Postpartum rupture of ovarian artery

Abstract

A 32-year-old para 4, prese nted to the A&E Department 48 hours aft er a successful home delivery. Her antenatal history was unremarkable and had four spontaneous vaginal deliveries in the past. On arrival, she complained of worsening abdominal pain over the past 48 h which was now unbearable. Her labour was precipitous with fi rst stage lasting 2 h and assisted third stage 30 min. Blood loss was 150 ml.On admission she was apyrexial, with blood pressure 89/42 mmHg and pulse 82 b.p.m. On examination, there was generalised abdominal tenderness with guarding and rebound. Bimanual examination revealed cervical excitation tenderness and mild bilateral adnexal tenderness. A diagnosis of endometritis was made and intravenous antibiotics and fl uids commenced.An ultrasound revealed a left adnexal mass. Haemoglobin on admission was 10.1 g/dl and this declined to 5 g/dl, prompting an emergency laparoscopy, which revealed a haemoperitoneum of 700 ml and a large left retroperitoneal haematoma extending to the splenic fl exure.An explorative laparotomy was performed in the presence of the vascular surgeons. Th ere was a high index of suspicion that the haematoma was possibly due to a ruptured uterine artery and a decision was made to ligate the left uterine artery using haemostatic sutures. Postoperatively, despite 7 units of blood transfusion, her haemoglobin remained at 6 g/dl. An urgent CT with contrast suggested a left ovarian artery abnormality. She remained tachycardic (pulse 106 b.p.m.) and the haemoglobin declined to 4.3 g/dl. She was transferred to the tertiary centre for angiography. Aortogram and selective catheterisation of the left ovarian artery confi rmed active bleeding into the pelvis. Th ere was contrast extravasating from the pelvic segment of the left ovarian artery, which was dilated and tortuous ( Figure 1). Aft er prolonged catheter manipulation due to arterial tortuosity and recurrent spasm, successful embolisation was performed using a total of fi ve embolisation coils of 5 mm diameter. Figure 2 shows the check angiogram.She was further transfused 6 units of blood and her haemoglobin stabilised at 9.9 g/dl. She had an unremarkable recovery and was discharged 3 days later. DiscussionTh e actual incidence of ovarian artery rupture is unknown. In 1904, Williams was the fi rst to report a spontaneous haemoperitoneum resulting from rupture of utero-ovarian vessels. A recent literature review in 2009 found 12 reported cases of pregnancy-related ruptured ovarian artery aneurysm. Some 10 of these cases occurred at the time of delivery or up to 4 days postpartum and two cases were in the 3rd trimester (Chao and Chen 2009). However, haemorrhage from the utero-ovarian vessels can occur from as early as the 10th week of pregnancy and as late as 3 weeks ' postpartum (Tsoutsoplides 1967).Maternal mortality is approximately 49% but with improvement in blood banking and surgical techniques, this may be 4% (Hodgkinson and Christenson 1950). Th e perinatal mortality is approximately 31%.

Spontaneous post‐partum rupture of bilateral ovarian arteries treated with transarterial embolization

“…Some bleeds may occur initially during delivery and are only recognized if the bleed progresses and the patient becomes symptomatic. While bilateral ovarian artery aneurysms have been reported, the significance of this case is the coinciding spontaneous rupture of those bilateral ovarian arteries in the peripartum period …”

“…While bilateral ovarian artery aneurysms have been reported, 2 the significance of this case is the coinciding spontaneous rupture of those bilateral ovarian arteries in the peripartum period. [3][4][5][6][7][8][9][10][11][12][13][14] An increasing trend for ovarian artery rupture treatment with TAE has been observed given the generally accepted improved morbidity with this less invasive procedure over open surgical approaches. Observation is a viable option for a hemodynamically stable patient.…”

Spontaneous post‐partum rupture of an ovarian artery aneurysm: A case report of successful embolization and a review of the published work

“…Aneurysms in children and those that occur during pregnancy are thought to be congenital in nature, resulting from factors such as fibromuscular dysplasia, congenital weakness of the vessel wall with hypoplasia of the arterial muscularis, Marfan's syndrome and Ehlers–Danlos syndrome . A search of the English‐language published work using the PubMed database, with ‘ovarian artery rupture’ and ‘pregnancy’ as search terms and limiting reports to those published in 1980 and later, indicates that pregnancy is associated with an extremely high risk of rupture, although rupture of an OAA has also been reported in non‐pregnant women . The mechanism of rupture in pregnancy is thought to be due to both hemodynamic and hormonal changes.…”

“…These include observation, transcatheter arterial embolization (TAE) and surgical intervention. According to recent reports, TAE is a frequently selected therapy . TAE is useful when the bleeding point is uncertain on CT.…”

“…According to recent reports, TAE is a frequently selected therapy. 3,5,9,10 TAE is useful when the bleeding point is uncertain on CT. If a bleeding point is clarified by angiography, we can treat it immediately.…”