European Journal of Obstetrics & Gynecology and Reproductive Biology
Uterine artery pseudoaneurysm: its occurrence after non-traumatic events, and possibility of “without embolization” strategy
Introduction
During delivery or abortion, the arterial wall is sometimes partly injured, from which hemorrhage occurs. If the surrounding tissues cover this blood accumulation and if the space still has continuity with the parent artery, a pseudoaneurysm forms [1], [2]. A uterine artery pseudoaneurysm (UAP), when it ruptures, sometimes causes massive bleeding [1], [2]. UAP has long been considered to occur “very rarely” after traumatic delivery or abortion, i.e., cesarean section (CS) or dilatation and evacuation (D&E). Previous reports focused on the situation after UAP rupture; vaginal bleeding caused physicians to examine its source, leading to the detection of UAP [1], [2].
We previously reported that UAP shows various features [3], [4], [5], [6], [7], [8], [9], [10], [11]. Widening the study population to patients without bleeding, we preliminarily showed that UAP occurred in approximately 0.2% of deliveries and, thus, is not “very rare”. A half occurred after “non-traumatic” delivery or abortion [12].
The treatment of choice for UAP is transarterial embolization (TAE) [2], [13], [14], [15]. We have been employing a “do TAE immediately after UAP detection” strategy including asymptomatic UAP. This is because it is unknown which UAP will rupture or resolve, and this strategy is consistent with that widely employed at present [2]. However, to “do TAE for all detected UAP” may be overtreatment. The small population in our previous study [12] prevented us from confirming this.
Here, we attempted: (1) to confirm the incidence rate of UAP, (2) to confirm that UAP may no less frequently occur after non-traumatic vaginal delivery/abortion than in traumatic cases, and (3) to characterize UAP that may not require TAE, at least immediately. Importantly, we routinely performed gray-scale ultrasound in all women after delivery or abortion as our routine departmental practice. We analyzed 50 UAP patients, in all of whom angiography confirmed the diagnosis and TAE was performed. Of the 50, 22 had already been reported [12].
Section snippets
Materials and methods
The Institutional Review Board approved this retrospective observational study. The medical records of our hospital were searched for all women treated in this institute from March 2007–August 2015: we treated 50 angiographically confirmed UAP patients, whom we analyzed. Since our previous study [12] revealed that some UAP cases showed no bleeding and can occur after non-traumatic delivery/abortion, in this study period, ultrasound was performed in all cases as a routine clinical practice. In
Results
While we dealt with 8800 deliveries during this study period, 50 UAP occurred. Of the 50, 27 delivered or underwent pregnancy termination in our institute, and the remaining 23 were transferred to us. Thus, the incidence rate was 0.3% (27/8800), meaning that UAP occurred in 3/1000 deliveries. Table 1, Table 2, Table 3 shows the clinical features of the 50 cases. Of the 50, 29 patients (Cases 1–29) underwent traumatic procedures in the deliveries/pregnancies just before UAP occurrence (Table 1
Discussion
We confirmed that UAP was not rare, with a significant percentage occurring after non-traumatic delivery/abortion. While all patients with current active bleeding showed angiographically confirmed extravasation, no patients with repeated bleeding (+) and intrauterine low echoic mass (−) showed current extravasation. This may indicate that bleeding patterns and ultrasound findings may, at least partly, predict “current” UAP rupture, possibly providing some indication regarding whether angiography
Conclusion
UAP is not rare and a significant portion occurs after non-traumatic delivery/abortion. Some UAP may not require TAE: it may be concomitance of the three, i.e., current active bleeding (−), bleeding history (+), and gray-scale-discernible intrauterine low echoic mass (−). The bleeding pattern and ultrasound findings may provide some hints for TAE requirement.
Compliance with ethical standards
The authors received no funding and declare that they have no conflict of interest regarding this study. All procedures were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Institutional Review Board of Jichi Medical University approved this study. Informed consent was obtained from all individual participants included in the study.
Conflicts of interest statement
The authors declare that they have no conflicts of interest regarding this article.
Funding
None.
Patient anonymity
Preserved.
Informed consent
Obtained.
Institutional review board approval
Obtained.
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