INTERESTING

CASE STUDY

Mrs. S , 27 years –previous 2 LSCSPOD 39 - Admitted with h/o bleeding PV

feverchills & rigor

Treated at local hospital & 3 O blood given there. Referred here At admission

patient consciousmild tachycardia. BP 100/60Temp – 101oFChest

NADCVSP/A soft wound clean & healed

uterus 14 weeks contractedmild tenderness LIF

LE : Fresh bleeding in trickles.

Hb . 9.9 g TC. 32,000

Dengue Ns1Ag - +ve

USG - Hepatosplenomegaly

contracted uterus

No evidence of residual

placental tissue

Treated with AB & TXA,

platelets N

D/d on 4th day

INVESTIGATIONS

Readmitted on POD55 with profuse bleeding x 2 days

Patient : paleP/A : soft, uterus contracted 12 weeks

scar healthyLE : Bleeding +, coming in bouts preceded by pain

What will you think of ?????????

SECONDARY PPH Excessive bleeding starting any time from

24 hrs after delivery up to 6 wks post partum , mostly 8-14 days

COMMON CAUSES Retained products of conception Sub involution of the placental bed Endometritis

RARE CAUSES Pseudo aneurysm of uterine artery AV malformation Choriocarcinoma

When common causes have been ruled out think of rare causes.!!!!!!!!!!!!

Scan 1 : involuted uterus with hematoma

close to anterior wall of lower segment

? DehiscenceScan 2 : post partum bulky uterus

heterogeneous area in lower segment with

fluid in pelvis ? Hematoma / wound dehiscence contents in lower segment

endometrial cavity ? Blood clots 6.5x4 cm

Doppler : high vascular flow

Uterus approximately measures 10.7 x 3.8 x5.3 cm and appear bulky. Adhesion of uterus to anterior abdominal wall seen. Right ovary measures 3.5 x 2.1 cm and left ovary measures 3.2 x 2.2 cm . Hazy fatty stranding and edema in parametrium region seen. Linear hypodense lesion-probable post operative changes in lower anterior body region of uterus seen measuring 0.9 cm in thickness. Moderate hyperdense localized free fluid in POD seen approximately measuring 5.7 x 4.3 cm – suggest haemoperitoneum within the pelvis. Endometrium measures 0.7 cm with minimal fluid collection in endometrial cavity.

CT & ANGIO DONE

On CT ANGIO study

Distal abdominal aorta just before bifurcation approximately measures 1.09 cm in diameter. IMA measures 0.29 cm. renal artery measures 0.4 cm. internal iliac artery measures 0.4 cm on right side and 0.43 cm on left side.

Mild dilatation of left uterine artery seen measuring 0.3 cm. tortuous vessels in left parametrium region extending into Myometrium and subendometrial region seen with focal tortuous aneurysm measuring 1.6 x 1.0 x 1.8 cm seen – probable pseudoaneurysm.

Hysterectomy done

1. Minimal abdominal wall edema2. Uterus involuted and adherent to the

anterior abdominal wall along with the bladder

3. Very minimal hemorrhagic fluid in the POD4. Small bowel adherent to the right adnexa5. Purulent discharge from the lower segment

of the uterus6. About 1.5x1.0cm sized pseudoaneurysm in

the left uterine artery at the level of internal os oozing blood.

7. Old and fresh blood clots seen in the uterine cavity

FINDINGS

Introduction

Pseudoaneurysm of the uterine artery is an uncommon cause of delayed postpartum hemorrhage following cesarean or vaginal delivery.A uterine artery pseudoaneurysm develops when the uterine artery is lacerated or injured. While maintaining contact with the parent vessel, extravasating blood dissects through tissues, finally establishing a connection with the uterine cavity, causing a delayed hemorrhage.

Risks increased if … Extended uterine incision Additional hemostatic sutures

Both increase risk of arterial wall damage

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 embolization.

Doppler

to and fro sign in neck of aneurysm Yin –yang sign in body of Pseudoaneurysm

A pseudoaneurysm is an extra-luminal collection of blood with turbulent flow that communicates with the parent vessel through a defect in the arterial wall.

The development of an arterial pseudoaneurysm is a rare but reported complication of pelvic surgery, vascular trauma during c-section or after uterine curettage.

After hematoma formation, there is central liquefaction that leaves a cavity with turbulent blood flow, as a result of persistent communication between that patent artery and the hematoma. The absence of a 3 layer arterial wall lining the pseudoaneurysm differentiates it from a true aneurysm, which is less common than a pseudoaneurysm.

Typically, the lesions are discovered because the patients have symptoms related to delayed rupture of the pseudoaneurysm causing hemorrhage.

A pseudoaneurysm may be asymptomatic, may thrombose, or may lead to distal painful embolization. The risk of rupture is proportional to the size and intramural pressure.Diagnosis is usually based on both Doppler sonography and arteriography. Transcatheter uterine artery embolization(UAE) has emerged as a highly effective technique for controlling obstetric and gynaecologic hemorrhage , including that from pseudoaneurysm.

When fertility preservation is desired

Angiographic arterial embolization

B/L internal iliac or uterine art ligation

When fertility preservation is not desired

Hysterectomy

Management

Keep your eyes open. Your eyes will see only what your brain knows

Thank you