A case of massive primary postpartum haemorrhage with previous myomectomy and a
possible arteriovenous malformation
M Islam, D Subramanian
King’s College Hospital, London, UK
Background
Case Report (continued)
Uterine AVMs (continued)
Uterine AVMs (continued)
re5
Postpartum haemorrhage (PPH) is a leading cause of maternal
mortality worldwide. It still presents a major challenge to
obstetricians and there has been increasing awareness of the
diagnosis and management of rare causes of intractable uterine
bleeding from arteriovenous malformations (AVM) involving the
uterine vasculature.
Rupture of a pseudoaneurysm usually presents as secondary
PPH, but often remains unrecognised. Diagnosis is frequently
delayed by lack of familiarity with the condition. Women typically
undergo a variety of interventions, such as uterine evacuation for
insignificant amounts of retained products of conception, blood
transfusion, antibiotic treatment or even hysterectomy before the
definitive diagnosis is made. The postpartum period can be a
time of psychological upheaval for women and their families
hence every effort should be made to find the definitive cause of
PPH.
Patient Case Report
We report a case of a 38 year old primiparous women with a
previous history of open myomectomy which involved the
removal of multiple fibroids, the largest measuring13 cm in the
posterior uterine wall. The cavity was not breached.
Antenatal events
Early dating scan showed gestational sac implanted high in the
endometrium in the anterior aspect of the cavity and
asymmetrically thickened and dilated blood vessels were seen
on the posterior wall.
The significance of this finding was not clear (figures 1,2 and 3).
22 week scan showed the placenta was high & anterior (away
from site of AVM)
Uneventful pregnancy other than one admission for minor vaginal
bleeding at 32/40 .
Labour
• Spontaneous labour at 40+5
• PVB ++ at full dilatation leading to easy Kiwi ventouse delivery.
• Ongoing heavy bleeding, not responding to uterotonics.
• 3-4cm left lateral cervical tear extending posteriorly at the level
of pouch of douglas leading to massive postpartum
haemorrhage of 5 litres and DIC.
• Extensive suturing and transfusion of blood products
• Admitted to intensive care unit with vaginal pack. Returned to
theatre for re-suturing and pack removal the following day.
Gynae clinic (10 months post delivery)
• On scan: 2cm aneurysmal dilatation of a vessel was seen deep
in the posterior myometrium on the right side of the uterus where
the fibroid was previously removed. AVM was thought unlikely to
be the direct cause of PPH, although the blood supply to the
uterus may have been relatively increased.
• Risk of bleeding secondary to the AVM in the next pregnancy is
increased, should the pregnancy implant posteriorly and the
placenta be deeply invasive.
•Referred to interventional radiology for embolisation. Awaiting
MRI prior to this.
Figure 4
Uterine AVMs
Vascular abnormalities that lead to abnormal uterine bleeding
include:
• Congenital or true AVM
• Acquired or false AVM, or pseudoaneurysm
Trauma to the uterine arteries is thought to be the commonest
cause of pseudoaneurysm. Uterine AVMs have a distinct
angiographic appearance, depending on their type.
Figure 3
TEMPLATE DESIGN © 2008
www.PosterPresentations.com
Caesarean section is frequently found to be associated with the
formation of vascular abnormalities. This can be due to lateral
extension of the lower uterine segment incision and failure to
secure the apex of an extension during repair. However,
pseudoaneurysms have also been reported even after normal
vaginal delivery (usually occurring within the myometrium).
Figure 5: A. True aneurysm B. False aneurysm
..
Figure 2
Figure 1
In contrast with true aneurysm, pseudoaneurysm lacks the three
arterial layers (tunica intima, media and adventitia). The false
aneurysm communicates with the main parent artery through the
injury to that artery.
Aetiology
Types of surgery that can to lead to
pseudoaneurysm formation:
• Caesarean section
• Surgical TOP
• Laparoscopic myomectomy
• Open myomectomy (our case)
• Laparoscopic ovarian cystectomy
• Uterine currettage
• SVD
Clinical presentations of pseudoaneurysm of the uterine artery:
• History of previous uterine surgery
• Brisk fresh vaginal bleeding
• Recurrent admissions with postpartum haemorrhage
• Failure to respond to uterine evacuation or medical therapy
Diagnostic tests
• Ultrasonography (Figures 6 & 7):
o Non- invasive;
o Diagnostic when used with colour Doppler;
o Widely available therefore can identify pathology at first
presentation;
o Can localise source of haemorrhage, in preparation for
therapeutic angiographic procedure
• Angiography:
o Gold standard;
o Very effective in defining vascular anatomy and treating
uterine vascular abnormalities;
o Can be combined
with treatment
procedure
• MRI, CT
Figure 6
(taken during systole)
On grey-scale ultrasound, a pseudoaneurysm may appear as a
heterogeneous, well outlined haematoma lateral to the uterus. Colour
Doppler will demonstrate blood flow within the lesion and a ‘to-and-fro’
phenomenon.
Figure 7
(taken during diastole)
Treatment
The condition is self limiting if the natural healing process has
managed to seal the injured artery permanently. However, if
bleeding persists and intervention is required, management
should involve a multidisciplinary approach. Interventional
radiology and embolisation of the vessel remains the main tool
for definitive treatment .
Advantages of UAE:
• Found to be successful in arresting PPH
• Minimally invasive
• Requires only local anaesthesithetic
• Preserves the uterus
• If the site of haemorrhage can be accurately identified, it can
be performed with minimal disruption of the normal vascular
supply to the uterus.
• May show alternative, unsuspected sources of haemorrhage
from other branches that can be embolised
Prevention
Every effort should be made to prevent the formation of
iatrogenic vascular abnormalities, such as pseudoaneurysm.
This involves careful planning of the uterine incision during
caesarean section, particularly when the cervix is fully dilated.
Any dextro-rotation of the uterus should be corrected before
making the incision and subsequent angle tears should be
avoided by extending the incision upwards rather than
downwards.
References
Abu-Ghazza O, Hayes K, Chandraharan E, Belli A. Review: Vascular malformations in
relation to obstetrics and gynaecology: diagnosis and treatment. The Obstetrician &
Gynaecologist, 2010;12:87–93
Abu-Yousef MM, Wiese JA, Shamma AR. The ‘to-and-fro’ sign: duplex doppler
evidence of femoral artery pseudoaneurysm. AJR Am J Roentgenol 1988;150:632.
Asai S, Asada H, Furuva M, Ishimoto H, Tanaka M, Yoshimura Y. Pseudoaneurysm of
the uterine artery after laparoscopic myomectomy. Fertil Steril, 2009 Mar;91(3):929.
Cura M, Martinez N, Cura A, Dasaso TJ, Elmerhi F. AVMs of the uterus. Acta Radiol,
2009 Sep;50(7):823-9.
Grivell RM, Reid KM, Mellor A. Uterine arteriovenous malformations: a review of the
current literature. Obstet Gynaecol Surv, 2005 Nov;60(11):761-7.
Takeda A, Kato K, Mori M, Sakai K, Mitsui T, Nakamura H. Late massive uterine
hemorrhage caused by ruptured uterine artery pseudoaneurysm after laparoscopicassisted myomectomy. J Minim Invasive Gynecol 2008;15:212–6.