BACKGROUND: Uterine artery pseudoaneurysm is a rare but potentially life threatening pathology that is usually caused by obstetric procedures. This is a case of uterine artery pseudoaneurysm manifesting as vaginal bleeding after cesarean section (CS) and treated with coil embolization.
Case: M. O. is a 26 year old Filipina, widi one pregnancy and delivery, who complained of recurrent vaginal bleeding two weeks post CS for failed induction of vaginal birth to a post-datism baby. Except for a family history of diabetes, past medical, personal, and social histories were insignificant. Initial work-up showed unremarkable complete blood count (CBC) and beta-HCG values. Transvaginal ultrasound (TVUS) revealed an intramural uterine mass suggestive of hematoma. This finding was confirmed by contrast computed tomography (CT) scan of the lower abdomen. However, TVUS with Doppler study revealed an arterial waveform within the mass. Thus, CT angiogram of die pelvic vessels was done, which demonstrated a blind pouch in the left uterine artery. With the diagnosis of pseudoaneurysm, the patient underwent angiography with endoluminal therapy. The left uterine artery was embolized widi two 22-mm-3-mm x 2 mm Boston Scientific vortex platinum coils, completely occluding the artery and devascularizing the pseudoaneurysm. The patient was discharged improved and remained asymptomatic.
DISCUSSION: A pseudoaneurysm is an outpouching of an artery encapsulated by periadventitial tissue that results from inadequate sealing of a laceration or puncture of the vessel wall. Pseudoaneurysm of die uterine artery is a rare condition usually caused by obstetric interventional procedures and infections. US is a valuable initial test that can show a cyst connected to a feeding artery by a neck with a "to-and-fro" waveform ofjalood widiin, while CT scan and magnetic resonance imaging (MRI) can demonstrate a rounded structure arising from a donor artery. However, angiography is the gold standard for the diagnosis of this padiology. Urgent intervention of uterine pseudoaneurysms is required since they are at risk of rupturing or expanding. Traditionally, they have been treated by ligation of the internal iliac artery or by hysterectomy. Recently, transcatheter arterial embolization has proven to be a therapeutic option with outstanding success rates and low complication rates. Embolic materials, such as gelatin sponge or coil, are introduced into one or both uterine arteries or odier feeding arteries until stasis of flow is confirmed angiographically. Preservation of fertility and resumption of menstruation are possible after embolization of both uterine arteries because of the temporary occlusion by absorbable gelatin sponge and the extensive collateral circulation from pelvic arteries.
CONCLUSION: Obstetric procedures can cause uterine vascular abnormalities such as pseudoaneurysms. US is an appropriate initial modality for detection, diagnosis, and follow-up after intervention. However, angiography remains to be the diagnostic gold standard and offers therapeutic option. Arterial embolization is a safe and effective method of treating this condition widi die advantage of preserving fertility, thus it should be an option before resorting to surgery in appropriate cases.