Management of uterine artery pseudoaneurysm: a case report of noninterventional treatment with systematic review

Background

Uterine artery pseudoaneurysm (UAP) is a rare but potentially life-threatening condition that can result in severe hemorrhage. Due to its nonspecific clinical presentation, it is often misdiagnosed, leading to delays in appropriate intervention. UAP commonly arises following uterine trauma, including cesarean section, vaginal delivery, and other gynecological procedures or pathologies, such as endometriosis. While selective arterial embolization is the preferred treatment, noninterventional management may be a viable alternative in selected cases.

Case Report

We present a case of a 33-year-old woman in her first pregnancy diagnosed with UAP at 27 gestational weeks (GW). She complained about intermittent left lower abdominal pain without vaginal bleeding. Initial imaging with Doppler ultrasonography and noncontrast magnetic resonance imaging (MRI) identified a left paracervical mass consistent with a UAP. Further imaging with contrast-enhanced MRI confirmed the diagnosis and revealed thrombosis of the lesion. Given the absence of perfusion and clinical stability, a noninterventional approach was pursued. The patient remained hemodynamically stable and was discharged after 6 days of hospitalization. At 38+4 GW, she underwent a scheduled cesarean section, and both maternal and neonatal outcomes were favorable. Follow-up at 12 months postdiagnosis showed no recurrence or complications.

Methods

A systematic review was conducted, analyzing peer-reviewed studies from 1955 to 2024 in PubMed and EMBASE databases. Inclusion criteria focused on human studies reporting UAP, with data extracted on risk factors, diagnostic modalities, treatment strategies, and clinical outcomes. Statistical analyses included the Student’s t test for continuous variables and the Pearson chi-square test for categorical variables.

Results

Out of 790 initially identified articles, 131 met inclusion criteria, comprising 144 patients with uterine artery UAP. Among these, 20 patients were pregnant, and 124 were nonpregnant. Comorbidities were more common in pregnant patients (55% vs 34.7%). Prior uterine manipulation occurred in 50% of pregnant and 90.3% of nonpregnant cases, with laparotomy and cesarean sections being most frequent. Vaginal bleeding was the most common symptom in nonpregnant patients (81.5%), while pain dominated in pregnant cases (85%). Imaging primarily involved ultrasound and angiography, combined with computed tomography (CT) in nonpregnant women (70% vs 35%) and MRI in pregnancy (70% vs 11.3%). Embolization was the main treatment (90% in pregnancy, 99% in nonpregnant), with few complications and no reported deaths. Statistical analysis showed a significant association in nonpregnant patients between vaginal bleeding and the need for transfusion (P<.05), as well as between bleeding and smaller UAP size (24.5 vs 32.3 mm, P<.05).

Conclusion

UAP is rare and potentially serious. Vaginal bleeding is the most common presentation in nonpregnant patients, while pain is more frequent in pregnancy. Smaller UAPs were more likely to bleed in nonpregnant patients, suggesting rupture risk isn’t solely size-dependent. Diagnostics can be performed by ultrasound, angiography, and CT, or in pregnancy, especially by MRI. Embolization is highly effective and remains the standard of care. Noninterventional management may be cautiously considered in hemodynamically stable patients with spontaneously thrombosed or nonperfused UAPs, though evidence of its effectiveness remains limited. An individualized, multidisciplinary management remains the key. Further data collection will help refine treatment strategies.