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Delayed Postpartum Hemorrhage Secondary to Ruptured Uterine Artery Pseudoaneurysm
Abstract Number: SUN-27
Abstract Type: Case Report/Case Series
Rapid diagnosis and early treatment of postpartum hemorrhage (PPH) is critical. Secondary PPH, occurring 24h after delivery, is commonly caused by retention of products of conception (POC) but vascular anomalies such as arteriovenous fistula or pseudoaneurysms can also be responsible. We describe the case of a primiparous patient who presented to the ED with severe PPH and syncope 16 days after cesarean section (CS) secondary to uterine artery pseudoaneurysm rupture (UAPR).
A 23-year-old woman (gravida 1, para 0) underwent primary CS at term for arrest of descent in labor after an otherwise uneventful pregnancy. Immediate postoperative course was complicated by PPH of 800 ml, requiring administration of uterotonics, temporary placement of intrauterine tamponade balloon and extensive resuscitation with blood products. Urgent CT demonstrated an organized clot in the endometrial canal. She was stabilized in the SICU and discharged on POD 5.
She was re-admitted 16 days later with brisk vaginal bleeding. Physical exam revealed a low transverse CS incision appearing clean and dry. Her uterus was well-contracted. Bedside ultrasound showed a normal uterine stripe without evidence of POC. Labs were notable for severe anemia (Hb 6 from 9.3 g/dL). Profuse vaginal bleeding continued despite aggressive resuscitation. Anesthesiology was consulted to guide transfusion with the use of rotational thromboelastometry, which was normal with regards to clotting time, clot strength, and fibrinolysis. EBL was 4.5 L requiring massive transfusion. In view of her history, an alternative cause of bleeding was sought; interventional radiology (IR) was consulted and a pelvic angiography revealed a distal left uterine artery branch pseudoaneurysm that was successfully occluded by transarterial embolization. Post-embolization angiogram demonstrated a loss of blood flow to the pseudoaneurysm. The patient had complete resolution of her symptoms with no surgical exploration required.
This patient’s immediate PPH placed her at greater risk for secondary PPH. The rate of UAPR as a cause for secondary PPH has been cited as 3% and only after uterine trauma (1). However, it has been countered that UAPR occurs much more frequently, often going unrecognized as a cause for PPH. Furthermore, it can occur after non-traumatic vaginal delivery (2). The exact frequency and associated risk factors for UAPR have yet to be identified—until then, it is of utmost importance that clinicians recognize UAPR as a potential cause for secondary PPH so as to provide timely diagnostic therapy and avoid unnecessary surgical procedures.
1 Dossou M et al. Severe secondary postpartum hemorrhage: a historical cohort. Birth. 2015 Jun:42(2):149-55
2 Matsubara S & Baba Y. Uterine artery pseudoaneurysm after nontraumatic vaginal delivery as a cause of postpartum hemorrhage: determination of its mechanism is urgently needed. Acta Obs Gyn Scand. 2015 Jul:94(7):788-9