Takeda Akihiro, Koike Wataru, Imoto Sanae, Nakamura Hiromi
Department of Obstetrics & Gynecology, Gifu Prefectural Tajimi Hospital, Tajimi, Gifu, Japan.
Department of Diagnostic Radiology, Gifu Prefectural Tajimi Hospital, Tajimi, Gifu, Japan.
Eur J Obstet Gynecol Reprod Biol. 2014 Nov;182:146-53. doi: 10.1016/j.ejogrb.2014.09.020. Epub 2014 Sep 19.
Uterine artery pseudoaneurysm is a rare potentially life-threatening complication after myomectomy. Its clinical characteristics and management, and the outcomes of subsequent pregnancy, are not well understood. The purpose of this study was to clarify these important issues.
Retrospective analysis of a case series of uterine artery pseudoaneurysm detected after laparoscopic-assisted myomectomy (LAM) in a single center over a 13-year period. During the early postoperative course, gray scale ultrasonographic evaluation was carried out routinely by searching for an anechoic or hypoechoic well-defined cystic structure in the post-myomectomy scar. In suspicious cases, further evaluation was performed by color Doppler flow analysis and three-dimensional computerized tomographic angiography. After finally confirming the diagnosis by digital subtraction angiography, uterine artery pseudoaneurysm was conservatively managed by angiographic intervention. In cases achieving successful conception, cesarean delivery was chosen and the uterine scar was evaluated.
Uterine artery pseudoaneurysm was diagnosed in 9 out of 854 cases of LAM. One case was undiagnosed until massive uterine hemorrhage occurred in the late postoperative period, while the other eight cases were diagnosed in the early postoperative course without hemorrhagic complication. Eight cases were managed by uterine artery embolization, but spontaneous resolution of pseudoaneurysm was observed in one case during a difficult prolonged attempt to superselect the offending branch of the uterine artery. Postembolization course was uneventful, except in a 41-year-old woman who developed oligomenorrhea. Among five women desiring preserved fertility, three women including one after spontaneous miscarriage achieved live birth by cesarean section. One woman experienced spontaneous miscarriage and one did not become pregnant by fertility treatment. In a case with elective cesarean delivery, severe early postpartum hemorrhage occurred from the placental bed and was conservatively managed by emergency uterine artery embolization.
The development of uterine artery pseudoaneurysm after myomectomy may be more common than previously considered, and should be carefully monitored to avoid potentially life-threatening hemorrhage and loss of fertility. Although spontaneous resolution may occur, conservative management by angiographic intervention could be a feasible management option for future fertility preservation, once a diagnosis has been made.
子宫动脉假性动脉瘤是子宫肌瘤剔除术后一种罕见但可能危及生命的并发症。其临床特征、治疗方法以及后续妊娠结局尚未完全明确。本研究旨在阐明这些重要问题。
对单中心13年间腹腔镜辅助子宫肌瘤剔除术（LAM）后检测出的子宫动脉假性动脉瘤病例系列进行回顾性分析。术后早期，通过在肌瘤剔除术后瘢痕处寻找无回声或低回声边界清晰的囊性结构，常规进行灰阶超声评估。对于可疑病例，进一步采用彩色多普勒血流分析和三维计算机断层血管造影进行评估。通过数字减影血管造影最终确诊后，对子宫动脉假性动脉瘤进行血管造影介入保守治疗。对于成功受孕的病例，选择剖宫产并评估子宫瘢痕。
854例LAM病例中有9例诊断为子宫动脉假性动脉瘤。1例在术后晚期发生大量子宫出血时才被诊断，而其他8例在术后早期诊断，无出血并发症。8例采用子宫动脉栓塞治疗，但在一次困难且耗时的超选择子宫动脉病变分支尝试过程中，1例假性动脉瘤自发消退。除1例41岁女性出现月经过少外，栓塞术后过程平稳。在5名希望保留生育能力的女性中，3名女性（包括1名自然流产后）通过剖宫产成功分娩。1名女性自然流产，1名女性经生育治疗未怀孕。在1例择期剖宫产病例中，胎盘床发生严重产后早期出血，通过紧急子宫动脉栓塞保守治疗。
子宫肌瘤剔除术后子宫动脉假性动脉瘤的发生可能比之前认为的更为常见，应仔细监测以避免潜在的危及生命的出血和生育能力丧失。尽管可能会自发消退，但一旦确诊，血管造影介入保守治疗对于未来保留生育能力可能是一种可行的治疗选择。
