INTERESTING
CASE STUDY
Mrs. S , 27 years –previous 2 LSCS
POD 39
- Admitted with h/o bleeding PV
fever
chills & rigor
Treated at local hospital & 3 O blood given there.
Referred here
At admission
patient conscious
mild tachycardia. BP 100/60
Temp – 101oF
Chest
NAD
CVS
P/A  soft wound clean & healed
uterus 14 weeks contracted
mild tenderness LIF
LE : Fresh bleeding in trickles.
INVESTIGATIONS
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
Readmitted on POD55 with profuse bleeding x 2 days
Patient
P/A
LE
: pale
: soft, uterus contracted 12 weeks
scar healthy
: 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
Scan 2
Doppler
: involuted uterus with hematoma
close to anterior wall of lower segment
? Dehiscence
: 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
: high vascular flow
CT & ANGIO DONE
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 lesionprobable 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.
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
FINDINGS
1. Minimal abdominal wall edema
2. Uterus involuted and adherent to the anterior
abdominal wall along with the bladder
3. Very minimal hemorrhagic fluid in the POD
4. Small bowel adherent to the right adnexa
5. Purulent discharge from the lower segment of the
uterus
6. 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
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.
Management
When fertility preservation is desired
 Angiographic arterial embolization
 B/L internal iliac or uterine art ligation
When fertility preservation is not desired
 Hysterectomy
Keep your eyes open. Your eyes will see only
what your brain knows
Thank you