A C TA Obstetricia et Gynecologica Letter to the Editor
References 1. Matsubara S, Yano H, Ohkuchi A, Kuwata T, Usui R, Suzuki M. Uterine compression sutures for postpartum hemorrhage: an overview. Acta Obstet Gynecol Scand. 2013;92:378–85. 2. Grotegut CA, Larsen FW, Jones MR, Livingston E. Erosion of a B-Lynch suture through the uterine wall: a case report. J Reprod Med. 2004;49:849–52. 3. Goojha CA, Case A, Pierson R. Development of Asherman syndrome after conservative surgical management of
intractable postpartum hemorrhage. Fertil Steril. 2010;94:1098. 4. Fuglsang J. Later reproductive health after B-Lynch sutures: a follow-up study after 10 years’ clinical use of the B-Lynch suture. Fertil Steril. 2014;101:1194–9. 5. Rasheed SM, Amin MM, Abd Ellah AH, Abo Elhassan AM, El Zahry MA, Wahab HA. Reproductive performance after conservative surgical treatment of postpartum hemorrhage. Int J Gynaecol Obstet. 2014;124:248–52.
Uterine artery pseudoaneurysm manifesting at the time of evacuation for abortion: pseudoaneurysm without preceding events
Sir The typical uterine artery pseudoaneurysm (UAP) manifests as postpartum or postabortal hemorrhage after traumatic delivery (usually cesarean section) or dilatation and curettage (1–3). During these “traumatic events,” the uterine artery is injured. The injured part is covered by surrounding tissues, making an
aneurysmal structure (pseudoaneurysm) with its lumen connecting with the artery. Its rupture causes hemorrhage (1–3). We reported some “atypical” UAP cases in which there were no preceding “traumatic events,” i.e. UAP after normal vaginal deliveries or after nontraumatic abortion (1–3). However, regardless of trauma, there were usually some “preceding events”
(a)
(b)
(c)
(d)
Figure 1. Ultrasound (a, b), CT (c), and pelvic angiography (d) findings. (a) Ultrasound findings: uterine cavity is occupied by echogenic masses (stars indicate hematoma) and echolucent masses (arrows indicate pseudoaneurysm cavity). (b) Color Doppler findings: black and white image, the echolucent area (arrow) shows pulsatile flow (right panel). (c) Coronal multiplanar reconstruction CT angiogram image shows contrast filling the large pseudoaneurysm [stars; indicative of echolucent masses detected by ultrasound in (a)] with hematoma [arrows; indicative of echogenic masses detected by ultrasound (a)] within the uterus. (d) Selective angiography: pseudoaneurysm (arrowhead) from the right uterine artery (single arrow) is observed. It is not determined whether the contrast medium accumulation (double arrows) above the pseudoaneurysm is another pseudoaneurysm or marked extravasation. Both disappeared after bilateral uterine artery embolization (data not shown).
ª 2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 93 (2014) 720–724
723
Letter to the Editor
for UAP. We recently reported UAP occurring “during” septic abortion, in which “septic status” may be a culprit of, and so in a wider meaning, a preceding event for, UAP occurrence (4). We have now encountered UAP without preceding events, which may have occurred during the course of spontaneous abortion. A 39-year-old pregnant woman was admitted due to massive genital bleeding. She had experienced termination of pregnancy, normal vaginal delivery, and cesarean delivery at 19, 21, and 27 years of age, respectively. Except for the cesarean section, she had no past history of abdominal surgery or trauma. In the 7th gestational week, ultrasound showed a normal-appearing uterus with an empty gestational sac. At 10 weeks of gestation, she had abdominal pain and slight genital bleeding with a urine human chorionic gonadotropin of 9405 U/L; ultrasound showed an empty sac, leading to the diagnosis of incomplete abortion. We decided to perform a curettage and laminaria (Lamicel, a synthetic hydrophilic polymer; Medtronic, Tokyo, Japan) were inserted to slowly dilate the cervix. Two hours later it was removed, resulting in massive bleeding (approximately 500 mL). She was transferred to us. Her blood pressure was 137/76 mmHg, pulse rate 77 bpm, white blood cell count 5700/lL, hemoglobin 9.8 g/dL, and platelets 14.0 9 104/lL. Ultrasound showed echogenic and echolucent masses in the uterine cavity (Figure 1a), with color Doppler showing pulsatile flow in the latter (Figure 1b). Enhanced CT revealed a mass within the uterine cavity (Figure 1c). Pelvic angiography suggested an aneurysm-like structure originating from the right uterine artery with extravasation (Figure 1d). Diagnosing this condition as UAP, the bilateral uterine arteries were embolized with gelatin sponge, stopping extravasation. Hemostasis was achieved. She had no bleeding thereafter and no ischemic events due to embolization. The most probable scenario was that, at the time of hemorrhage, the uterine cavity was filled with echogenic and echolucent masses, with the former suggesting a hematoma and the latter a pseudoaneurysm. The tip of the laminaria may have ruptured the pseudoaneurysm, possibly present at the time of laminaria insertion, in which case, the laminaria acted as a plug until its removal. Although this scenario cannot be confirmed, the important point is that a “preceding event” for the occurrence of UAP was lacking. It is possible that the UAP occurred during the course of the abortion. Previously (5) some underlying condi-
724
tions have been described as responsible for UAP, which could not be determined in this case. UAP may be present when the pregnant uterus is occupied by echogenic and echolucent masses and even when obvious preceding events are absent.
Shigeki Matsubara1,*, Yoshifumi Takahashi1 and Akira Kawai2 1 Department of Obstetrics and Gynecology, and 2Department of Radiology, Jichi Medical University, Tochigi, Japan *Corresponding Author: Shigeki Matsubara E-mail: [email protected] DOI: 10.1111/aogs.12361
References 1. Dohan A, Soyer P, Subhani A, Hequet D, Fargeaudou Y, Morel O, et al. Postpartum hemorrhage resulting from pelvic pseudoaneurysm: a retrospective analysis of 588 consecutive cases treated by arterial embolization. Cardiovasc Intervent Radiol. 2013;36:1247–55. 2. Matsubara S, Takahashi Y, Usui R, Nakata M, Kuwata T, Suzuki M. Uterine artery pseudoaneurysm manifesting as postpartum hemorrhage after uneventful second-trimester pregnancy termination. J Obstet Gynaecol Res. 2010;36:856– 60. 3. Matsubara S, Kuwata T, Usui R, Ohkuchi A. Uterine artery pseudoaneurysm: a master of deception. Arch Gynecol Obstet. 2014;289:469–70. 4. Matsubara S, Nakata M, Baba Y, Suzuki H, Nakamura H, Suzuki M. Uterine artery pseudoaneurysm hidden behind septic abortion: pseudoaneurysm without preceding procedure. J Obstet Gynaecol Res. 2014;40:586–9. 5. Matsubara S, Nonaka H, Kobayashi M, Kawai A, Fujii H. Uterine artery pseudoaneurysm after dilatation and curettage in a woman with multiple hepatic and pulmonary cavernous hemangiomas. Int J Gynecol Obstet. 2014;125: 84–5.
ª 2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 93 (2014) 720–724
References 1. Matsubara S, Yano H, Ohkuchi A, Kuwata T, Usui R, Suzuki M. Uterine compression sutures for postpartum hemorrhage: an overview. Acta Obstet Gynecol Scand. 2013;92:378–85. 2. Grotegut CA, Larsen FW, Jones MR, Livingston E. Erosion of a B-Lynch suture through the uterine wall: a case report. J Reprod Med. 2004;49:849–52. 3. Goojha CA, Case A, Pierson R. Development of Asherman syndrome after conservative surgical management of
intractable postpartum hemorrhage. Fertil Steril. 2010;94:1098. 4. Fuglsang J. Later reproductive health after B-Lynch sutures: a follow-up study after 10 years’ clinical use of the B-Lynch suture. Fertil Steril. 2014;101:1194–9. 5. Rasheed SM, Amin MM, Abd Ellah AH, Abo Elhassan AM, El Zahry MA, Wahab HA. Reproductive performance after conservative surgical treatment of postpartum hemorrhage. Int J Gynaecol Obstet. 2014;124:248–52.
Uterine artery pseudoaneurysm manifesting at the time of evacuation for abortion: pseudoaneurysm without preceding events
Sir The typical uterine artery pseudoaneurysm (UAP) manifests as postpartum or postabortal hemorrhage after traumatic delivery (usually cesarean section) or dilatation and curettage (1–3). During these “traumatic events,” the uterine artery is injured. The injured part is covered by surrounding tissues, making an
aneurysmal structure (pseudoaneurysm) with its lumen connecting with the artery. Its rupture causes hemorrhage (1–3). We reported some “atypical” UAP cases in which there were no preceding “traumatic events,” i.e. UAP after normal vaginal deliveries or after nontraumatic abortion (1–3). However, regardless of trauma, there were usually some “preceding events”
(a)
(b)
(c)
(d)
Figure 1. Ultrasound (a, b), CT (c), and pelvic angiography (d) findings. (a) Ultrasound findings: uterine cavity is occupied by echogenic masses (stars indicate hematoma) and echolucent masses (arrows indicate pseudoaneurysm cavity). (b) Color Doppler findings: black and white image, the echolucent area (arrow) shows pulsatile flow (right panel). (c) Coronal multiplanar reconstruction CT angiogram image shows contrast filling the large pseudoaneurysm [stars; indicative of echolucent masses detected by ultrasound in (a)] with hematoma [arrows; indicative of echogenic masses detected by ultrasound (a)] within the uterus. (d) Selective angiography: pseudoaneurysm (arrowhead) from the right uterine artery (single arrow) is observed. It is not determined whether the contrast medium accumulation (double arrows) above the pseudoaneurysm is another pseudoaneurysm or marked extravasation. Both disappeared after bilateral uterine artery embolization (data not shown).
ª 2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 93 (2014) 720–724
723
Letter to the Editor
for UAP. We recently reported UAP occurring “during” septic abortion, in which “septic status” may be a culprit of, and so in a wider meaning, a preceding event for, UAP occurrence (4). We have now encountered UAP without preceding events, which may have occurred during the course of spontaneous abortion. A 39-year-old pregnant woman was admitted due to massive genital bleeding. She had experienced termination of pregnancy, normal vaginal delivery, and cesarean delivery at 19, 21, and 27 years of age, respectively. Except for the cesarean section, she had no past history of abdominal surgery or trauma. In the 7th gestational week, ultrasound showed a normal-appearing uterus with an empty gestational sac. At 10 weeks of gestation, she had abdominal pain and slight genital bleeding with a urine human chorionic gonadotropin of 9405 U/L; ultrasound showed an empty sac, leading to the diagnosis of incomplete abortion. We decided to perform a curettage and laminaria (Lamicel, a synthetic hydrophilic polymer; Medtronic, Tokyo, Japan) were inserted to slowly dilate the cervix. Two hours later it was removed, resulting in massive bleeding (approximately 500 mL). She was transferred to us. Her blood pressure was 137/76 mmHg, pulse rate 77 bpm, white blood cell count 5700/lL, hemoglobin 9.8 g/dL, and platelets 14.0 9 104/lL. Ultrasound showed echogenic and echolucent masses in the uterine cavity (Figure 1a), with color Doppler showing pulsatile flow in the latter (Figure 1b). Enhanced CT revealed a mass within the uterine cavity (Figure 1c). Pelvic angiography suggested an aneurysm-like structure originating from the right uterine artery with extravasation (Figure 1d). Diagnosing this condition as UAP, the bilateral uterine arteries were embolized with gelatin sponge, stopping extravasation. Hemostasis was achieved. She had no bleeding thereafter and no ischemic events due to embolization. The most probable scenario was that, at the time of hemorrhage, the uterine cavity was filled with echogenic and echolucent masses, with the former suggesting a hematoma and the latter a pseudoaneurysm. The tip of the laminaria may have ruptured the pseudoaneurysm, possibly present at the time of laminaria insertion, in which case, the laminaria acted as a plug until its removal. Although this scenario cannot be confirmed, the important point is that a “preceding event” for the occurrence of UAP was lacking. It is possible that the UAP occurred during the course of the abortion. Previously (5) some underlying condi-
724
tions have been described as responsible for UAP, which could not be determined in this case. UAP may be present when the pregnant uterus is occupied by echogenic and echolucent masses and even when obvious preceding events are absent.
Shigeki Matsubara1,*, Yoshifumi Takahashi1 and Akira Kawai2 1 Department of Obstetrics and Gynecology, and 2Department of Radiology, Jichi Medical University, Tochigi, Japan *Corresponding Author: Shigeki Matsubara E-mail: [email protected] DOI: 10.1111/aogs.12361
References 1. Dohan A, Soyer P, Subhani A, Hequet D, Fargeaudou Y, Morel O, et al. Postpartum hemorrhage resulting from pelvic pseudoaneurysm: a retrospective analysis of 588 consecutive cases treated by arterial embolization. Cardiovasc Intervent Radiol. 2013;36:1247–55. 2. Matsubara S, Takahashi Y, Usui R, Nakata M, Kuwata T, Suzuki M. Uterine artery pseudoaneurysm manifesting as postpartum hemorrhage after uneventful second-trimester pregnancy termination. J Obstet Gynaecol Res. 2010;36:856– 60. 3. Matsubara S, Kuwata T, Usui R, Ohkuchi A. Uterine artery pseudoaneurysm: a master of deception. Arch Gynecol Obstet. 2014;289:469–70. 4. Matsubara S, Nakata M, Baba Y, Suzuki H, Nakamura H, Suzuki M. Uterine artery pseudoaneurysm hidden behind septic abortion: pseudoaneurysm without preceding procedure. J Obstet Gynaecol Res. 2014;40:586–9. 5. Matsubara S, Nonaka H, Kobayashi M, Kawai A, Fujii H. Uterine artery pseudoaneurysm after dilatation and curettage in a woman with multiple hepatic and pulmonary cavernous hemangiomas. Int J Gynecol Obstet. 2014;125: 84–5.
ª 2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 93 (2014) 720–724
