Top

CardioVascular and Interventional Radiology

Published in:

01-10-2013 | Clinical Investigation

Postpartum Hemorrhage Resulting from Pelvic Pseudoaneurysm: A Retrospective Analysis of 588 Consecutive Cases Treated by Arterial Embolization

Authors: Anthony Dohan, Philippe Soyer, Aqeel Subhani, Delphine Hequet, Yann Fargeaudou, Olivier Morel, Mourad Boudiaf, Etienne Gayat, Emmanuel Barranger, Olivier Le Dref, Marc Sirol

Published in: CardioVascular and Interventional Radiology | Issue 5/2013

Abstract

Objective

This study was designed to determine the incidence of arterial pseudoaneurysm in patients presenting with postpartum hemorrhage (PPH), to analyze the angiographic characteristics of pseudoaneurysms that cause PPH, and to evaluate the effectiveness of pelvic arterial embolization for the treatment of this condition.

Study design

Eighteen women with pelvic arterial pseudoaneurysm were retrieved from a series of 588 consecutive patients with PPH treated by arterial embolization. Clinical files, angiographic examinations, and procedure details were reviewed.

Results

The incidence of pseudoaneurysm was 3.06 % (18/588; 95 % confidence interval (CI): 1.82–4.8 %). A total of 20 pseudoaneurysms were found; 15/20 (75 %) were located on the uterine arteries. Angiography revealed extravasation of contrast material from pseudoaneurysm indicating rupture in 9 of 18 (50 %) patients. Arterial embolization was performed using gelatin sponge alone in 12 of 18 (67 %) patients or in association with metallic coils in 5 of 18 (28 %) patients or n-butyl-2-cyanoacrylate in 1 of 18 (6 %) patients. Arterial embolization allowed controlling the bleeding in all patients after one or two embolization sessions in 17 of 18 (94 %) and 1 of 18 patients (6 %) respectively, without complications, obviating the need for further surgery.

Conclusions

Pseudoaneurysm is rarely associated with PPH. Arterial embolization is an effective and safe procedure for the treatment of PPH due to uterine or vaginal artery pseudoaneurysm. Our results suggest that gelatin sponge is effective for the treatment of ruptured pseudoaneurysms, although we agree that our series does not contain sufficient material to allow drawing definitive conclusions with respect to the most effective embolic material.

Al-Zirqi I, Vangen S, Forsen L, Stray-Pedersen B (2008) Prevalence and risk factors of severe obstetric haemorrhage. BJOG 115:1265–1272PubMedCrossRef

Jouppila P (1995) Postpartum haemorrhage. Curr Opin Obstet Gynecol 7:446–450PubMedCrossRef

Pelage JP, Le Dref O, Mateo J et al (1998) Life-threatening primary postpartum hemorrhage: treatment with emergency selective arterial embolization. Radiology 208:359–362PubMed

Combs CA, Murphy EL, Laros RK Jr (1991) Factors associated with postpartum hemorrhage with vaginal birth. Obstet Gynecol 77:69–76PubMed

Pelage JP, Soyer P, Repiquet D et al (1999) Secondary postpartum hemorrhage: treatment with selective arterial embolization. Radiology 212:385–389PubMed

Khong TY, Khong TK (1993) Delayed postpartum hemorrhage: a morphologic study of causes and their relation to other pregnancy disorders. Obstet Gynecol 82:17–22PubMed

Kwon JH, Kim GS (2002) Obstetric iatrogenic arterial injuries of the uterus: diagnosis with US and treatment with transcatheter arterial embolization. Radiographics 22:35–46PubMed

Langer JE, Cope C (1999) Ultrasonographic diagnosis of uterine artery pseudoaneurysm after hysterectomy. J Ultrasound Med 18:711–714PubMed

Wald DA (2003) Postpartum hemorrhage resulting from uterine artery pseudoaneurysm. J Emerg Med 25:57–60PubMedCrossRef

10.

Zimon AE, Hwang JK, Principe DL, Bahado-Singh RO (1999) Pseudoaneurysm of the uterine artery. Obstet Gynecol 94:827–830PubMedCrossRef

11.

Bromley PJ, Clark T, Weir IH, Zwirewich CV (1997) Radiologic diagnosis and management of uterine artery pseudoaneurysm: case report. Can Assoc Radiol J 48:119–122PubMed

12.

McGonegle SJ, Dziedzic TS, Thomas J, Hertzberg BS (2006) Pseudoaneurysm of the uterine artery after an uncomplicated vaginal delivery. J Ultrasound Med 25:1593–1597PubMed

13.

Combs CA, Murphy EL, Laros RK Jr (1991) Factors associated with hemorrhage in cesarean delivery. Obstet Gynecol 77:77–82PubMed

14.

Brunschwig A, Brockunier A (1960) Postoperative rupture of major vessels after radical pelvic operation. Am J Obstet Gynecol 80:485–489PubMed

15.

Cooper BC, Hocking-Brown M, Sorosky JI, Hansen WF (2004) Pseudoaneurysm of the uterine artery requiring bilateral uterine artery embolization. J Perinatol 24:560–562PubMedCrossRef

16.

Eason DE, Tank RA (2006) Avoidable morbidity in a patient with pseudoaneurysm of the uterine artery after cesarean section. J Clin Ultrasound 34:407–411PubMedCrossRef

17.

Lee HY, Shin JH, Kim J et al (2012) Primary postpartum hemorrhage: outcome of pelvic arterial embolization in 251 patients at a single institution. Radiology 264:903–909PubMedCrossRef

18.

Bardou P, Orabona M, Vincelot A, Maubon A, Nathan N (2010) Uterine artery false aneurysm after caesarean delivery: an uncommon cause of post-partum haemorrhage. Ann Fr Anesth Reanim 29:909–912PubMedCrossRef

19.

Samad S, Jonetzko P, Hawkins AP, Booth J, Thorpe-Beeston G, Marwood R (2009) An unusual cause of delayed postpartum haemorrhage following caesarean section. Emerg Med J 26:621–622PubMedCrossRef

20.

Isono W, Tsutsumi R, Wada-Hiraike O et al (2010) Uterine artery pseudoaneurysm after cesarean section: case report and literature review. J Minim Invasive Gynecol 17:687–691PubMedCrossRef

21.

Nagayama C, Gibo M, Nitta H et al (2011) Rupture of pseudoaneurysm after vaginal delivery successfully treated by selective arterial embolization. Arch Gynecol Obstet 283:37–40PubMedCrossRef

22.

Nanjundan P, Rohilla M, Raveendran A, Jain V, Khandelwal N (2011) Pseudoaneurysm of uterine artery: a rare cause of secondary postpartum hemorrhage, managed with uterine artery embolisation. J Clin Imaging Sci 1:14PubMed

23.

Shimizu M, Kondoh E, Ueda M, Kakui K, Tatsumi K, Konishi I (2011) Secondary postpartum hemorrhage due to uterine artery pseudoaneurysm rupture in von Willebrand disease. J Obstet Gynaecol Res 37:1887–1890PubMedCrossRef

24.

Arab TS, Dy J (2011) Pseudoaneurysm of the vaginal artery as a cause of postpartum haemorrhage. J Obstet Gynaecol 31:185–186PubMedCrossRef

25.

Goupil J, Fohlen A, Linard M et al (2010) Ruptured uterine artery pseudo-aneurysm treated by embolization for post-partum bleeding: about 2 cases. J Gynecol Obstet Biol Reprod 39:325–330CrossRef

26.

Ozdemir H, Ozturk T, Kocakoc E, Kayal A (2009) Uterine arterial pseudoaneurysm: transcatheter arterial embolization as a rare complication of Caesarean section. South Med J 102:1176–1178PubMedCrossRef

27.

Butori N, Coulange L, Filipuzzi L, Krausé D, Loffroy R (2009) Pseudoaneurysm of the uterine artery after cesarean delivery: management with superselective arterial embolization. Obstet Gynecol 113:540–543PubMed

28.

Mammen T, Shanthakumari H, Gopi K, Lionel J, Ayyappan AP, Kekre A (2006) Iatrogenic secondary post-partum haemorrhage: apropos of two uncommon cases. Australas Radiol 50:392–394PubMedCrossRef

29.

Lausman AY, Ellis CA, Beecroft JR, Simons M, Shapiro JL (2008) A rare etiology of delayed postpartum hemorrhage. J Obstet Gynaecol Can 30:239–243PubMed

30.

Gürses C, Yilmaz S, Biyikli S, Yildiz IO, Sindel T (2008) Uterine artery pseudoaneurysm: unusual cause of delayed postpartum hemorrhage. J Clin Ultrasound 36:189–191PubMedCrossRef

31.

Ho SP, Ong CL, Tan BS (2002) A case of uterine artery pseudoaneurysm. Singapore Med J 43:202–204PubMed

32.

Bromley PJ, Clark T, Weir IH, Zwirewich CV (1997) Radiologic diagnosis and management of uterine artery pseudoaneurysm: case report. Can Assoc Radiol J 48:119–122PubMed

33.

Sergent F, Clavier E, Rachet B, Marpeau L (1997) Late post-partum hemorrhage after cesarean section due to rupture of a false aneurysm of the uterine pedicle. J Gynecol Obstet Biol Reprod 26:641–644

34.

Kim YA, Han YH, Jun KC, Jeon MK, Lee ES (2008) Uterine artery pseudoaneurysm manifesting delayed postabortal bleeding. Fertil Steril 90:849.e11–849.e14CrossRef

35.

Cooper BC, Hocking-Brown M, Sorosky JI, Hansen WF (2004) Pseudoaneurysm of the uterine artery requiring bilateral uterine artery embolization. J Perinatol 24:560–562PubMedCrossRef

36.

Matsubara S, Takahashi Y, Usui R, Nakata M, Kuwata T, Suzuki M (2010) Uterine artery pseudoaneurysm manifesting as postpartum hemorrhage after uneventful second-trimester pregnancy termination. J Obstet Gynaecol Res 36:856–860PubMedCrossRef

37.

Sharma S, Gupta U, Kumar M et al (2011) Pseudoaneurysm as a cause of secondary postpartum hemorrhage: a case report and literature review. Anatol J Obstet Gynecol 4:3

38.

Deux JF, Bazot M, Le Blanche AF et al (2001) Is selective embolization of uterine arteries a safe alternative to hysterectomy in patients with postpartum hemorrhage? AJR Am J Roengenol 77:145–149CrossRef

39.

Loffroy R, Rao P, Ota S et al (2010) Packing technique for endovascular coil embolisation of peripheral arterial pseudo-aneurysms with preservation of the parent artery: safety, efficacy and outcomes. Eur J Vasc Endovasc Surg 40:209–215PubMedCrossRef

40.

Soyer P, Fargeaudou Y, Morel O, Boudiaf M, Le Dref O, Rymer R (2008) Severe postpartum haemorrhage from ruptured pseudoaneurysm: successful treatment with transcatheter arterial embolization. Eur Radiol 18:1181–1187PubMedCrossRef

41.

Yi SW, Lee JH (2012) Uterine pseudoaneurysm leakage may cause delayed postpartum haemorrhage: multidetector CT with angiography and transcatheter uterine arterial embolisation. J Obstet Gynaecol 32:552–555PubMedCrossRef

42.

Yun SY, Lee DH, Cho KH, Lee HM, Choi YH (2012) Delayed postpartum hemorrhage resulting from uterine artery pseudoaneurysm rupture. J Emerg Med 42:e11–e14PubMedCrossRef

43.

Chitra TV, Panicker S (2011) Pseudoaneurysm of uterine artery: a rare cause of secondary postpartum hemorrhage. J Obstet Gynaecol India 61:614–641

44.

Soyer P, Morel O, Fargeaudou Y et al (2011) Value of pelvic embolization in the management of severe postpartum hemorrhage due to placenta accreta, increta or percreta. Eur J Radiol 80:729–735PubMedCrossRef

45.

Fargeaudou Y, Morel O, Soyer P et al (2010) Persistent postpartum haemorrhage after failed arterial ligation: value of pelvic embolisation. Eur Radiol 20:1777–1785PubMedCrossRef

46.

Fargeaudou Y, Soyer P, Morel O et al (2009) Severe primary postpartum hemorrhage due to genital tract laceration after operative vaginal delivery: successful treatment with transcatheter arterial embolization. Eur Radiol 19:2197–2203PubMedCrossRef

47.

Pelage JP, Soyer P, Le Dref O et al (1999) Uterine arteries: bilateral catheterization with a single femoral approach and a single 5-F catheter-technical note. Radiology 210:573–575PubMed

48.

Pelage JP, Le Dref O, Soyer P et al (1999) Arterial anatomy of the female genital tract: variations and relevance to transcatheter embolization of the uterus. AJR Am J Roentgenol 172:989–994PubMedCrossRef

49.

Soyer P, Taourel P, Trillaud H, Vicaut E, Laurent F, Dion E (2011) Why and how to write and publish a paper in a radiology journal. J Radiol 92:171–182PubMedCrossRef

50.

Saad NE, Saad WE, Davies MG, Waldman DL, Fultz PJ, Rubens DJ (2005) Pseudoaneurysms and the role of minimally invasive techniques in their management. Radiographics 25(Suppl 1):S173–S189PubMedCrossRef

51.

Bhatt A, Odujebe O, Bhatt S, Houry D (2010) Uterine artery pseudoaneurysm rupture: a life-threatening presentation of vaginal bleeding. Ann Emerg Med 55:460–463PubMedCrossRef

52.

Soyer P, Sirol M, Fargeaudou Y et al (2013) Placental vascularity and resorption delay after conservative management of invasive placenta: MR imaging evaluation. Eur Radiol 23:262–271PubMedCrossRef

53.

Dönmez H, Öztürk MH, Gürgen F, Soylu SÖ, Hekimoglu B (2007) Intractable hemorrhage resulting from uterine artery pseudoaneurysm: superselective arteriographic embolization via the collateral route. Cardiovasc Intervent Radiol 30:310–312PubMedCrossRef

54.

Cottier JP, Fignon A, Tranquart F, Herbreteau D (2002) Uterine necrosis after arterial embolization for postpartum hemorrhage. Obstet Gynecol 100:1074–1077PubMedCrossRef

Title: Postpartum Hemorrhage Resulting from Pelvic Pseudoaneurysm: A Retrospective Analysis of 588 Consecutive Cases Treated by Arterial Embolization
Authors: Anthony Dohan
Philippe Soyer
Aqeel Subhani
Delphine Hequet
Yann Fargeaudou
Olivier Morel
Mourad Boudiaf
Etienne Gayat
Emmanuel Barranger
Olivier Le Dref
Marc Sirol
Publication date: 01-10-2013
Publisher: Springer US
Published in: CardioVascular and Interventional Radiology / Issue 5/2013
Print ISSN: 0174-1551
Electronic ISSN: 1432-086X
DOI: https://doi.org/10.1007/s00270-013-0668-1

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Postpartum Hemorrhage Resulting from Pelvic Pseudoaneurysm: A Retrospective Analysis of 588 Consecutive Cases Treated by Arterial Embolization

Abstract

Objective

Study design

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Objective

Study design

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 5/2013

MR-Guided High-Intensity Focused Ultrasound: Current Status of an Emerging Technology

The Role of Postintervention Pullback Pressure Gradient in Percutaneous Transluminal Angioplasty for Central Vein Stenosis in Dialysis Patients

CT Guided Bone Biopsy Using a Battery Powered Intraosseous Device

Transarterial Embolization of Type II Endoleaks after EVAR: The Role of Ethylene Vinyl Alcohol Copolymer (Onyx)

Fluoroscopically Guided Balloon Dilation for Postintubation Tracheal Stenosis

Percutaneous Management of Postoperative Duodenal Stump Leakage with Foley Catheter