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INTERESTING CASE STUDY

INTERESTING CASE STUDY. Mrs. S , 27 years –previous 2 LSCS POD 39 - Admitted with h/o bleeding PV fever chills & rigor Treated at local hospital & 3 O blood given there. Referred here At admission patient conscious mild tachycardia. BP 100/60 Temp – 101 o F Chest

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INTERESTING CASE STUDY

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  1. INTERESTING CASE STUDY

  2. Mrs. S , 27 years –previous 2 LSCS POD 39 - Admitted with h/o bleeding PV fever chills & rigor Treated at local hospital & 3 O blood given there. Referred here At admission patient conscious mild tachycardia. BP 100/60 Temp – 101oF Chest NAD CVS P/A  soft wound clean & healed uterus 14 weeks contracted mild tenderness LIF LE : Fresh bleeding in trickles.

  3. INVESTIGATIONS Hb . 9.9 g TC. 32,000 Dengue Ns1Ag - +ve USG - Hepatosplenomegaly contracted uterus No evidence of residual placental tissue Treated with AB & TXA, platelets N D/d on 4th day

  4. Readmitted on POD55 with profuse bleeding x 2 days Patient : pale P/A : soft, uterus contracted 12 weeks scar healthy LE : Bleeding +, coming in bouts preceded by pain

  5. What will you think of ????????? • SECONDARY PPH • Excessive bleeding starting any time from 24 hrs after delivery up to 6 wks post partum , mostly 8-14 days • COMMON CAUSES • Retained products of conception • Sub involution of the placental bed • Endometritis • RARE CAUSES • Pseudo aneurysm of uterine artery • AV malformation • Choriocarcinoma • When common causes have been ruled out think of rare causes.!!!!!!!!!!!!

  6. Scan 1 : involuted uterus with hematoma close to anterior wall of lower segment ? Dehiscence Scan 2 : post partum bulky uterus heterogeneous area in lower segment with fluid in pelvis ? Hematoma / wound dehiscence contents in lower segment endometrial cavity ? Blood clots 6.5x4 cm Doppler : high vascular flow

  7. CT & ANGIO DONE Uterus approximately measures 10.7 x 3.8 x5.3 cm and appear bulky. Adhesion of uterus to anterior abdominal wall seen. Right ovary measures 3.5 x 2.1 cm and left ovary measures 3.2 x 2.2 cm . Hazy fatty stranding and edema in parametrium region seen. Linear hypodense lesion-probable post operative changes in lower anterior body region of uterus seen measuring 0.9 cm in thickness. Moderate hyperdense localized free fluid in POD seen approximately measuring 5.7 x 4.3 cm – suggest haemoperitoneum within the pelvis. Endometrium measures 0.7 cm with minimal fluid collection in endometrial cavity.

  8. On CT ANGIO study Distal abdominal aorta just before bifurcation approximately measures 1.09 cm in diameter. IMA measures 0.29 cm. renal artery measures 0.4 cm. internal iliac artery measures 0.4 cm on right side and 0.43 cm on left side. Mild dilatation of left uterine artery seen measuring 0.3 cm. tortuous vessels in left parametrium region extending into Myometrium and subendometrial region seen with focal tortuous aneurysm measuring 1.6 x 1.0 x 1.8 cm seen – probable pseudoaneurysm.

  9. Hysterectomy done FINDINGS • Minimal abdominal wall edema • Uterus involuted and adherent to the anterior abdominal wall along with the bladder • Very minimal hemorrhagic fluid in the POD • Small bowel adherent to the right adnexa • Purulent discharge from the lower segment of the uterus • About 1.5x1.0cm sized pseudoaneurysm in the left uterine artery at the level of internal os oozing blood. • Old and fresh blood clots seen in the uterine cavity

  10. Introduction • Pseudoaneurysm of the uterine artery is an uncommon cause of delayed postpartum hemorrhage following cesarean or vaginal delivery. • A uterine artery pseudoaneurysm develops when the uterine artery is lacerated or injured. While maintaining contact with the parent vessel, extravasating blood dissects through tissues, finally establishing a connection with the uterine cavity, causing a delayed hemorrhage. • Risks increased if … • Extended uterine incision • Additional hemostatic sutures • Both increase risk of arterial wall damage

  11. The boundaries of a false aneurysm are constituted by thrombus, as opposed to the three arterial layers as in a true aneurysm. Although Doppler ultrasound can aid in the assessment, uterine artery angiography is necessary to make the diagnosis and provides the subsequent means for embolization. • Doppler • to and fro sign in neck of aneurysm • Yin –yang sign in body of Pseudoaneurysm

  12. A pseudoaneurysm is an extra-luminal collection of blood with turbulent flow that communicates with the parent vessel through a defect in the arterial wall. The development of an arterial pseudoaneurysm is a rare but reported complication of pelvic surgery, vascular trauma during c-section or after uterine curettage. After hematoma formation, there is central liquefaction that leaves a cavity with turbulent blood flow, as a result of persistent communication between that patent artery and the hematoma. The absence of a 3 layer arterial wall lining the pseudoaneurysm differentiates it from a true aneurysm, which is less common than a pseudoaneurysm.

  13. Typically, the lesions are discovered because the patients have symptoms related to delayed rupture of the pseudoaneurysm causing hemorrhage. A pseudoaneurysm may be asymptomatic, may thrombose, or may lead to distal painful embolization. The risk of rupture is proportional to the size and intramural pressure. Diagnosis is usually based on both Doppler sonography and arteriography. Transcatheter uterine artery embolization(UAE) has emerged as a highly effective technique for controlling obstetric and gynaecologic hemorrhage , including that from pseudoaneurysm.

  14. Management • When fertility preservation is desired • Angiographic arterial embolization • B/L internal iliac or uterine art ligation • When fertility preservation is not desired • Hysterectomy

  15. Keep your eyes open. Your eyes will see only what your brain knows

  16. Thank you

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