Fatal risk in hysteroscopic surgery that should not be overlooked: Uterine artery pseudoaneurysm

Abstract

This article provides a detailed account of the diagnosis and treatment of a case involving a uterine artery pseudoaneurysm (UAP), as well as an analysis of UAP etiology. This finding emphasizes that UAP should be considered in patients presenting with abnormal genital bleeding after hysteroscopy and offers valuable insights and lessons for gynecologists in hysteroscopic procedures. The patient underwent timely relevant examinations to confirm the diagnosis, allowing for crucial time required for her treatment. In this study, the primary cause of UAP formation in the patient was attributed to a prior hysteroscopic surgical procedure conducted at another medical facility, suggesting that the selection and implementation of dilatation catheters are some of the predisposing factors for UAP. In conclusion, this case study offers a comprehensive analysis of the etiology of UAP and effectively provides timely diagnosis and treatment, offering valuable insights for the clinical diagnosis and management of UAP.

Key Words: Editorial; Uterine artery pseudoaneurysm; Case report; Hysteroscopic surgery; Uterine arteriovenous malformations

Core Tip: This article provides a detailed review of the diagnosis and treatment of uterine artery pseudoaneurysm (UAP), explores its etiology, highlights cervical dilation as a key risk factor, and emphasizes the significance of ultrasound and pelvic contrast-enhanced computed tomography for early UAP detection.

TO THE EDITOR

Pseudoaneurysm refers to a hematoma formed by extravasation of blood due to a defect in the arterial wall, which is surrounded by surrounding tissues and communicates with an artery. Pseudoaneurysms of the uterine artery are referred to as uterine artery pseudoaneurysm (UAP). The UAP is a pathological condition characterized by an extraluminal accumulation of blood exhibiting turbulent flow, which communicates with the flowing blood within the uterine artery through a defect in its arterial wall. UAP is an exceedingly rare condition, with an incidence of two to three cases per thousand deliveries (2-3/1000). This condition represents an atypical complication following normal vaginal delivery, cesarean section, myomectomy, or hysterectomy[1]. Clinical manifestations can range from asymptomatic when unruptured to fatal massive hemorrhage upon rupture. The typical presentation of UAPs is vaginal bleeding following rupture of the pseudoaneurysm[2]. Owing to insufficient awareness, diagnosis may be delayed, ultimately leading to severe consequences such as hypovolemic shock and hysterectomy. Therefore, this hemorrhagic manifestation poses a significant threat to life and requires urgent diagnosis on the basis of a high degree of clinical suspicion[3,4]. This article presents a case of a rare UAP. The case involved a 48-year-old primigravida who underwent hysteroscopic polyp resection at another hospital and experienced significant postoperative genital hemorrhage. She was transferred to the author's hospital by ambulance, where she was diagnosed with UAP after evaluation and examination. The patient underwent successful treatment with uterine artery embolization (UAE), which effectively addressed the UAP. A follow-up examination six months later indicated that her condition had significantly improved[5]. In recent years, the incidence of late bleeding and UAPs after cesarean section and invasive gynecological procedures has increased, yet no clinical guidelines exist for their diagnosis and management. This article provides a detailed report on the accurate diagnosis and successful treatment of a case of UAP, which holds significant clinical reference value. Although rare, this case underscores the need for vigilance regarding intraoperative UAPs during hysteroscopic procedures, particularly in cases of postoperative abnormal genital bleeding. During the initial surgery, the patient experienced significant bleeding upon removal of the cervical dilator, necessitating the consideration of a ruptured UAP. In such cases, it is imperative to conduct intraoperative color Doppler ultrasound examination to accurately identify the source of bleeding and take proactive measures for hemostasis. However, doctors from external hospitals still perform electrical resection surgery for uterine polyps. Continuing with hysteroscopic procedures at this point is extremely dangerous and can lead to hemorrhagic shock, arterial embolism, water intoxication, and even life-threatening situations for the patient. UAP can lead to life-threatening bleeding. We consider that muscle damage and subsequent infection caused by electrical cutting may be high-risk factors for UAP, which needs further study. Therefore, early identification and diagnosis of UAP by obstetricians and gynecologists are crucial. This case report offers valuable information and experiential insights for the early diagnosis and urgent treatment of this condition, serving as a reference for future treatment decisions.

Diagnosis and treatment of UAP

UAPs are commonly associated with prior traumatic surgical procedures, with the most frequent being cesarean section. They may also occur as complications of myomectomy, hysterectomy, laparoscopic excision of deep endometriotic lesions, dilatation and curettage, and cervical conization[6,7]. The UAP may result from inadvertent disruption of uterine artery wall continuity during prior surgeries. Some UAP cases also occur after nontraumatic deliveries or miscarriages, typically presenting as asymptomatic vaginal bleeding or delayed postpartum hemorrhage[8,9]. In this case, the patient experienced persistent bleeding following hysteroscopic surgery. After transvaginal ultrasound and enhanced pelvic computed tomography (CT) examinations were performed, the final diagnosis was a right UAP. Then, UAE was performed, which successfully achieved hemostasis by occluding the responsible uterine artery and ensuring patient safety. With the widespread application of vascular intervention techniques in the field of obstetric hemorrhage, selective UAE has become the primary treatment for UAP because of its minimal invasiveness, few adverse reactions, definite hemostatic effects and preservation of fertility. This case serves as a reminder that for patients experiencing abnormal genital bleeding following hysteroscopy, it is essential to consider the possibility of UAP. Transvaginal color Doppler ultrasound is a valuable tool for diagnosing UAPs, whereas enhanced CT can demonstrate the continuity of UAPs with blood vessels and identify the responsible blood vessels, aiding in determining the treatment strategy. This article reports a case in which a patient underwent timely pelvic enhanced CT and ultrasound examinations upon arrival at the author's hospital by ambulance, emphasizing the importance of ultrasound and pelvic enhanced CT in clinical practice for the early detection of UAPs. The patient's initial hysteroscopy was conducted via a conventional rigid hysteroscope. The author's analysis identified this procedure as a primary trigger for UAP formation. This suggests that during hysteroscopic surgery, gentle manipulation and the use of appropriately sized instruments to minimize excessive dilation are essential. Preoperative assessment of the orientation of the uterus is crucial. Additionally, careful consideration should be given to fluid infusion to prevent excessive intrauterine pressure and UAP formation. These findings provide valuable guidance for future gynecological surgical procedures. This study revealed that there is no consensus on the need for the clinical treatment of asymptomatic UAP. It is also essential to conduct relevant tests prior to performing a hysteroscopic procedure to ascertain the presence of UAP in the patient.

Uterine pseudoangiomas and uterine arteriovenous malformations

Uterine arteriovenous malformations (UVAMs) can be classified into congenital and acquired types. Congenital UVAMs are mostly attributed to genetic mutations and abnormal development of the primitive vascular structure during the embryonic period, making them exceedingly rare in clinical practice. Acquired UAVMs are associated primarily with trauma, infection, and tumors. Compared with UVAM, UAP is mostly a complication during obstetrics and gynecology surgery. The pathological changes associated with UVAM mainly involve the formation of multiple small arteriovenous fistulas between the arterial branches of the injured muscle and the venous layer of the muscle. The boundary of a pseudoaneurysm is composed of a blood clot, lacking the three-layered arterial wall structure found in true aneurysms. This distinction sets it apart from UVAM and true aneurysms. Vaginal bleeding is the most common clinical symptom of UVAM and UAP. The initial imaging modality of choice for both diseases is color Doppler ultrasound. CTA is the gold standard technique for diagnosing UVAVM and UAP, and it is highly useful for differentiating between these two diseases. Regarding treatment, the preferred method for patients with recurrent and severe bleeding of UVAMs is UAE[10], similar to UAPs.

CONCLUSION

In conclusion, this case report provides valuable insights into a case of UAP and emphasizes the importance of gynecological ultrasound and pelvic enhanced CT in diagnosing UAP. This case serves as a reminder that for patients experiencing abnormal genital bleeding following hysteroscopic surgery, the possibility of UAP must be considered, and prompt, appropriate management should be undertaken. Additionally, attention to operative techniques during hysteroscopic surgery is crucial for minimizing the formation of UAPs. Our experience suggests that the location of the UAP mass may serve as a more significant predictor of its prognosis than its size. Therefore, the potential roles of blood flow, pressure, and UAP wall strength as predictors of UAP resolution warrant further investigation. However, this was a case report. Additional studies with larger sample sizes are essential to enhance our understanding of the natural history of UAP.