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Rupture of an ovarian artery aneurysm following normal vaginal delivery.

Introduction

Ruptured ovarian artery aneurysms are extremely rare, occurring during the peripartum or early postpartum periods. Only 11 cases have been reported in the English literature; the following represents the 12th.

Case report

A 30-year-old woman presented at the casualty department 12 days after having given birth to a healthy baby via normal vaginal delivery. She complained of increasing pain and a mass in her right flank. There were no complaints of nausea, vomiting, dysuria or abnormal bowel habits. On examination, the patient was acutely distressed, in severe pain and anaemic with an Hb of 5 g/dl. Her blood pressure was 151/71 mmHg and her pulse 125/minute. Physical examination revealed a severely distended abdomen with features of peritonitis.

[FIGURE 1 OMITTED]

Abdominal ultrasound revealed a large abdominal fluid collection; a CT scan was therefore requested. A contrast-enhanced CT scan demonstrated a large homogenous retroperitoneal fluid collection in the right flank, with a 25mm rounded, intensely enhancing focus located close to the inferior border of the collection (Fig. 1). The collection displaced the bowel to the left and inferiorly, and the liver superiorly.

The differential diagnosis included a ruptured ovarian artery aneurysm. As soon as the patient was stable, she was taken for ovarian artery embolisation, which was successfully accomplished (Fig. 2). She recovered well in the ward.

[FIGURE 2 OMITTED]

Discussion

In their review of pregnancy-related ruptured arterial aneurysms, Barret et al. list in decreasing order of frequency those of intracranial, aortic, splenic, renal and ovarian artery origin. Of these, the ovarian artery location is by far the least frequent, with only 11 cases recorded in the English-language literature. (1)

The pathogenesis of these lesions is poorly understood, with homodynamic and hormonal factors suggested. (2-4) Systemic haemodynamic changes that occur in pregnancy include increased cardiac output and blood volume. Systemic hypertension is common, and significant swings in blood pressure are thought to result from compression of the abdominal aorta by the gravid uterus in the supine position. Also, enlargement of the uterus with dilatation of the pelvis arteries cause increased uterine blood flow. Burnett and Carfrae (2) have postulated that during the normal process of involution that occurs during the postpartum period, a segment or segments of the ovarian circulation may fail to involute, predisposing to aneurysm formation in subsequent pregnancy.

Concerning hormonal factors, Barret et al. (1) noted the results of both animal and human studies suggesting that the pregnancy-related alterations in steroid hormones may cause a variety of arterial changes, including intimal hyperplasia, thickening of the media associated with smooth muscle hyperplasia, fragmentation of reticular fibres and loss of normal corrugation of elastic fibres.

The most common symptom of rupture of ovarian artery aneurysm is acute flank pain or abdominal pain. (3), (4) A ruptured ovarian artery aneurysm may be surgically treated by adnexectomy or ligation proximal and distal to the point of rupture. (1), (3) Arterial embolisation is now developing as an alternative therapy. (5)

Conclusion

Although rupture of an ovarian artery aneurysm is an extremely rare event, it is life-threatening and is often associated with a non-specific clinical picture. Awareness of this entity and a high index of suspicion may lead to early diagnosis and treatment. Intravenous contrast-enhanced multidetector CT with two-dimensional reconstructions is an excellent imaging technique for rapid and safe evaluation, and may be the examination of choice for such patients.

(1.) rupture of arterial aneurysms. Obstet Gynecol Surv 1982;37:557-560.

(2.) Burnett RA, Carfrae DC. Spontaneous rupture of ovarian artery aneurysm in the puerperium. Two case reports and a review of the literature. Br J Obstet Gynaecol 1976;83:744-750.

(3.) Blachar A, Bloom A.I, Golan G, et al. Case reports. Spiral CT imaging of a ruptured postpartum ovarian artery aneurysm. Clin Radiol 2000;55:718-720.

(4.) King WL. Ruptured ovarian artery aneurysm: a case report. J Vasc Surg 1999;13:445-448.

(5.) Guillem P, Bondue X, Chambon JP, et al. Spontaneous retroperitoneal haematoma from rupturing of an aneurysm of the ovarian artery following delivery. Ann Vasc Surg 1999;13:445-448.

Francois van Schouwenburg, MB ChB

Hassan Lameen, MB ChB, MD, FCRad (Diag) SA

Department of Radiology, Grey's Hospital, Pietermaritzburg

Corresponding author: H Lameen (h.alameen1@yahoo.com)
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Article Details
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Author:van Schouwenburg, Francois; Lameen, Hassan
Publication:South African Journal of Radiology
Article Type:Case study
Geographic Code:6SOUT
Date:Jun 1, 2011
Words:700
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