Uterine transarterial embolization as nonsurgical management for uterine rupture following vaginal delivery: A report of two cases

Abstract

Uterine rupture (UR) is an unexpected, rare, and serious obstetrical condition, occurring in less than 0.1% of pregnancies. Complete UR is defined as a direct communication between the uterine cavity and the peritoneum due to a complete rupture of the myometrium. Here, we present 2 cases of non-surgical management of UR following vaginal delivery, which were both treated by uterine transarterial embolization (UAE). A 26-year-old woman (G0P0) was referred to the emergency ward at 35 weeks of amenorrhea to treat the rupture of membranes, in the context of twin pregnancy. A vaginal delivery was performed and blood loss exceeded 2 liters. Gelatin sponge was injected in an attempt to occlude the right uterine artery. The injection was unsuccessful. After the medical team's discussion, it was decided to definitively occlude the right uterine artery. A 37-year-old woman (G3P3) was referred for a vaginal delivery for a medical termination at 38 weeks of amenorrhea. The ultrasound revealed a left latero-uterine pelvic hematoma, suggestive of UR. Four fibered coils were used to definitively occlude the left uterine artery. Computed tomography scan showed a progressive resorption of hematoma and satisfactory enhancement of the uterine wall in the 2 cases. Transarterial embolization may allow for bleeding to stop without resorting to exploratory laparotomy, with ad-integrum restitution of the uterine wall, and thus prevent a potential hysterectomy. The findings in these 2 cases suggest that UAE should be considered if pregnant women develop UR after delivery.

Keywords: Coils; Embolization; Hemorrhage; Uterine rupture.

Fig. 1

(A) Aortography after placement of 5F right femoral catheter, showing no active bleeding. (B) The selective introduction of a catheter into the right uterine artery shows active bleeding into the peritoneal cavity. (C) Angiography after injection of resorbable gelatin sponge shows slight but persistent, active bleeding. (D) After placement of the microcoils (arrow), angiography shows satisfactory occlusion of the uterine artery without active bleeding. (E) Enhanced CT scan in coronal section the day after embolization shows a gravid uterus associated with a right latero-uterine hematoma (star) with retention of contrast medium (dotted arrow), associated with a defect in enhancement and air the right uterine wall (arrow). (F) CT scan in coronal section performed 1 month after AUE shows a reduction in the size of the hematoma (star) and a restitution ad-integrum of the uterine wall.

Fig. 2

(A) CT scan without contrast injection in coronal section showing a large left lateropelvic hematoma (star) in contact with the gravid uterus (arrow). (B) CT scan with contrast injection shows active left lateropelvic hematoma (arrow) associated with hemoperitoneum (star). (C) Sagittal MIP reconstructions confirm that the bleeding (arrow) is coming from the uterine artery (dotted arrow). (D) Aortography confirms active bleeding. (E) After placement of the coils and embolization with absorbable gelatin, angiography shows satisfactory occlusion of the uterine artery at its ostium. (F) One CT scan in coronal section after injection of contrast medium shows a clear reduction in the size of the hematoma and a complete restitution of the uterine wall.