Pitfalls in diagnosis of uterine artery pseudoaneurysm after Cesarean section

Abstract

Prenatal diagnosis of Blake's pouch cyst following first-trimester observation of enlarged intracranial translucencyA 27-year-old primigravida with no relevant medical history was seen for her first prenatal appointment and first-trimester ultrasound scan at 12 + 1 weeks' gestation. The crown-rump length (CRL) was 57.8 mm and the nuchal translucency thickness was 1.3 mm. First-trimester evaluation for combined risk did not indicate that the pregnancy was at high risk for aneuploidy, with a risk of 1/10 000.Following the publications by Chaoui and Nicolaides et al. 1 -3 , we systematically measure intracranial translucency (IT) at the first-trimester scan. For this fetus the IT was 3.5 mm (Figure 1), which is well above the 95 th percentile for CRL according to established reference ranges 1 . The patient was examined again at 23 and 32 weeks' gestation. Examination of fetal anatomy at 23 weeks showed a large cyst connecting the fourth ventricle with the retrocerebellar space. The vermis was present, along with otherwise normal fetal morphology and biometry. We noted an enlargement of the fourth ventricle and an elevation of the lower part of the vermis, which was shifted away from the posterior part of the brainstem in an anticlockwise rotation (Figure 2). Using the methodology described by Guibaud and des Portes 4 for the diagnosis of anomalies of the posterior fossa, we concluded that the fetus had a persistent Blake's pouch (or Blake's pouch cyst). At the time of writing the infant was 1 month old with normal findings on neurological examination and on transfontanellar ultrasound examination performed 2 weeks after birth (Figure 3).

Management of uterine artery pseudoaneurysm: advanced ultrasonography imaging and laparoscopic surgery as an alternative method to angio-computed tomography and transarterial embolization.

“…Angiography is considered a gold standard for the confirmation of uterine vascular lesions. The main disadvantage of computed tomography (CT) angiography is its invasive character [5–8]. Pseudoaneurysms have a characteristic sonographic appearance, manifesting as a pulsating anechoic or hypoechoic structure connected to the parent artery by a thin vascular neck.…”

“…Pseudoaneurysms have a characteristic sonographic appearance, manifesting as a pulsating anechoic or hypoechoic structure connected to the parent artery by a thin vascular neck. Spectral Doppler presents turbulent arterial blood flow with a ‘to and fro’ pattern in UAPs [4, 5, 8]. …”

“…Embolization of the uterine arteries is an effective and safe way of controlling the clinical symptoms of UAP in centers experienced in intravascular therapy. Hysterectomy is recommended for postmenopausal patients [3, 6, 8, 9]. Laparoscopic methods are reported rarely [10].…”

The successful detection of postpartum unruptured vaginal pseudoaneurysm using ultrasonography: a case report

“…Pseudoaneurysm rupture can lead to devastating patient outcomes, including life-threatening bleeding. Ultrasonography is a useful modality in the diagnosis of unruptured pseudoaneurysm occurring after cesarean section or D&C (Pelage et al 1999; Kwon and Kim 2002; Cooper et al 2004; Kovo et al 2007; Bouchet et al 2012; Kim et al 2008; Padavala and Ahluwalia 2004). Rupture of vaginal pseudoaneurysm is a rare cause of postpartum hemorrhage after transvaginal delivery; however, when it occurs, the condition can be life threatening.…”

Conservative treatment of giant uterine artery pseudoaneurysm

“…According to the literature, embolization is the treatment of choice in visceral artery pseudoaneurysms generally, including UAPs. Considering that hemorrhage of ruptured UAP may occur as long as 40 days after surgery, ultrasound, particularly in cases of non‐standard Cesarean section with uterine exteriorization and repositioning, adjunctive hemostatic sutures, uterine laceration or large uterine incision, may be a useful tool both for the early diagnosis of UAP and for follow‐up to avoid the consequences of possible rupture.…”