I read the article, ‘‘Delayed postpartum hemorrhage: the implications of making a diagnostic mistake’’ by Surico et al. [1]. Postpartum hemorrhage (PPH) occurred after cesarean section (CS): a vascular abnormality was initially considered the culprit but uterine scar dehiscence proved to be its true culprit. The context of this article is that (1) PPH sometimes leads to a ‘‘diagnostic mistake’’, and (2) hysteroscopy should be performed to confirm the diagnosis of PPH. We wish to comment on these two points. First, we partly agree with Surico et al. first opinion: PPH sometimes leads to a ‘‘diagnostic mistake’’. However, we would like the readers to recall uterine artery pseudoaneurysm (UAP), which has recently attracted wider attention as a causative disorder of PPH. Yes, PPH sometimes leads to a ‘‘diagnostic mistake’’; however, not coexistence of, or misunderstanding as, vascular abnormality but UAP (acquired vascular abnormality) itself may lead to a ‘‘diagnostic mistake’’. In a 2011 article in this Journal [2], we stated that a typical UAP is characterized by the following five points: (1) hemorrhage occurs mainly after CS, (2) hemorrhage manifests as PPH, (3) ultrasound reveals anechoic mass within the uterus, (4) color Doppler shows a yin-yang sign, a swirling blood flow, and (5) embolization usually stops the bleeding. However, some UAPs show atypical features. Thus, we concluded, ‘‘a pseudoaneurysm may behave as a chameleon, with its skin color easily changing’’. During the 2 years after publishing this article [2], we experienced additional patients with UAP, strengthened our belief that ‘‘UAP behaves like a chameleon’’. We would like to summarize the point, adding new insight to that described in the previous article [2]. Why chameleon? We previously reported a patient in whom UAP occurred after non-traumatic mid-trimester pregnancy termination and not after CS [3]. We recently experienced two other patients in whom UAP occurred after non-traumatic preterm or term vaginal delivery, and thus point (1) (after CS) did not apply. In fact, during a 6-year period in this institute, which deals with 1,100 deliveries annually, we encountered 11 patients with UAP, of whom 6 were after vaginal delivery. We also previously reported a patient after CS in whom routine hospital discharge examination incidentally revealed a pelvic cystic mass, which was confirmed to be UAP [4], and thus point (2) (PPH) did not apply. Point (3) (anechoic mass) also does not always hold true. The cavity of UAP is sometimes occupied by hematoma, an echogenic mass [4]. Retained product of conception sometimes coexists with UAP [5, 6]. These two may make the anechoic mass difficult to detect. More recently, we experienced a post-abortive patient with a large UAP, which occupied the entire uterine cavity. Several echogenic and anechoic areas coexisted: the echogenic areas were hematomas and the anechoic areas continued to be supplied with blood and remained anechoic [7]. Thus, of the five characteristic features of UAP, three (1–3) are not always present and thus we named UAP ‘‘a chameleon’’, changing its color (features) in a patient-bypatient manner [2]. At the time of writing the 2011 article [2], we assumed that point (4) (swirling flow) is always true. However, a more recent report disproved our assumption. Bouchet et al. [8] described a UAP patient in whom low blood S. Matsubara (&) T. Kuwata R. Usui A. Ohkuchi Department of Obstetrics and Gynecology, Jichi Medical University, 3311-1 Shimotsuke, Tochigi 329-0498, Japan e-mail: matsushi@jichi.ac.jp
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Jul 22, 2014
Ghada M Mansour + 3
Open Access