British Journal of Radiology (2004) 77, 157-158
© 2004 British Institute of Radiology
doi: 10.1259/bjr/43329609
Spontaneous rupture of a true uterine artery aneurysm: a cause of retroperitoneal haematoma
M Nicolaou, MRCS
1
Y K Ruben, MRCS
1
C M A Peel, MBBS
1
A J Kuriakose, FRCS
1
T R F Paes, FRCS
1 and
J E Jackson, FRCR
2
1 Department of Vascular Surgery, The Hillingdon Hospital, Pield Heath Road, Uxbridge, UB8 3NN and 2 Department of Imaging, Hammersmith Hospital, London, UK
Correspondence: Mr Paes Secretary, Mount Vernon Hospital, Rickmansworth Road, Northwood HA6 2RN, UK
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Abstract
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We report the first case of spontaneous rupture of a true uterine artery aneurysm in a 69-year-old woman presenting with severe abdominal pain, a left iliac fossa mass, anaemia and a retroperitoneal haematoma on CT scanning. In this patient, the aneurysm was successfully embolised using microcoils. The different imaging modalities used for diagnosis and the treatment options are discussed.
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Case report
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A 69-year-old woman presented to the accident and emergency department with a 3 day history of sudden onset severe left iliac fossa pain, fainting attacks and two episodes of vomiting. She had no past history of similar pain. Her gynaecological history was unremarkable. She suffered from hypertension and stable angina but no other symptoms to suggest peripheral vascular disease. She was on oestrogen replacement, thyroxine, bendrofluazide and aspirin. On examination she was tachycardic (at 123 beats per minute) but normotensive. Palpation of the abdomen revealed a tender, non-pulsatile, diffuse but firm mass in the left iliac fossa extending up to the umbilicus. This tender mass was also palpable in the left adnexum on vaginal examination and the cervix was located posteriorly. There was neither organomegaly nor a palpable aortic aneurysm. All distal pulses were present and normal. Initial investigations showed a haemoglobin of 6.9 g l-1 with normal platelet count, a urea of 13.4 mmol l-1 and a creatinine of 163 µmol l-1 with otherwise normal chemistry and liver function tests. Clotting was normal, C-reactive protein was 10 mg l-1 and CA 125 was 10 U ml-1. A CT scan of the abdomen showed an ill-defined retroperitoneal mass arising from the pelvis consistent with a haematoma (Figure 1
). A transfemoral arteriogram was performed which demonstrated a 1 cm fusiform aneurysm arising from the left uterine artery (Figure 2a). Selective embolisation of the aneurysm was subsequently performed using 3 Fr co-axial catheter (Fastracker -18 MX; Target Therapeutics, Boston Scientific Cork Ltd, Cork, Ireland) and 13 complex helical and straight fibred platinum microcoils (Target Therapeutics) which were placed within the uterine artery on both sides of the aneurysm so as to exclude it from the circulation. A repeat angiogram performed after embolisation confirmed complete occlusion of the aneurysm (Figure 2b). The patient was discharged 2 days later and when seen in clinic 2 months later she was well and asymptomatic.
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Figure 1. A CT-scan of the pelvis showing a large retroperitoneal haematoma (arrows) on the left displacing the uterus (Ut) to the right.
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Figure 2. Angiograms showing the internal iliac (II), superior gluteal (SG) and uterine artery (UA) with its aneurysm (arrow) (a) before embolisation and (b) after embolisation using microcoils. Notice the complete occlusion of the uterine artery and its branches after the procedure.
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Discussion
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Uterine artery aneurysms are rare but are well-recognised complications of pregnancy or previous surgery. There have been previous reports of uterine artery pseudoaneurysms rupturing during pregnancy, and immediately post-partum [1, 2], after trauma or following pelvic surgery [3] and there is a single report of a true aneurysm misdiagnosed radiologically as a pelvic sarcoma and subsequently detected at laparotomy [4]. We present the first case of a spontaneous rupture of a true uterine artery aneurysm presenting as an unusual cause of anaemia, abdominal pain, left iliac fossa mass and a retroperitoneal haematoma.
The diagnosis of a uterine artery aneurysm can be made with ultrasound but when small, and when rupture has occurred, visualization may be difficult. Both ultrasound and CT scanning may be useful in identifying the presence of a retroperitoneal haematoma but an underlying arterial abnormality is often best demonstrated by angiography; this imaging modality has the obvious added advantage that, if the anatomy is suitable, treatment by embolisation may be performed at the same time. This should be considered as the treatment of first choice of uterine artery aneurysmal disease as it is relatively non-invasive when compared with open surgical techniques and has been proven to be both safe and effective [1]. The surgical option of ligation of the internal iliac artery should be reserved for cases when embolisation is not possible. It may itself fail, however, as the aneurysm is not completely excluded from the circulation and may continue to be perfused via collaterals arising from the contralateral internal iliac artery thus remaining at risk of haemorrhage.
Received for publication January 13, 2003.
Revision received May 9, 2003.
Accepted for publication May 30, 2003.
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References
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- Pelage JP, Soyer P, Repiquet D, Herbreteau D, Le Dref O, Houdart E, et al. Secondary postpartum hemorrhage: treatment with selective arterial embolization. Radiology 1999;212:385–9.[Abstract/Free Full Text]
- Steinberg LH, Goodfellow C, Rankin L. Spontaneous rupture of the uterine artery in pregnancy. Br J Obstet Gynaecol 1993;100:184.[Medline]
- Lee WK, Roche CJ, Duddalwar VA, Buckley AR, Morris DC. Pseudoaneurysm of the uterine artery after abdominal hysterectomy: radiologic diagnosis and management. Am J Obstet Gynecol 2001;185:1269–72.[Medline]
- Raslan WF, Marier RR. Uterine artery aneurysm mimicking pelvic sarcoma. A case report and review of literature. Eur J Obstet Gynecol Reprod Biol 2001;97:245–8.[Medline]
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Abstract
Case report
