharge and was diagnosed with preterm premature rupture of membranes. She was treated with tocolytic agents, corticosteroids, and antibiotics. Twelve days later, she complained of regular uterine contractions. Her cervix was dilated to 4 cm in diameter, so tocolytics were stopped. Fifteen minutes later, her cervix dilated fully and she delivered a 1,020-g female infant. She was discharged from hospital 2 days after delivery without any complications. Seven days later, she visited our
UAP Manifesting as Delayed Postpartum Hemorrhage after Precipitous Delivery
Gynecol Obstet Invest 2014;78:136–140 DOI: 10.1159/000363742
137
Color version available online
Fig. 1. Results of speculum examination in case 1. a On the first visit, a 4-cm-sized ne-
a
b
a
b
Color version available online
crotic mass was revealed protruding from the cervix (arrow). b Ten days after uterine arterial embolization, there was no mass lesion.
Fig. 2. Ultrasonographic examination in
case 3 revealing an echocomplex mass (arrows) of the uterine cervix with turbulent flow on color Doppler.
Fig. 3. Fourth embolization due to failed hemorrhage control in case 2. a A selective
right uterine artery angiogram demonstrates an engorged and tortuous uterine artery. An active extravasation into the uterine cavity is also seen (arrow). The right uterine artery was embolized with 344–500 μm contour PVA particles and fibered microcoils. b A selective right internal iliac artery angiogram obtained after embolization confirmed no further extravasation and complete exclusion of the right uterine artery. Note evidence of coil embolization of the left uterine artery (arrowhead).
138
Gynecol Obstet Invest 2014;78:136–140 DOI: 10.1159/000363742
Kim /Kim /Kim /Cho /Kang /Kim /Yim / Song
hospital with vaginal bleeding. On physical examination, a 3-cmsized necrotic mass was found protruding from the external os. She was diagnosed as having an UAP by ultrasonogram and pelvic angiogram. Uterine artery embolization was performed. She experienced vaginal bleeding again several days later. Additional embolization was performed three times (fig. 3). Twenty days later (80 days after delivery), she visited the outpatient department. No cervical necrotic mass was evident on pelvic examination. Case 3 A 28-year-old woman, gravida 1 para 1 at 38 weeks of gestation, visited our hospital with regular uterine contractions. The time interval between active phase and delivery was 60 min. She delivered a 3,050-g male infant. She was discharged from hospital 1 day after delivery without any complications. Thirty days later, she visited our hospital with vaginal bleeding. An ultrasonographic examination showed an echocomplex mass in the endometrium and UAP was diagnosed on color Doppler imaging. A pelvic angiogram and uterine artery embolization were performed the next day. She recovered uneventfully following embolization and was discharged. Ten days later, she visited the outpatient department. At her follow-up visit (after 34 days) there was no lesion on ultrasonographic examination.
Discussion
In this case series, we observed that UAP manifested as delayed postpartum hemorrhage after precipitous delivery. UAP is a rare complication of obstetric and gynecologic procedures, such as cesarean section, myomectomy, hysterectomy, and abortion [4, 5]. A pseudoaneurysm is a blood-filled space resulting from an incomplete sealing of the arterial lumen due to a deficiency of one or more layers of the arterial wall [6]. A pseudoaneurysm differs from a true aneurysm in that the former partly consists of the peripheral thrombus and the latter is surrounded by three arterial layers [7]. Injuries to the arterial vessel are more likely during a cesarean section, which could subsequently give rise to UAP [8]. Considering the strong forces in precipitous labor, the uterine arterial wall may be damaged and form a pseudoaneurysm after precipitous delivery. No report has mentioned the relationship between precipitous delivery and UAP so far. In the past, the majority of UAPs were treated with hysterectomy, with or without hypogastric artery ligation [7]. The efficacy and safety of selective arterial embolization of the uterine artery have also been improved in women with delayed postpartum hemorrhage. The success rate following embolization is 97–100% [9, 10]. Gelatin sponge and metallic coils are effective for the treatment of ruptured pseudoaneurysms [11]. As spontaneous UAP Manifesting as Delayed Postpartum Hemorrhage after Precipitous Delivery
resolution or separation after embolization is possible, as in the currently described cases, embolization should be the first-line treatment when the vital signs are stable. A necrotic mass protruding through the cervix was seen in cases 1 and 2. This is unusual for pseudoaneurysm, and differential diagnosis should include retained placenta, pedunculated myoma, uterine inversion, cervical prolapse, and cervix cancer. Ultrasonographic examination of a pseudoaneurysm shows the turbulent flow on color Doppler. Periodic assessment of vaginal bleeding and ultrasonographic examination should be performed after embolization. In cases 1 and 3, vaginal bleeding was stopped, and there was no turbulent flow on color Doppler. As in case 2, if vaginal bleeding and turbulent flow on color Doppler still remain, additional therapeutic options including embolization can be performed, and repeat embolization is frequently successful [12]. UAP may lead to massive bleeding upon manipulation and even soft touch. The bleeding risk increases when the pseudoaneurysm protrudes from the cervix, as occurred in 2 of the present cases. Careful and thorough postpartum management is therefore essential in women who had a precipitous delivery. Management should include gentle physical examination and ultrasonographic evaluation using color Doppler. According to our experience, UAP may be a complication of precipitous delivery.
Disclosure Statement The authors have no conflicts of interest to disclose.
References
1 Mahon TR, Chazotte C, Cohen WR: Short labor: characteristics and outcome. Obstet Gynecol 1994;84:47–51. 2 Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F, Kirmeyer S, Mathews TJ: Births: Final data for 2006. National vital statistics reports from the Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System 2009;57:1–104. 3 Kovo M, Behar DJ, Friedman V, Malinger G: Pelvic arterial pseudoaneurysm – a rare complication of cesarean section: diagnosis and novel treatment. Ultrasound Obstet Gynecol 2007;30:783–785. 4 Kim YA, Han YH, Jun KC, Jeon MK, Lee ES: Uterine artery pseudoaneurysm manifesting delayed postabortal bleeding. Fertil Steril 2008;90:849.
Gynecol Obstet Invest 2014;78:136–140 DOI: 10.1159/000363742
139
5 Lee WK, Roche CJ, Duddalwar VA, Buckley AR, Morris DC: Pseudoaneurysm of the uterine artery after abdominal hysterectomy: radiologic diagnosis and management. Am J Obstet Gynecol 2001;185:1269–1272. 6 Zimon AE, Hwang JK, Principe DL, BahadoSingh RO: Pseudoaneurysm of the uterine artery. Obstet Gynecol 1999;94:827–830. 7 Descargues G, Douvrin F, Gravier A, Lemoine JP, Marpeau L, Clavier E: False aneurysm of the uterine pedicle: an uncommon cause of post-partum haemorrhage after caesarean section treated with selective arterial embolization. Eur J Obstet Gynecol Reprod Biol 2001;97:26–29.
140
8 Chitra TV, Panicker S: Pseudoaneurysm of uterine artery: a rare cause of secondary postpartum hemorrhage. J Obstet Gynaecol India 2011;61:641–644. 9 Vedantham S, Goodwin SC, McLucas B, Mohr G: Uterine artery embolization: an underused method of controlling pelvic hemorrhage. Am J Obstet Gynecol 1997; 176: 938– 948. 10 Soyer P, Fargeaudou Y, Morel O, Boudiaf M, Le Dref O, Rymer R: Severe postpartum haemorrhage from ruptured pseudoaneurysm: successful treatment with transcatheter arterial embolization. Eur Radiol 2008;18: 1181–1187.
Gynecol Obstet Invest 2014;78:136–140 DOI: 10.1159/000363742
11 Dohan A, Soyer P, Subhani A, Hequet D, Fargeaudou Y, Morel O, Boudiaf M, Gayat E, Barranger E, Le Dref O, Sirol M: Postpartum hemorrhage resulting from pelvic pseudoaneurysm: a retrospective analysis of 588 consecutive cases treated by arterial embolization. Cardiovasc Intervent Radiol 2013; 36: 1247–1255. 12 Kirby JM, Kachura JR, Rajan DK, Sniderman KW, Simons ME, Windrim RC, Kingdom JC: Arterial embolization for primary postpartum hemorrhage. J Vasc Interv Radiol 2009; 20:1036–1045.
Kim /Kim /Kim /Cho /Kang /Kim /Yim / Song
Copyright: S. Karger AG, Basel 2014. Reproduced with the permission of S. Karger AG, Basel. Further reproduction or distribution (electronic or otherwise) is prohibited without permission from the copyright holder.
