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AJOG Glob Rep
AJOG Glob Rep
AJOG Global Reports
2666-5778
Elsevier

S2666-5778(24)00076-5
10.1016/j.xagr.2024.100382
100382
Images in Obstetrics
Uterine artery pseudoaneurysm presenting with subcutaneous hematoma and vaginal bleeding following cesarean delivery
Frikha Hatem hfrikha@gmail.com
⁎
Aloui Haithem
Karoui Abir
Hamami Rami
Menjli Sana
Abouda Hassine Saber
Chanoufi Mohamed Badis
Faculty of Medicine of Tunis, Tunis Maternity and Neonatology Center, Department ‘C’ of Gynecology and Obstetrics, University of Tunis El Manar, Tunis, Tunisia (Frikha, Aloui, Karoui, Hamami, Menjli, Abouda, and Chanoufi)
⁎ Corresponding author: Hatem Frikha. hfrikha@gmail.com
27 7 2024
8 2024
27 7 2024
4 3 100382© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
We present a rare case of uterine artery pseudoaneurysm (UAP) following an emergency cesarean section, which led to severe vaginal bleeding and subcutaneous hematoma. The patient, a 40-year-old woman with no history of hemophilia or hemostasis disorders, presented with sudden profuse vaginal bleeding and multiple subcutaneous hematomas at the site of the cesarean scar ten days postoperation. Ultrasound and CT scan confirmed the presence of a pseudoaneurysm in the right uterine artery. Due to the unavailability of radiological embolization, surgical ligation of the right internal iliac artery was performed. Postoperative follow-up showed successful resolution of the pseudoaneurysm and cessation of bleeding. This case highlights the importance of considering UAP in the differential diagnosis of postpartum hemorrhage and demonstrates the efficacy of surgical intervention when embolization is not available.

Key words

cesarean section complications
emergency surgery
internal iliac artery
postpartum hemorrhage
subcutaneous hematoma
surgical ligation
uterine artery pseudoaneurysm
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pmcWe relate a case of a 40-year-old woman, gravida three, para one, with no history of hemophilia or hemostasis disorders who underwent an emergency cesarean section due to fetal distress. During the cesarean delivery, a tear occurred at the right angle of the hysterotomy, which was repaired with a simple suture using vicryl 1.

Ten days after the surgery, she consulted the emergency department with a complaint of sudden profuse vaginal bleeding. After being examined, it was observed that she had a pale skin tone. Her heart rate was 99 beats per minute, and her blood pressure was 120/80 mmHg. Multiple subcutaneous hematomas were visible at the site of the cesarean scar and on both thighs (Figure 1). The abdominal wall was soft and nontender. Moderate vaginal bleeding was observed. No signs of postoperative infection were observed.Figure 1 Multiple subcutaneous hematomas at the site of the cesarean scar

Figure 1Frikha. Uterine artery pseudoaneurysm presenting with subcutaneous hematoma and vaginal bleeding. Am J Obstet Gynecol MFM 2024.

The ultrasound examination revealed a 3.75 × 3.5 cm right uterine mass (Figure 2A) with internal “yin-yang” flow on color Doppler, suggesting a uterine artery pseudoaneurysm (Figure 2B).Figure 2 (A) 3.75 * 3.5 cm right uterine mass, (B) internal “yin-yang” flow on color Doppler

Figure 2 (Frikha. Uterine artery pseudoaneurysm presenting with subcutaneous hematoma and vaginal bleeding. Am J Obstet Gynecol MFM 2024.

An emergency blood cell count showed a hemoglobin level of 7.3 g/dL, palets count was 189,000/mm3, and white blood cells = 9,200/mm3. The prothrombin time (PT), activated partial thromboplastin time (aPTT), and fibrinogen levels were all within normal limits.

Following the transfusion of 2 units of packed red blood cells and resuscitation, a pelvic CT scan with contrast injection confirmed the existence of a pseudoaneurysm measuring 5 centimeters in the right uterine artery.

Since radiological embolization was not available, the medical team decided to perform surgical management, and for the safety of our patient the ligation of the right internal iliac artery was done by a surgeon skilled in vascular procedures (Figure 3).Figure 3 Blood extravasation and selective ligation of the internal iliac artery

Figure 3Frikha. Uterine artery pseudoaneurysm presenting with subcutaneous hematoma and vaginal bleeding. Am J Obstet Gynecol MFM 2024.

Postoperative follow-up revealed the complete disappearance of Doppler flow on ultrasound (Figure 4), as well as the absence of any further episodes of vaginal bleeding. The patient was subsequently discharged after six days.Figure 4 Postoperative Doppler ultrasound with complete disappearance of Doppler flow

Figure 4Frikha. Uterine artery pseudoaneurysm presenting with subcutaneous hematoma and vaginal bleeding. Am J Obstet Gynecol MFM 2024.

Comments:

A true aneurysm involves the dilation of all three vascular wall layers. In contrast, a false aneurysm, or pseudoaneurysm, occurs when one or more layers, typically the intima and media, are damaged. Uterine Artery Pseudoaneurysm (UAP) predominantly occurs in a post-traumatic context, often postcesarean delivery.1 However, UAPs can also develop following nontraumatic deliveries or procedures.2 In our case, the tear in the right angle of the hysterotomy may have caused uterine artery trauma, and a selective homolateral uterine artery ligation could have prevented the risk of late UAP rupture.

We also noticed that our case is unique as the literature lacks reports of UAP complicated by subcutaneous hematoma, an aspect that remains unexplained in our case. This unusual presentation might be attributed to the rupture of the aneurysm into the surrounding soft tissue. According to the findings by Baba et al., the likelihood of aneurysm rupture is influenced by the balance between the internal blood pressure within the aneurysm and the strength of the UAP wall.3 This interaction may be critical in understanding the pathophysiology behind the complications observed in our patient.

Diagnosis of UAP is feasible via ultrasound, computed tomography (CT), or angiography. Ultrasound typically reveals a hypoechoic mass at the artery trajectory. Color Doppler ultrasound is beneficial, showing a to-and-fro or yin-and-yang pattern indicative of arterial flow into the pseudoaneurysm during systole and reverse flow during diastole.4

Awareness of UAP is crucial, as its enlargement or rupture can lead to late severe vaginal bleeding and potentially hemorrhagic shock.

For ruptured UAP, management involves resuscitation and interventional radiology. Uterine artery embolization is the preferred treatment.5 If an embolization platform is unavailable, conservative treatments, such as bilateral iliac artery ligation, have been described.6 In our case, however, emergency surgical management by unilateral ligation of the right internal iliac artery conducted to a successful treatment with complete disappearance of Doppler flow without recurrence.

As mentioned, regarding to success rates, radiologic vascular embolization outperforms surgical uterine artery ligation. However, this case highlights the effective surgical treatment of a pseudoaneurysm in the uterine artery. It demonstrates the efficacy of surgical management in treating a uterine artery pseudoaneurysm, particularly in situations where embolization is not an option or is contraindicated.

CRediT authorship contribution statement

Hatem Frikha: Investigation. Haithem Aloui: Writing – original draft. Abir Karoui: Conceptualization. Rami Hamami: Methodology. Sana Menjli: Software. Hassine Saber Abouda: Validation. Mohamed Badis Chanoufi: Visualization.

The authors report no conflict of interest. The authors confirm that written permission from the patient on whom the report is based has been obtained.
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References

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