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Postpartum Spontaneous Rupture of Ovarian Artery - a Case Report
Abstract Number: S 43
Abstract Type: Case Report/Case Series
Introduction: Spontaneous retroperitoneal hemorrhage from a ruptured ovarian artery (OA) is an extremely rare event, with unknown incidence and high mortality rate. We describe a case where patient presented with unspecific symptoms and signs of severe hypovolemic shock due to postpartum rupture of OA.
Case report: A healthy 36 y/o G4P4 woman presented to postpartum clinic on 6th day after her cesarean section and tubal ligation for removal of staples. In clinic, patient had a syncopal episode and was rushed to L&D where she arrived semiconscious, pale, cold, clammy, with HR 50/min and BP 70/30mmHg. Resuscitation with crystalloids was started immediately, labs were sent, EKG showed sinus bradycardia and an abdominal ultrasound (US) was normal. An initial diagnosis of vasovagal syncopal episode was made. Patient recovered consciousness and BP returned to 90/40mmHg but she remained bradycardic. She reported constipation since her operation and fever with severe back and lower abdominal pain that started 12h before. Hb returned as 5 mg/dL, and while PRBCs were being transfused she experienced a second syncopal episode. A repeat abdominal US showed retroperitoneal fluid collection and the patient’s BP dropped to 60/30mmHg despite aggressive fluid resuscitation, prompting emergent laparotomy. An extensive expanding retroperitoneal hematoma was found, aorta was clamped and the bleeding OA, distant from previous surgical site, was identified and ligated. EBL was 5L. Massive transfusion protocol was activated, she developed DIC and remained hypothermic. She was transferred to SICU, had an uneventful recovery and was discharged from the hospital without sequelae.
Discussion: Spontaneous rupture of an OA aneurysm is an extremely rare event, with only few cases described in the literature. It is believed that pregnancy predisposes to aneurysm formation due to the hormonal, hemodynamic and mechanical changes of pregnancy. Additional risk factors are: multiparty, advanced maternal age, hypertensive disease and presence of fibroids. Presentation is usually vague with acute abdominal, flank or lower back pain, vomiting and ileus associated with hemodynamic compromise. Paradoxical bradycardia instead of tachycardia is ominous, represents severe hemorrhage, and requires immediate volume resuscitation. High mortality rate seen in this clinical picture is due to delayed diagnosis, because bleeding usually occurs in a previously healthy patient with normal course of pregnancy and delivery. Awareness of this entity and a high index of suspicion may lead to an earlier diagnosis and treatment. Bedside US and exploration rather than CT, angiography, and embolization may be the only option in hemodynamically compromised patient.
References: Gynecol Obstet Invest. 2009;68(2):104-7. Ann Vasc Surg. 1999 Jul;13(4):445-8. J Obstet Gynaecol. 2011 Aug;31(6):548-9. Am J Obstet Gynecol. 2009 Mar;200(3):e7-9