Conservative management of uterine artery pseudoaneurysm after laparoscopic-assisted myomectomy and subsequent pregnancy outcome: case series and review of the literature.

OBJECTIVE: 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.

STUDY DESIGN: 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.

RESULTS: 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.

CONCLUSION: 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.