Secondary postpartum haemorrhage with uterine artery pseudoaneurysm after caesarean section, managed with uterine artery embolisation

Abstract

CASE REPORTUterine artery pseudoaneurysm (PA) is a rare but serious complication of caesarean section (C/S). If inadequately treated, it can lead to life-threatening postpartum haemorrhage. We report the case of a 28-year-old woman who developed secondary postpartum haemorrhage resulting from uterine artery PA after C/S. Angiographic embolisation is a safe and effective procedure for treating postpartum haemorrhage resulting from PA in haemodynamically stable patients. However, uterine artery ligation may be the surgical procedure of choice for haemodynamically unstable patients when preservation of fertility is desired. Pseudoaneurysm (PA) of the uterine artery is an uncommon cause of delayed postpartum haemorrhage following cesarean section (C/S) or vaginal delivery. This condition may result in secondary postpartum haemorrhage, which is defined as haemorrhage that occurs between 24 hours, and 6 and 12 weeks postpartum. S Afr J Obstet Gynaecol[1] Although a diagnosis of retained gestational products or endometritis should be considered initially, a diagnosis of PA of the uterine artery and caesarean scar dehiscence should be considered after ruling out disseminated intravascular coagulation as a possible diagnosis when a patient presents with massive uterine bleeding without any associated symptoms, such as fever and tenderness, or subinvolution of the uterus. [2] Haematoma formation involving the uterine artery is the main suggested mechanism associated with PA of the uterine artery. After haematoma formation, there is central liquefaction that leaves a cavity with turbulent blood flow as a result of persistent communication between the parent artery and the hematoma. A uterine artery PA develops when the uterine artery is lacerated or injured in a way that would breach the integrity of the three-layer arterial wall lining. While maintaining contact with the parent vessel, extravasating blood dissects through the tissues, finally establishing a connection with the uterine cavity, which causes a delayed haemorrhage. The boundaries of a false aneurysm are constituted by thrombus, as opposed to the three arterial layers as in a true aneurysm. Although Doppler ultrasound can aid in the assessment, uterine artery angiography is necessary to make the diagnosis and provides the subsequent means for embolisation. We present a case of a uterine artery PA presenting as delayed postpartum haemorrhage.[3] Case reportA 28-year-old para 3 was transferred to our institution at 27 days post operation with symptoms of excessive bleeding per vagina. She had undergone an elective low transverse segment C/S delivery for breech presentation at a gestational age of 39 weeks at another hospital. Her intraoperative course was smooth and uneventful, and the estimated blood loss was ~600 mL. Her postoperative course was also uncomplicated until day 13 postoperatively.On postoperative day 13, she was readmitted to the same hospital for management of a delayed postpartum haemorrhage, which had developed abruptly with no previous history...