Ruptured Exophytic Uterine Artery Pseudoaneurysm, Seven Days after Vaginal Delivery

A 31-year-old woman was hospitalized due to an excruciating abdominal pain eight days after a vaginal delivery. 

The lady had no history of vascular issues or relevant medical background. She had had a normal pregnancy and delivered vaginally at 39 weeks and 2 days gestation. Labor augmentation involved oxytocin and uterine fundal pressure due to stalled labor, lasting 11 hours and 20 minutes for the first stage and 48 minutes for the second, with a total blood loss of 200 mL. The infant weighed 3,710 g and had an Apgar score of 1 at one minute and 5 at five minutes, with an umbilical artery pH of 7.08.

The initial discharge was uneventful, but on the seventh postpartum day, the mother developed persistent abdominal pain and fever. She was prescribed antibiotics before being transferred to the tertiary perinatal center due to unresolved symptoms.

On examination, the patient presented with stable vital signs and negative vaginal and blood cultures. Laboratory findings showed a white blood cell count of 11.7x103/μL, CRP level of 14.8 mg/dL, and hemoglobin level of 9.4 g/dL.

Transvaginal ultrasound identified an 8 cm hematoma housing a 17.6x16.7 mm hypoechoic mass near the left cervicocorporeal junction – suggestive of an exophytic uterine artery pseudoaneurysm (UAP) with hemoperitoneum. A contrast-enhanced CT confirmed a pseudoaneurysm originating from the left uterine artery alongside the hemoperitoneum.

Angiography revealed a pseudoaneurysm at the left uterine artery bifurcation, which was managed through embolization using n-butyl-2-cyanoacrylate (NBCA) and coils. This intervention resolved the patient's pain. 

Subsequent imaging revealed a thrombosed pseudoaneurysm, suggesting a laceration on the left broad ligament. The lady was treated for possible sepsis. She was discharged after 12 days. 

Follow-up at eight months postpartum showed resolution of symptoms and absence of the UAP. This case underscores the importance of recognizing postpartum fever and abdominal pain in diagnosing ruptured exophytic UAPs – as prompt intervention can prevent complications.

Source: Toshimitsu M, Iriyama T, Sato J, Abe O, Ichinose M, Sayama S, Seyama T, Sone K, Kumasawa K, Osuga Y. Case Reports Obst Gynec. 2023 Nov 25;2023.