Pseudoanaeurysm of right uterine artery: Rare cause of secondary postpartum hemorrhage (PPH) & managed by uterine artery embolisation

A 24 yrs-old woman (G1P1) had an uneventful first pregnancy, delivered by emergency caesarian section at term. The patient was transferred to our institution on 24th postoperative day with symptoms of severe bleeding per vaginum with syncopal attacks of two episodes. On examination, her vitals were stable, the C- section scar was healthy and uterus well retracted and cervical OS closed with minimal bleeding. Her hemoglobin was 6.1gm/dl and 1 unit of compatible packed cell transfusion was given and broadspectrum antibiotics were started. Trans vaginal ultrasound scan (TVS) with color doppler was done. It confirmed postpartum uterus without any evidence of retained products of conception. Endometrial thickness was 7 mm. A hypoechoic lesion of size 1.7 x 1.0 cm with ‘yin and yang’ blood flow pattern was detected, posteroinferior to the site of scar in the lower segment, suggestive of pseudoaneurysm. CT angiography was done and it was confirmed as pseudoaneurysm of distal branches of right uterine artery. To preserve fertility, right uterine artery and pseudoaneurysm were selectively cannulated and embolization of pseudoaneurysm was performed using N-Butylcyano Acrylate with lipoidol mixture. A post embolization angiographic study was performed to ensure complete exclusion of aneurysm from circulation. She was asymptomatic on follow-up. Doppler and CT angiography are useful techniques to diagnose this condition. Being a minimally invasive procedure selective embolization should be done whenever feasible. Keywords: Pseudoanaeurysm; Uterine artery; Secondary postpartum hemorrhage