Massive Uterine Bleeding Research Articles

Pregnancy associated atypical hemolytic uremic syndrome triggered by massive uterine bleeding after outpatient dilatation and evacuation

Background: Atypical Hemolytic Uremic Syndrome (aHUS) is a renal threatening multi-system disorder with significant hematologic findings of microangiopathic hemolytic anemia (MAHA) and thrombocytopenia. Early recognition and institution of late complement inhibitors can interrupt a cycle of progressive hemolysis and renal injury. Methods: We present an informative case of aHUS triggered by pregnancy termination. Diagnostic, laboratory, and treatment measures are reviewed. Results: Clinical evidence demonstrates immediate improvement in hemolysis, platelet consumption, and acute kidney injury following initiation of eculizumab. Conclusion: Pregnancy is a recognized trigger of aHUS and its proper management requires early recognition and institution of late complement blockade. Genetic testing can be sent for genetic counseling purposes, but initiation of treatment should neither await these results nor be discontinued when high-risk polymorphisms are absent.

Thrombotic Microangiopathy Associated with Pregnancy: Various Outcomes in Different Disorders

Thrombotic microangiopathy (TMA) associated with pregnancy can be fulminant and fatal disorder. Pregnancy outcomes and survival of patients depend on the precise diagnose and appropriate treatment approaches. When a pregnant or postpartum woman presents with sudden and severe microangiopathic hemolytic anemia and thrombocytopenia, conditions that require urgent care must be considered: preeclampsia with severe features (PE/HELLP syndrome), thrombotic thrombocytopenic purpura (TTP), catastrophic antiphospholipid syndrome (CAPS), complement-mediated thrombotic microangiopathy (atypical hemolytic-uremic syndrome, aHUS). The distinction among these syndromes is often unclear because they share multiple clinical features. Overlap between PE/HELLP and TTP, CAPS and aHUS is also apparent from the fact that pregnancy can be a trigger for TMA before and after delivery. These disorders, especially PE imitators, are very important as the causes of maternal and fetal death.Since 2010 we observed 104 patients with pregnancy-associated TMA. Women's age at the time of pregnancy was 32,04±0,83 years old, delivery performed at 34,89±0,74 gestation weeks. The reasons of TMA defined as PE/HELLP in 71 (68,3%) women (main signs: blood pressure more than 160 mm systolic or 110 mm diastolic, platelet count <100 x 10⁹/l and/or abnormal liver function, renal insufficiency, pulmonary edema, cerebral symptoms, eclampsia - generalized seizures, peripartum cardiomyopathy), aHUS- 32 (30,8%), TTP-1 (0,9%) (ADAMTS13 level less than 10%). All of them required preterm operative delivery. Therapeutic plasma exchange (1-9 procedures) performed in 88 (84,6%). ADAMTS13 level assessed before plasma therapy (45-84%, excluding the TTP case), as well as lupus anticoagulant (LA) and antiphospholipid antibodies (APLA) (negative in all patients). In cases of aHUS we use eculizumab in 14/32 (43,75%), but a full course with subsequent successful discontinuation of the drug was received only by one patient. 13/14 patients received 1 to 6 injections of eculizumab.Overall mortality rate was 10 (9,6%), It is noteworthy that only patients with aHUS died- 10/32 (31,25%). Antenatal fetal death occured in 16 (15,4%), among them 12/32 (37,5%) were diagnosed with aHUS. The condition of patients with PE/HELLP improved on 1-3 days after delivery in all cases. In aHUS patients, life-threatening complications persisted and even progressed after delivery: massive uterine bleeding required hysterectomy occurred in 23,2%, acute kidney injury registered in 100% patients, neurological symptoms had 61%, respiratory distress syndrome- 55%, dilated cardiomyopathy- 16,7%. 61,3% required hemodialysis, 51,8%- respiratory care. All of patients who died had 2 “waves” of TMA: first wave has damaged 2-5 organs without any proved infections, but treated with antibacterial combination. Second TMA wave was fatal due to superimposed septic disorders, resistant to antibiotic therapy. Patients on eculizumab treatment had more severe disease at debut with shorter history of aHUS and responded well to eculizumab. Survival of aHUS patients on eculizumab treatment was 71,4%, without it - 64,7%.Therapeutic approaches in TMA associated with pregnancy are different and survival of patients depends on a timely diagnosis. Clinical vigilance requires for early detection of TMA. After that is necessary as soon as possible investigate the ADAMTS13 level to avoid TTP, and LA and APLA to avoid CAPS. Plasma exchange may be first urgent step of treatment in all cases of TMA, but after clarifying the diagnosis therapy should be adjusted. Timely diagnosis and effective approaches including early prescribed targeted therapy in aHUS patients can improve the survival rate and pregnancy outcomes. DisclosuresNo relevant conflicts of interest to declare.

Unusual complications following left ventricular assisted device implantation: case series

BackgroundWhile left ventricular assisted devices (LVAD) have revolutionized the treatment of advanced heart failure, they are associated with a wide range of complications, including bleeding and infection which are the most common complications reported in the literature. Our case series report four unusual complications not related to gastrointestinal bleeding and infections and their management.Case presentationA 61 year old female after LVAD implantation with late onset of severe symptomatic aortic regurgitation treated by transfemoral transcatheter valve implantation (TAVI) with good long term results.A 75 year old male patient with acute pump failure secondary to cable damage, who underwent urgent pump replacement. A 49 year old female patient with a history of myoma who developed massive uterine bleeding which was treated with emergent open hysterectomy after failed gonadotropin-releasing hormone therapy replacement. A 57 year old male patient with device display failure 1 month after LVAD implantation without the ability to monitor speed, power consumption and blood flow.ConclusionsLVAD patients can be presented with a great variety of complications. Physicians should be aware of their manifestations and the management options.

Evaluation of the efficacy of vaginal progesterone in preventing preterm birth after abdominal trachelectomy

ObjectiveTo determine whether vaginal progesterone (VP) reduces the rate of preterm birth in pregnant women after abdominal trachelectomy (AT) for early-stage cervical cancer Study DesignThis is an interventional study with a historical cohort. For the interventional study participants who had singleton pregnancies after AT between October 2016 and September 2020, the administration of vaginal progesterone was started between 16+ and 19+6 weeks of gestation and discontinued at 34 weeks of gestation or at the time of delivery, rupture of membranes, or massive uterine bleeding. We investigated obstetric and neonatal outcomes among the study participants and compared them with outcomes of the historical control group participants, included women with singleton pregnancies after AT who were managed without VP at our institution between January 2007 and September 2016, using Fisher’s exact test and the Mann–Whitney U test The main outcomes were the gestational age at delivery and incidence of preterm birth before 37 weeks and 34 weeks of gestation. ResultTwelve pregnancies in ten women were included in the VP group. In contrast, 19 pregnancies in 17 women were included in the historical control group. The incidence of preterm birth at <37 weeks was 10/12 (83 %) in the VP group and 11/19 (58 %) in the control group. The incidence of preterm birth at <34 weeks was 6/12 (50 %) in the VP group and 9/19 (48 %) in the control group. The incidence of preterm birth in the two groups was similar, and the difference between the two groups was not statistically significant. ConclusionThe administration of vaginal progesterone did not reduce the rate of preterm birth among pregnant women after AT.

The Choice of Anesthesia During Organ-Saving Operations Concerning Patients With Placenta Accreta Spectrum Disorders

Abstract Placenta accreta (PAS-disorders) is one of the most serious complications of pregnancy, associated with the risk of massive uterine bleeding, massive hemotransfusion and maternal mortality. Peripartum hysterectomy is a common treatment strategy for patients with placenta accreta. Currently, there is a clear trend of changing surgical tactics in favor of organ-saving operations, but there are no studies devoted to anesthesiological support of such operations.The aim of the study is to substantiate an effective and safe method of anaesthesia in organ-saving operations for placenta accreta spectrum disorders.Materia l and methods The study involved 80 patients with a diagnosis of placenta accreta spectrum disorders, confirmed intraoperatively, who underwent organ-saving operations. The patients were randomized depending on the method of anesthesia into 3 groups: general anesthesia, spinal anesthesia with planned conversion to general after fetal extraction and epidural anesthesia with planned conversion to general also after fetal extraction. The comparison of intraoperative hemodynamics, efficiency of tissue perfusion, efficiency of antinociceptive protection at the stages of surgery was performed. A comparative analysis of the volume of blood loss and blood transfusion, time of patients activation in the postoperative period, severity of pain on the first day after surgery, duration of hospital stay before discharge and comparison of the assessment of the newborn according to Apgar score at first and fifth minute after extraction.Conclusion The study shows that the optimal method of anesthesia in organ-saving operations for placenta accreta spectrum disorders is epidural anesthesia with its planned conversion to general anesthesia with an artificial lung ventilation after fetal extraction. Such an approach to anesthesia allows to maintain stable hemodynamic profile with minimal vasopressor support, sufficient heart performance, providing effective tissue perfusion and a high level of antinociceptive protection at the intraoperative stage and reduce the volume of intraoperative blood loss and hemotransfusion. In the current study there were no differences in neonatal outcomes and duration of hospitalization depending on the method of anesthesia. The advantage of epidural anesthesia with its conversion to general anesthesia was earlier activation after surgery and lower intensity of postoperative pain syndrome.

Successful conservative treatment for massive uterine bleeding with non-septic disseminated intravascular coagulation after termination of early pregnancy in a woman with huge adenomyosis: case report

BackgroundAdenomyosis is a benign gynecological condition in which endometrial tissue or endometrial-like tissue develops within the uterine myometrium. Few cases of disseminated intravascular coagulation has been reported in the patients with adenomyosis. Although hysterectomy is indicated for refractory massive uterine bleeding in the patients with advanced uterine adenomyosis, conservative treatment is often desired in women in the late reproductive age. Recently such cases are increasing due to the social trend of late marriage.Case presentationA 37-year-old woman with huge adenomyosis, gravida 2 para 0, was referred to our hospital to terminate her pregnancy. Acute, non-septic, disseminated intravascular coagulation (DIC) developed after early pregnancy was terminated in a woman with huge adenomyosis. Massive bleeding and DIC occurred 3 days after the dilatation and curettage. There was no evidence of infection as the cause of the DIC, because neither bacteria nor endotoxin could be detected in her blood, and antithrombin 3 (AT3), which would be expected to decrease in septic patients, was not decreased. Hemorrhage in the adenomyotic tissue after the termination presumably developed inflammation, with numerous microthrombi and necrosis in the adenomyotic tissue, which subsequently promoted coagulation and fibrinolysis, leading to the onset of massive uterine bleeding and DIC. Although severe hyperfibrinolysis is observed in peripheral blood, the fibrinolysis state in the uterine myometrium is considered to be even more severe. The newly formed clots for hemostasis under the uterine mucosa could be removed due to the excessive activation of fibrinolytic system happened in the adjacent myometrium, leading to the onset of massive uterine bleeding. Massive bleeding and DIC resolved quickly after the patient was treated with nafamostat mesilate, which is effective for both excessive coagulation and fibrinolysis.ConclusionsAdenomyosis could cause massive bleeding and DIC when pregnancy is terminated. Massive bleeding was considered to occur because the excessive fibrinolysis system inside adenomyosis affected the adjacent endometrium. Before considering hysterectomy to control refractory uterine bleeding, nafamostat mesilate should be considered as one option, thinking the pathophysiology of the massive bleeding due to uterine adenomyosis.

Hypoglycemia as a presenting manifestation of Sheehan’s syndrome

Sheehan’s syndrome is caused by ischemic necrosis of the pituitary gland from massive postpartum uterine bleeding. Despite advances in obstetric care, it is still an important cause of hypopituitarism in developing countries. Sheehan’s syndrome has an insidious course with variable presentation. Here, we present a case having recurrent hypoglycemia and was later found to have hypopituitarism due to Sheehan’s syndrome. Despite the presence of lactation failure and secondary amenorrhea following the delivery, she was diagnosed ten years later. Awareness of these clues and prompt evaluation for pan hypopituitarism can significantly reduce the morbidity and mortality in these patients.

FEATURES OF DEVELOPING MENOPAUSAL METABOLIC SYNDROME

Special attention is paid to the problem of menstrual cycle disorders, massive uterine bleeding in particular, in case of excessive body weight and obesity in the pеremenopause age. According to WHO data, from 64 % to 96 % women of this age have problems with excessive body weight, and massive preclimacteric bleedings are as frequent as 1025 %. Pathological processes connected with changes of lipid and carbohydratic metabolism (hyper- and dyslipidemy, insulin-resistancy, glucose tolerance disorder) stipulate obesety, and at the same time they are intensified with increasing of body weight.

EP28.01: Uterine artery pseudoaneurysm with coexisting artrovenous malformation

A 33-year old woman with a massive uterine bleeding occurred after a LPS treated uterine rupture due to a miomectomy scar pregnancy. US revealed an anechoic intramiometrial lesion surrounded by multiple tubular anechoic lesions distributed in the myometrium. 2D US and Colour Doppler sonography revealed a central arterial-like turbulent, low impedance blood flow inside the lesion. The hypothesis was of a uterine artery pseudoaneusysm and coexisting AV malformation. A 3DTVUS was performed to evaluate the exact position of the lesion and its angioarchitecture. The HD-flow 3D reconstruction of the resulting image revealed a large right pseudoaneurysm vascularised by an ecstatic vessel originated by the right uterine artery. Right artery embolisation was performed. 3D HD flow Doppler evaluation four days later showed persistent blood flow deriving from a collateral left uterine artery vessel. The patient was led to left uterine artery embolisation as well. Supporting information can be found in the online version of this abstract Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Efficacy of microwave ablation for the treatment of endometrial carcinoma: A report of 3 cases.

Microwave endometrial ablation (MEA) is effective for the emergency control of uterine hemorrhage. However, to the best of our knowledge, there has been only a single report of life-threatening hemorrhage induced by endometrial carcinoma that was treated with MEA. The present report evaluates the efficacy of MEA as an emergency therapeutic option for the control of bleeding due to advanced endometrial carcinoma and minimally-invasive, early-stage endometrial carcinoma in 3 patients. MEA was able to effectively control massive uterine bleeding due to endometrial carcinoma in 2 patients with advanced disease and was curative in a patient with minimally-invasive endometrial carcinoma. Given its safety, simplicity and effectiveness, MEA may be utilized for the emergency treatment of uterine bleeding in advanced endometrial carcinoma, and may be used as a curative treatment in early-stage endometrial carcinoma.

Medical Treatment of Uterine Arteriovenous Malformations: A Case Report

Background and Aim: Uterine arteriovenous malformation (AVM) is one of the complications of cesarean section and uterine curettage which is life-threatening. The aim of this case report was to assess medical treatment of a symptomatic case of AVM as uncommon cause of vaginal bleeding. Case Report: A 24-year-old female with an episode of heavy vaginal bleeding after curettage of pregnancy first trimester was referred to Ghaem Hospital of Mashhad University of Medical Sciences in 2014. She had a history of elective caesarian section in first pregnancy. Based on clinical findings and color Doppler ultrasonography, uterine AVM was diagnosed and modality conservative medical management was arranged. She was successfully treated with GnRH analogs and she had regular and normal menstrual cycles in her 1 year serial follow-up. Now, she has spent three months of pregnancy after 15 months of her disease. Conclusion: Diagnosis of uterine AVM should be considered in the case of massive uterine vaginal bleeding and a history of prior uterus surgery. The gonadotropin-releasing hormone agonist is useful in this situations. Keywords: Abnormal vaginal bleeding, medical treatment, ultra sonography, uterine arteriovenous malformation.

A case of severe uterine arteriovenous malformation treated with danazol followed by a transarterial embolization of unilateral uterine and ovarian arteries

Abstract Uterine arteriovenous malformation (AVM) is a potentially life-threatening condition characterized by abrupt and profuse uterine bleeding from abnormal connections between arteries and veins in the myometrium. It is commonly associated with prior pregnancy or uterine trauma. We present a case of severe uterine AVM treated with danazol and transarterial embolization (TAE). A 38-year-old patient with a history of two abortions and a myomectomy was referred to our hospital for intermittent massive uterine bleeding. She was diagnosed with uterine AVM by transvaginal color Doppler ultrasonography and helical computed tomography (CT). Diagnostic three-dimensional CT (3D-CT) angiography clearly demonstrated hypervascular tangles of uterine vessels, feeding arteries, remarkably dilated draining veins, as well as early filling of the internal iliac vein and the inferior vena cava, indicating massive arteriovenous shunting in the uterus. Danazol was administrated for 10 months to reduce the shunting of the uterine AVM before TAE with N-butyl-cyanoacrylate of the left ovarian artery and left uterine artery was successfully performed. After the procedure, we confirmed that shunting through the uterine AVM was markedly reduced. The patient has not experienced any severe uterine bleeding since the treatment.

A Growing Concern: Cesarean Scar Defect and Massive Uterine Bleeding

Cesarean Scar Defect (CSD) is the formation of a diverticulum at the site of the old caesarean incision [1]. With a rising cesarean sections being performed, the complications caused by CSDs has attracted more and more attentions. These include conditions such as scar pregnancy, placenta accreta, placenta previa, and uterine rupture in subsequent pregnancies [2,3].

Conservative Management of Uterine Artery Pseudoaneurysm Rupture with Rectal Fistula after Laparoscopic Myomectomy and Review of the Literature

Late uterine hemorrhage caused by uterine artery pseudoaneurysm is a rare but life-threatening complication after uterine surgery. The association of uterine pseudoanerysm rupture causing rectal fistula has not been reported in literature as well as its management. Herein we report a case of massive late uterine bleeding and rectal bleeding after laparoscopic myomectomy. A 43 year old Caucasian nulliparous woman underwent laparoscopic excision of 8 cm posterior intramural myoma. One month later she developed acute abdominal pain and proctorrhagia. A Computer Tomography scan (CT) demonstrated a 10 cm pelvic hematoma. The transvaginal ultrasound (TVU) showed 1 cm aneurism of the uterine artery. Transarterial angiography confirmed the ruptured uterine artery pseudoaneurysm that was successfully embolized. Repeated colonoscopy showed a rectal fistula. Total parenteral nutrition (TPN) and antibiotic prophylaxis were started. During the following month the intensity and frequency of proctorrhagia gradually declined. After four week of TPN colonoscopy confirmed a complete fistula healing. Oral feeding was gradually reintroduced. Two months later an ultrasound scan showed a complete resolution of the pelvic hematoma. To the best of our knowledge this the first described association of two rare complications: a pseudoaneurysm rupture and the subsequent rectal laceration successfully treated with embolization and conservative management.

Successful use of extracorporeal membrane oxygenation in the reversal of cardiorespiratory failure induced by atonic uterine bleeding: a case report

IntroductionAlthough extracorporeal membrane oxygenation has made sufficient progress to be considered for the management of life-threatening cardiac and respiratory failure, the risk of hemorrhagic complications may outweigh the benefits for patients with bleeding tendencies. We report, to the best of our knowledge, the first case of successful treatment by extracorporeal membrane oxygenation, without any hemorrhagic complications, of postpartum cardiorespiratory failure after massive uterine bleeding.Case presentationA 25-year-old Japanese woman experienced massive atonic bleeding after delivering her second baby. Recovery from hemorrhagic shock was managed by conservative treatments, but she developed decompensated heart failure and refractory hypoxia. Because we could not obtain hemodynamic stability and proper oxygenation even with high doses of catecholamines and maximal ventilator settings, we administered venoarterial extracorporeal membrane oxygenation, whereupon her hemodynamic status immediately stabilized. After 72 hours of support without major bleeding, extracorporeal membrane oxygenation was successfully withdrawn.ConclusionEven in cases of obstetric bleeding, if clotting status is stringently monitored, extracorporeal membrane oxygenation can be considered as an ultimate means of life support.

Risk factors for intraoperative hemorrhage at evacuation of a cesarean scar pregnancy following uterine artery embolization

ObjectiveTo determine risk factors associated with massive uterine bleeding during dilation and suction curettage (D&C) after uterine artery embolization (UAE) for the treatment of cesarean scar pregnancy (CSP). MethodsData from 128 CSP patients treated with D&C after UAE were analyzed to assess risk factors associated with massive uterine bleeding (blood loss 500mL or more) during D&C after UAE. ResultsIn total, 15 CSP patients had massive bleeding during D&C after UAE. Univariate analysis showed that a greater gestational age (GA), a larger CSP mass size, a thinner myometrium at the implantation site, a GA of 8weeks or more, a CSP mass diameter of 6cm or more, and evidence of fetal heartbeat were risk factors for massive bleeding (P<0.05). In a binary logistic regression analysis, GA of 8weeks or more and CSP mass diameter of 6cm or more remained as the only significant risk factors for massive bleeding (OR 11.49 [95% CI 1.08–122.13] and OR 96.59 [95% CI 6.20–150.57], respectively; P<0.05). ConclusionFor CSP masses with a GA of 8weeks or more and a diameter of 6cm or more, the outcome of surgical evacuation after UAE tends to be unsatisfactory.

Uterine Arteriovenous Fistula Treated With Repetitive Transcatheter Embolization: Case Report

Uterine arteriovenous fistula (AVF) is a rare entity, but may lead to life-threatening hemorrhage. Although transcatheter embolization, surgical ligation, or hysterectomy would be considered for treatment of uterine AVF, there is poor knowledge as to how gynecologists can manage the uterine AVF with multiple large inflow arteries. Herein we report a uterine AVF successfully treated using multiple-step transcatheter embolization. The patient, a 58-year-old postmenopausal woman with a history of dilation and curettage, had intermittent massive uterine bleeding. Radiologic imaging revealed the presence of a large vasculature mass. The mass occupied the entire pelvis, and the source of hemorrhage was identified as an accompanying AVF. We thought that surgical intervention was contraindicated because of the potential risk of uncontrollable intraoperative bleeding. Multiple-step transcatheter embolization was performed, with complete resolution of the AVF. Thereafter, the patient had no further uterine bleeding. Multiple-step transcatheter embolization might be the most beneficial and efficient treatment option for a uterine AVF with multiple large inflow arteries.

Spontaneous cessation and recurrence of massive uterine bleeding can occur in uterine artery pseudoaneurysm after laparoscopically assisted myomectomy

A uterine artery pseudoaneurysm (UAP) is a rare but life-threatening complication that can occur after gynecologic surgery. Herein, we present a case of a 38-year-old woman who presented with massive uterine bleeding one month after a laparoscopically assisted myomectomy. Although the bleeding ceased spontaneously, a massive hemorrhage reoccurred three weeks thereafter, and a ruptured perfusion sac at the right uterine artery was identified by computed tomography angiography and ultrasonography. The patient was treated with transfemoral catheter embolization of the right uterine artery, and complete resolution of the UAP was successfully obtained. Our case suggests that a UAP may be a cause of unexplained repetitive metrorrhagia after myomectomy.

Effective salvage of acute massive uterine bleeding using intrauterine balloon tamponade in a uterine adenomyosis patient on dienogest

We present the case of a 37-year-old nulliparous woman in whom acute massive uterine bleeding during dienogest therapy was successfully treated using intrauterine balloon tamponade. Abnormal uterine bleeding and several cases of profuse bleeding causing severe anemia in association with dienogest therapy have been reported, but this is the first reported case involving hypovolemic shock. While successful control of postpartum hemorrhage with intrauterine balloon tamponade has been well described, applications for non-obstetric bleeding, particularly in the presence of underlying diseases, such as adenomyosis, have only rarely been reported. This procedure can be easily, promptly, and safely implemented without analgesia, anesthesia, or laparotomy; it can be used with a minimally dilated external cervical os or narrow uterine cavity; and it can preserve fertility.

Kasuistik: Rezidivierende postpartale Blutung nach Notsectio - Clipping, Embolisation und hämostaseologische Therapie

Immediately after emergency caesarean section a 37 yr old patient suffered severe atonic bleeding requiring different operating procedures (Clipping of the uterine arteries) in combination with an uterotonic and haemostaseological medication as well as massive transfusion of blood components and recombinant factor VIIa. After a period of 17 days without any bleeding the patient presented to the emergency room with recurrent massive uterine bleeding. Transarterial embolization of the anterior bundles of the iliac arteries in combination with a second uterotonic and haemostaseological medication stopped the haemorrhage. Reasons and risk factors of a recurrent postpartum bleeding are discussed and a multidisciplinary algorithm for treatment is proposed.