Postpartum Retroperitoneal Hemorrhage Secondary to Ovarian Artery Pseudoaneurysm

• Published in: Applied radiology (1976) Vol. 52; no. 6; pp. 49 - 51
• Main Authors: Zarour, Christopher C, Zaki-Metias, Kaitlin M, Tawil, Tima F, Wang, Huijuan, Seedial, Stephen M
• Format: Journal Article
• Language: English
• Published: Scotch Plains Anderson Publishing Ltd 01-11-2023
• Subjects: Abdomen; Angiography; Blood; Blood flow; Case reports; Catheters; Childbirth & labor; Correlation; Embolization; Etiology; Evacuation; Hematoma; Hemodynamics; Hemoglobin; Hemorrhage; Hyperplasia; Hypertension; Medical imaging; Ovaries; Parity; Patients; Pregnancy; Pseudoaneurysm; Rupturing; Sickle cell anemia; Ultrasonic imaging; Uterus; Vagina; Veins & arteries
• ISSN: 1879-2898; 0160-9963; 1879-2898
• DOI: 10.37549/AR2941

Discussion Retroperitoneal postpartum hemorrhage is a rare complication of childbirth that most commonly occurs following assisted delivery or Caesarean section.1 Anticoagulation therapy, prolonged labor, and manual placental removal have also been associated with the development of postpartum retroperitoneal hemorrhage.2 The incidence of puerperal hematoma formation is approximately between 1 in 309 and 1 in 1500 deliveries.1 Although there is little published information regarding retroperitoneal hemorrhage in the pregnant and postpartum population, data suggest a correlation between parity and ovarian artery aneurysm and pseudoaneurysm formation.2 Twenty-five cases of spontaneous ovarian artery aneurysm (OAA) rupture have been reported in the literature, of which 72% were associated with pregnancy.3'4 Pregnant patients were all multigravida, suggesting that multiparity is a risk factor.5'6 No ruptured OAA have been reported in nulliparous patients, reinforcing the correlation between OAA formation and pregnancy, leading to an increased risk of retroperitoneal hemorrhage.5 However, the mechanism of OAA formation is not well understood. Additionally, as the uterus expands, dilatation of the pelvic arteries directly increases uterine blood flow.3 During normal uterine involution in the postpartum period, one or multiple segments of the ovarian artery may not involute; it is thought to be by this mechanism that the artery may become more susceptible to aneurysm formation in subsequent pregnancies.3 Hormonal alterations during pregnancy are also responsible for microscopic vascular wall changes, including intimal hyperplasia, smooth muscle hyperplasia of the media, fragmentation of reticular fibers, and loss of the normal corrugation of elastic fibers, rendering the wall of the ovarian artery susceptible to aneurysm formation.3 Repeated pregnancies bring about further hemodynamic and endocrine changes which can exacerbate or rupture a pre-existing aneurysm. Catheter angiography remains the gold standard for diagnosing and treating the cause of retroperitoneal hematomas with an identifiable etiology.9 Treatment options consist of conservative management, endovascular intervention, and surgical evacuation and vascular repair.9 Conservative management is typically pursued in hemodynamically stable patients without significantly decreasing serum hemoglobin.9 Transarterial embolization is typically performed in patients with continuously decreasing serum hemoglobin, with or without hemodynamic instability, where the etiology of hemorrhage is identified on cross-sectional imaging.3,4 Catheter angiography may be pursued in unstable patients with active hemorrhage without an identified etiology.3,4 Surgical evacuation is reserved for hemodynamically unstable patients in whom endovascular intervention is unsuccessful or the cause of hemorrhage cannot be identified.8 Conclusion Nontraumatic obstetric retroperitoneal hematomas are an exceedingly rare complication of spontaneous vaginal delivery, with literature demonstrating a correlation between parity and ovarian artery aneurysms.