Type of Blunt Expansion of the Low Transverse Uterine Incision During Caesarean Section and the Risk of Postoperative Complications: A Prospective Randomized Controlled Trial.

OBJECTIVE: To evaluate two techniques of uterine incision expansion (cephalad-caudad vs. transverse) during Caesarean section (CS). METHODS: A total of 839 patients were randomized to either a cephalad-caudad blunt expansion of uterine incision during CS versus a transverse (lateral-lateral) expansion. The primary outcome was blood loss, measured with the descent of hemoglobin level. Secondary outcomes were the need for blood transfusion and the number of surgical or postoperative complications presented in both groups. RESULTS: There was no statistical difference with regard to decrease in hemoglobin level, but there was a higher number of surgical complications in the transverse expansion group (Cephalad-caudad: 11.53% vs. transverse: 16.42%; odds ratio [OR] 0.66; 95% confidence interval [CI] 0.45-0.98; P = 0.04). There were more cases of unintended extensions of uterine incision (10.35% vs. 16.18%; OR 0.6; 95% CI 0.4-0.9; P = 0.01) but no statistical difference in the number of hematomas, uterine vessel injury, or the need to transfuse. CONCLUSION: The cephalad-caudad blunt expansion technique of the low transverse uterine incision is safer than the transverse expansion. There was no difference in regard to decrease in hemoglobin level, but there is a lower risk of surgical complications not associated with an increased need for blood transfusions when compared with the transverse expansion.

Uterine Artery Pseudoaneurysm: A Life-Threatening Cause of Vaginal Bleeding in the Emergency Department.

BACKGROUND: Vaginal bleeding is a common presenting complaint in the emergency department (ED); life-threatening hemorrhage is rare. Uterine artery pseudoaneurysm (UAP) is an uncommon but potentially life-threatening cause of vaginal bleeding that is most likely to present primarily to EDs, given its delayed postpartum or postoperative presentation. CASE REPORT: A 25-year-old female gravida two, para one, who was 19 days post dilation and evacuation for an elective termination of a pregnancy at 20 weeks, presented to the ED with profuse vaginal bleeding. She was hypotensive and tachycardic at presentation, requiring resuscitation with 0.9% normal saline and transfusions of packed red blood cells. Transvaginal ultrasound completed in the ED demonstrated a pulsatile mass in the cervix with internal "ying-yang" flow on Doppler images, suggestive of a uterine artery pseudoaneurysm within the cervix. The patient underwent emergent uterine artery embolization with resolution of bleeding and improvement in her hemodynamic status. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: UAP is an uncommon cause of vaginal bleeding, but UAP rupture can be life-threatening. UAP is an important differential diagnosis for vaginal bleeding, particularly in the postpartum or postoperative setting. Delaying diagnosis may worsen bleeding in the setting of a ruptured UAP if treatment is pursued for alternative diagnosis; for example, treating retained products of conception with a dilation and curettage. Being aware of UAP and how to diagnose it will allow early proper treatment and more favorable patient outcomes.

Successful management of acquired uterine arteriovenous malformation.

Uterine arteriovenous malformation (UAVM) is uncommon. They are usually acquired, due to previous intra uterine trauma. We report a case of acquired UAVM in a 28-years-old patient after a medical abortion, diagnosed with ultrasonography and successfully managed with uterine artery embolization.

Delayed hemorrhage as a result of ruptured uterine artery pseudoaneurysm after transmyometrial oocyte retrieval: Management by transcatheter arterial embolization using N-butyl-2-cyanoacrylate.

Uterine artery pseudoaneurysm is a rare but potentially life-threatening complication that can occur after various uterine manipulations. A 34-year-old nulliparous patient with a previous history of four consecutive miscarriages with unknown etiologies underwent transmyometrial oocyte retrieval as a result of malpositioning of the right ovary. Six days later, she experienced massive vaginal bleeding after a day of intermittent bleeding and was transferred to our hospital. At triage, continuous bleeding from the cervical canal was observed. Color Doppler ultrasonography and three-dimensional computerized tomographic angiography revealed a ruptured pseudoaneurysm originating from the peripheral branch of the right uterine artery in the lower uterine segment. It was successfully treated by transcatheter arterial embolization with N-butyl-2-cyanoacrylate. Transcatheter arterial embolization with N-butyl-2-cyanoacrylate is a feasible option for uterus-preserving management of late massive hemorrhage resulting from a ruptured uterine artery pseudoaneurysm after transmyometrial oocyte retrieval.

Hemoperitoneum Following Sexual Intercourse in a Woman with Deep Infiltrating Endometriosis.

Endometriosis is an estrogen-dependent chronic inflammatory disease, defined by the presence of endometrial glands and stroma at ectopic sites. A rare and life-threatening complication associated with endometriosis is represented by spontaneous hemoperitoneum due to the rupture of utero-ovarian vessels. Most cases of spontaneous hemoperitoneum previously described involved pregnant women affected by endometriosis; here, we present a case of acute and massive hemoperitoneum in a nulliparous woman with deep infiltrating endometriosis. When acute abdominal pain with hemoperitoneum occurs in non-gravid reproductive age women, with no positive findings for liver or spleen lesions, a possible spontaneous rupture of utero-ovarian vessels related to the presence of deep infiltrating endometriosis should be included among the possible causes of the condition.

Predicting significant maternal morbidity in women attempting vaginal birth after cesarean section.

Attempting vaginal birth after cesarean section (VBAC) places women at an increased risk for complications. We set out to identify factors that are predictive of major morbidity in women who attempt VBAC. A nested case-control study was performed within a large retrospective cohort study of women with a history of at least one cesarean. Women who attempted VBAC were identified and those who experienced at least one complication of a composite adverse outcome consisting of uterine rupture, bladder injury, and bowel injury (cases) were compared with those who did not experience one of these adverse outcomes (controls). We analyzed risk factors for major maternal morbidity using univariable and multivariable methods. The accuracy of the multivariable prediction model was assessed with receiver operator characteristic (ROC) curve analysis. Of 25,005 women with a history of previous cesarean, 13,706 (54.9%) attempted VBAC. The composite outcome occurred in 300 (2.1%) women attempting VBAC. Using logistic regression analysis, prior abdominal surgery (odds ratio [OR] 1.58, 95% confidence interval [CI] 1.2 to 2.1), augmented labor (OR 1.78, 95% CI 1.29 to 2.46), and induction of labor (OR 2.03, 95% CI 1.48 to 2.76) were associated with an increased risk of the composite outcome. Prior vaginal delivery (OR 0.39, 95% CI 0.29 to 0.54) was associated with decreased risk for the composite outcome. The ROC curve generated from the regression model has an area under the curve of 0.65 and an unfavorable tradeoff between sensitivity and specificity. Women attempting VBAC with a history of abdominal surgery or those who undergo augmentation or induction of labor are at an increased risk for major maternal morbidity, and women with a prior vaginal delivery have a decreased risk of major morbidity. The multivariable model developed cannot accurately predict major maternal morbidity.

Laparoscopic ureterolysis and dissection of the paravesical space for deeply scarred adnexal masses.

INTRODUCTION: Laparoscopic ureterolysis is a delicate procedure that requires advanced laparoscopic skills. MATERIALS AND METHODS: We are reporting two cases of laparoscopic hysterectomy and salpingo-oophorectomy with severe adhesions to the pelvic sidewall that required ureterolysis and describing a modified technique suitable for the laparoscopic performance of this procedure. RESULTS: In more than 15 years of doing laparoscopic ureterolysis to deal with various gynecological cases, we have never had a ureteral injury related to the ureterolysis procedure. There have been uterine artery lacerations, usually when trying to apply clips for uterine artery ligation in which case the artery can be compressed with a clamp until it is reclipped, bipolar-cauterized or suture-ligated using intracorporeal knot tying. However, we did not have a single patient that required open surgery because of these lacerations. CONCLUSION: Because of the advantage of magnified viewing and laparoscopic dissection techniques which control small vessel bleeding, the laparoscopic route for ureterolysis is far easier to use than its open counterpart once it is learned. Laparoscopy, in addition, offers the added advantages of shorter hospital stay, reduced patient pain, reduced transfusion requirements and far better cosmetic results.

Pathology of lethal peripartum broad ligament haematoma in 31 Thoroughbred mares.

REASONS FOR PERFORMING STUDY: Broad ligament haemorrhage in peripartum mares is a life-threatening disease and there are few reports on the aetiology and pathogenesis of broad ligament haematoma. OBJECTIVES: To obtain information regarding the sites for the early diagnosis and pathogenesis of broad ligament haematoma of mares. METHODS: Thirty-one mares that died of broad ligament haematoma peripartum were examined pathologically for bleeding sites. The arterial distribution of 5 young mares with several parities served as negative controls. RESULTS: Age and/or multiparity were the predisposing factors for the disease. Arterial injuries were most commonly observed in the uterine artery (24 of 31 mares). Among these, the proximal uterine artery that lies within 15 cm of the bifurcation of the iliac artery was the most frequent site for rupture (18 mares). The lesions occurred preferentially at the bifurcations, lateral part of curvatures and abrupt flexures of the artery. The morphology of the injuries was classified into 3 types: ruptures with and without longitudinal fissures, and transections. Histologically, the arterial wall adjacent to the rupture showed atrophy of smooth muscle cells with fibrosis of the tunica media and disruption and/or calcification of the internal elastic lamina. CONCLUSIONS: Arterial injuries that led to broad ligament haematoma in peripartum mares occurred most frequently in the proximal uterine artery, and atrophy of smooth muscle cells with fibrosis of the arterial wall was as one of the predisposing factors in aged and multiparous mares. POTENTIAL RELEVANCE: Monitoring small aneurysms, mural tearing, medial fibrosis at the proximal uterine artery by transrectal echography could provide useful information for the early diagnosis and possible prevention of broad ligament haematoma of peripartum mares.

Massive hemoperitoneum due to uterine perforation by the Bakri Balloon, during the treatment of postpartum hemorrhage.

The current case describes a very rare complication of Bakri Balloon during the treatment of postpartum hemorrhage; a massive hemoperitoneum with a hemodynamic shock, due to a migration through the right broad ligament, with an anterior uterine rupture, and an irreversible wound of the right uterine artery. This event occurred even if the unfold placement was controlled with ultrasound guidance, to a patient who has never had abdominal surgery (Cesarean section included).

Risk Factor for Residue After Uterine Artery Chemotherapy and Embolization in Combination with Dilatation and Curettage for Treating Caesarean Scar Pregnancy.

OBJECTIVE: We aimed to investigate the potential risk factors for residual lesions after uterine artery chemotherapy and embolization (UACE) in combination with dilatation and curettage (D&C) in patients with cesarean scar pregnancy (CSP). SETTINGS: Retrospective case-control study. METHOD: Univariate analysis and logistic analysis were applied to analyze these data to assess the risk factor of residue after UACE in combination with D&C. RESULTS: Gestational age, human chorionic gonadotropin (HCG) level, and the gestation sac (GS) evagination to the bladder were the risk factors for the postoperative lesion. The most relevant was GS evagination to the bladder, followed by the preoperative HCG level and the gestational age. We defined the cut-off value of gestational age as 28 days with a sensitivity and specificity of 100 and 0, respectively. CONCLUSION: In cases with GS evagination to bladder and HCG of >28,113.65 mIU/ml as well as a gestational age of >28 days, the possibility of residual lesions was high.

A Rare Case: Rupture of Internal Pudendal and Uterine Artery in a Vaginal Delivery.

The management of puerperal hematomas after normal delivery has always been challenging for obstetricians. Vulvar, vulvovaginal, or paravaginal hematomas are common. On the other hand, retroperitoneal hematomas are uncommon and can be life-threatening. The diagnosis of vascular injury is rarely made preoperatively as atonic or traumatic postpartum hemorrhage (PPH), uterine rupture and amniotic fluid embolism are more common differential diagnoses. Injury to internal pudendal and uterine vessels is extremely rare in cases of vaginal delivery and, therefore, the literature on this topic is very scarce. We present a rare case of both internal pudendal and uterine artery rupture in a normal vaginal delivery, which led to massive postpartum hemorrhage. The diagnosis was made on Magnetic Resonance imaging (MRI) and arterial embolization was performed. This case stresses on the need for careful post-delivery monitoring for revealed postpartum hemorrhage. Vascular injury is a rare life-threatening cause of obstetric shock, and active; and timely operative intervention can prevent morbidity and mortality.

Massive retroperitoneal hemorrhage secondary to femoral artery puncture: A case report and review of literature.

RATIONALE: A rare case of massive bleeding with rupture of the branch artery deriving from uterine artery was reported in the present study. PATIENT CONCERNS: A 29-year old female patient received embolism of malformed cerebral vessels. Ten hours after the operation, a sudden drop in blood pressure occurred. The patient developed coma and shock, and again underwent interventional angiography, which revealed bleeding at the right femoral artery puncture site of the first interventional procedure. The bleeding sign disappeared by pressure dressing. At 19 hours after stable condition, blood pressure fell again, and it was considered that recurrent bleeding occurred at the femoral artery puncture point. Therefore surgical suture of punctured blood vessel was performed. Then the condition was stabilized again. After another 20 hours, the third times blood pressure dropped. The third interventional angiography displayed a rupture of the branch artery deriving from the right uterine artery. Blood pressure of the patient elevated after embolism of right uterine artery, and the condition gradually stabilized. DIAGNOSES: The massive bleeding with rupture of the branch artery deriving from uterine artery seconded huge retroperitoneal hematoma after femoral artery puncture. INTERVENTIONS: The patient underwent three times interventional treatment including an embolism of malformed cerebral vessels, a right femoral artery interventional treatment, an embolism of the branch artery deriving from the right uterine artery and one time of surgical suture of punctured blood vessel. OUTCOMES: Half a month of comprehensive treatment later, the patient was discharged from the hospital. LESSONS: Massive bleeding with rupture of branch of artery deriving from the uterine artery following grain retroperitoneal hemorrhage is extremely rare, to the best of our knowledge, it has not been previously reported. The rupture of branch of artery deriving from the uterine artery should be considered as one the differential diagnosis in the retroperitoneal hemorrhage when the bleeding cause was not found. Endovascular trans-arterial embolism was a safe, effective, and minimally invasive therapeutic option.

[Severe blood loss days after suction and curettage: consider a pseudoaneurysm]. / Hevig bloedverlies dagen na een vacuümcurettage: denk aan een pseudo-aneurysma.

BACKGROUND: A pseudo-aneurysm of the arteria uterina is a rare cause of hemorrhage after gynaecological surgery. Usually there is an interval of a few days to weeks between the inciting factor and the blood loss. The often late diagnosis can lead to a life-threatening hemorrhage. Correct diagnosis is necessary because a therapeutic curettage may worsen the blood loss. On ultrasound a pseudo-aneurysm can be suspected by the typical image of a anechogenicity with varying turbulent flow on doppler ultrasound. The gold standard for treatment is a arterial embolization that is minimal invasive, has a high success rate and can store the fertility. CASE DESCRIPTION: A 32-year old woman underwent a curettage because of an incomplete miscarriage. Nine days after surgery the blood loss increased. A pseudo-aneurysm was diagnosed and treated successfully by an embolization of the right uterine artery. CONCLUSION: Hemorrhage is the most common complication of a curettage. Delayed blood loss after curettage can be caused by a pseudo-aneurysm. In literature there are mostly case reports of pseudo-aneurysms as a cause of a late postpartum haemorrhage after a caesarean section. Arterial embolization is the gold standard for the treatment of a pseudo-aneurysm with a high success rate and conservation of fertility. The advantage is that diagnosis and treatment can happen at once, so there is no time lost. The indication for curettage should be made correctly given the possible adverse effects.

Postpartum hemorrhage.

Postpartum hemorrhage (PPH) is a very common obstetric emergency with high morbidity and mortality rates worldwide. Understanding its etiology is fundamental to effectively managing PPH in an acute setting. Active management of the third stage of labor is also a key component in its prevention. Management strategies include conservative measures (medications, uterine tamponade, and arterial embolization) as well as surgical interventions (arterial ligations, compression sutures, and hysterectomy). Creating a standardized PPH protocol and running simulation-based drills with a multidisciplinary team may also help decrease maternal morbidity and improve perinatal outcomes, although further studies are needed.

Fatal non-traumatic spontaneous hemoperitoneum in second trimester of pregnancy--autopsy findings.

Spontaneous hemoperitoneum in second trimester of pregnancy is a very rare but lethal condition which demands prompt diagnosis and management for the survival of both mother and fetus. A 21-year old primigravida woman was presented at 29 weeks of pregnancy with acute abdominal pain and hypovolumic shock. In a District Hospital patient was managed conservatively and referred but was brought dead at tertiary level hospital. On autopsy gross hemoperitoneum was found without any injury and uterine artery found ruptured against the suspicion of brutal beating by the relatives of husband.

[Ruptured uterine artery pseudo-aneurysm treated by embolization for post-partum bleeding: About 2 cases]. / Pseudo-anévrisme rompu de l'artère utérine traité par embolisation pour hémorragie du post-partum : à propos de deux cas.

Pseudo-aneurysms of uterine arteries are rare causes of post-partum hemorrhage. We report two cases of rupture, revealed in one case by a hemoperitoneum and in a second case by a retroperitoneal hematoma. The treatment consisted of embolization of uterine arteries with immediate clinical success, to avoid surgery.