Postpartum Uterine Artery Pseudoaneurysm in a Woman with vWD – Case Study
Women with von Willebrand disease (vWD) have a significantly higher risk of postpartum hemorrhage. American experts from University Hospital in Augusta have published their experience with an unusual case of secondary postpartum hemorrhage in a young woman with type 1 vWD.
Case Description
A woman in her early 20s, primipara, with a history of type 1 vWD was monitored in hematology during her pregnancy without bleeding complications. On the day of hospital admission for labor induction, a plasma concentrate of factor VIII (FVIII) and von Willebrand factor (vWF) was administered. The woman then delivered via cesarean section due to non-progressive labor and cephalopelvic disproportion. The surgery was uncomplicated, with an estimated blood loss of 850 ml. After delivery, an antifibrinolytic (aminocaproic acid) was administered, and no additional hemostatic treatment was necessary. The mother was discharged 2 days post-operation.
Late Postpartum Complications
On the 35th day postpartum, the woman visited the obstetric emergency with heavy vaginal bleeding, nausea, diarrhea, and abdominal pain around the navel and right lower abdomen. Examination revealed a calm scar without erythema, only mildly tender on palpation. The uterine fundus was palpable 3 cm below the navel, moderately tender. Bright red blood was present in the vaginal cavity. A pelvic ultrasound showed a 1.8 cm hyperechoic area at the uterine fundus with prominent surrounding vessels, suggesting an arterial malformation.
CT imaging of the abdomen and pelvis with intravenous contrast revealed a hypervascularized structure measuring 1.6 × 1.0 × 1.4 cm in the endometrial cavity fundus. This structure communicated with the fundal branches of the uterine artery, raising suspicion of a uterine artery pseudoaneurysm. The diagnosis was confirmed by urgent magnetic resonance imaging (MRI).
Management
In the interventional radiology department, catheterization of the left internal iliac artery was performed, followed by embolization of the left uterine artery using gel foam. The patient tolerated the procedure well, and a CT scan performed 6 weeks post-procedure showed complete resolution of the pseudoaneurysm. The patient's fertility was preserved, and approximately 1 year later, she conceived again. The pregnancy was uncomplicated, and the patient delivered at term via planned cesarean section.
Discussion and Conclusion
Bleeding due to a uterine artery pseudoaneurysm (UAP) is a rare cause of secondary postpartum hemorrhage, with cesarean delivery being the most significant risk factor. Typical symptoms include abnormal vaginal bleeding and abdominal or pelvic pain.
Patients with vWD are at higher risk of developing UAP, and its rupture can lead to life-threatening bleeding. Early diagnosis using imaging techniques (Doppler ultrasound, CT, or MRI) is crucial, and the treatment of choice is uterine artery embolization.
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Source: Wayson J., Allen J. T., Laks S., Allen M. Case of postpartum uterine artery pseudoaneurysm associated with von Willebrand disease. BMJ Case Rep 2022; 15 (12): e253804, doi: 10.1136/bcr-2022-253804.
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