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Hemorrhage after myomectomy resulting from pseudoaneurysm of the uterine artery
Hemorrhage after myomectomy resulting from pseudoaneurysm of the uterine artery María A. Higón, M.D.,a Santiago Domingo, M.D.,a Celia Bauset, M.D.,a José Martínez, M.D.,b and Antonio Pellicer, M.D.a a
Department of Obstetrics and Gynecology, and b Department of Radiology, Hospital Universitario Dr Peset, Valencia, Spain
Objective: To study a case of uterine artery hemorrhage after laparotomic myomectomy in a 40-year-old woman. Design: Retrospective clinical case. Setting: Tertiary clinical care university hospital. Patient(s): A 40-year-old woman, 1 month after a laparotomic myomectomy presenting sudden metrorrhagia. Intervention(s): The diagnosis of uterine artery pseudoaneurysm was made by color and duplex Doppler ultrasonography (CDDUS) and confirmed by arteriography. The angiographic study showed an intramyometrial uterine artery pseudoaneurysm. Main Outcome Measure(s): Clinical response to treatment. Result(s): The uterine artery pseudoaneurysm was successfully treated by embolization. The patient’s recovery was extraordinary, and now she has normal menses. Conclusion(s): CDDUS is a useful imaging technique in the diagnosis of arterial pseodoaneurysms. Transcatheter arterial embolization is a good alternative for management. It has the advantage that it is a less invasive technique and also is able to preserve the reproductive function. (Fertil Steril威 2007;87:417.e5– 8. ©2007 by American Society for Reproductive Medicine.) Key Words: Pseudoaneurysm, aneurysm, embolization, uterine artery
A pseudoaneurysm is the result of an incomplete laceration of the arterial wall that enables blood flow to perivascular tissues. In a pseudoaneurysm, there is persistent blood flow that communicates the lesion with the parent vessel (1). The main difference with a true aneurysm is that the boundaries of a pseudoaneurysm are formed by a peripheral thrombus and are not surrounded by three arterial layers as in a true aneurysm (2). Some cases have been described related to uterine surgery. Cesarean section is the most frequent antecedent found in these patients. Uterine artery pseudoaneurysm is a rare but reported complication of pelvic surgery (3). The incidence of this complication after uterine surgery is not very well known. Although the diagnosis is usually made after a pelvic hemorrhage, some cases may go unnoticed if they do not have a clinical repercussion, reducing the actual incidence of this complication. Typically, the lesion is discovered because the patient has symptoms related to delayed rupture causing an important hemorrhage (4). The most frequent clinical manifestation at the diagnosis is abnormal uterine bleeding. Ultrasonography (US) is the most commonly perfomed initial imaging examination for uterine hemorrhage. Color and duplex Doppler US (CDDUS) may be a useful imaging technique in the Received February 13, 2006; revised and accepted April 25, 2006. Reprint requests: Antonio Pellicer, M.D., Department of Obstetrics and Gynecology, Hospital Universitario Dr Peset, Av. Gaspar Aguilar 90, 46017 Valencia, Spain (FAX: 34-96-3861916; E-mail: pellicer_ant@ gva.es).
0015-0282/07/$32.00 doi:10.1016/j.fertnstert.2006.04.056
diagnosis. It also allows convincing detection and diagnosis of these vascular abnormalities and helps differentiate vascular abnormalities that require embolization from nonvascular abnormalities. Radiology has an important role in the early diagnosis and primary management of the uterine artery pseudoaneurysm. Embolization of the uterine artery is a technique introduced some years ago and employed in gynecology to treat uterine hemorrhages, mainly myomas, but also to treat uterine pseudoaneurysms (3). The elective management is transcatheter arterial embolization, which has the advantage of being less invasive and also able to preserve the reproductive function. We report a case of uterine artery pseudoaneurysm after a laparotomic myomectomy in a 40-year-old woman. A MEDLINE search of English-language medical literature using keywords “aneurysm,” “pseudoaneurysm,” “embolization,” and “uterine artery” found some cases of pseudoaneurysm after pelvic surgery. A cesarean section was the most common surgery done in all cases. To our knowledge, it is the first reported case of pseudoaneurysm after a myomectomy. CASE REPORT A 40-year-old woman, gravida 1, with a cesarean section a year previously was diagnosed as having an intramural myoma in the posterior side of the uterus that measured 7 cm in diameter and deformed the endometrial cavity causing hypermenorrheas and abdominal pain. After discussing with
Fertility and Sterility姞 Vol. 87, No. 2, February 2007 417.e5 Copyright ©2007 American Society for Reproductive Medicine, Published by Elsevier Inc.
the patient the treatment alternatives, she underwent a laparotomy in our hospital on October 29, 2004. Intramyoma injection of vasopressin was used in order to provoke a vasoconstriction of the myoma vessels. At the time of the myomectomy, an entrance to the endometrial cavity was made. A reconstruction of the uterus was made by two-layer reabsorbable suture. There were no complications after surgery, and the patient was released from the hospital 5 days later. Forty days after surgery, the patient came to the emergency service because of a sudden and abundant episode of metrorrhagia. Active bleeding from the uterine cavity in more quantity than a menstruation was evidenced. Transvaginal gray-scale US showed a suspicious image of hematometra and an echodense cyst with turbulence structure measuring 30 ⫻ 18 ⫻ 20 mm in the myometrium. This image was near the suture of the previous myomectomy, and it appeared as an intramyometrial hematoma. It had a perfectly defined and slender wall without excrescences. The clot of the hematometra was pulsing with the heartbeat, and no myometrial tissue was observed between the hematometra and the pseudoaneurysm (Fig. 1). CDDUS showed vascular flow and an arterial typical wave. The patient was stable from a hemodynamic point of view, with a normal blood pressure and cardiac frequency. A blood analysis showed a hemoglobin of 12.3 g/dL and a hematocrit of 37.3%. Because of the stable situation of the patient, an expectant attitude was decided. Twenty-four hours later, hemoglobin dropped to
9.6 g/dL and hematocrit to 28.6%. Because of the non– self-limited hemorrhage, it was decided then to perform an angiography. Under the effect of local anesthesia, the right common femoral artery was located and punctured. A selective left internal iliac angiogram was obtained. It showed a markedly opacified vascular tangle and a pseudoaneurysm in the myometrium (Fig. 2). After embolization with absorbable gelatin sponge pledgets and four 3-mm-diameter coils, the vascular image and the pseudoaneurysm disappeared. A contralateral angiogram showed no communication with the lesion. Follow-up US showed no evidence of pseudoaneurysm. One month after surgery, the patient was asymptomatic and had a normal menstruation. At sonography, an heterogeneous intrauterine image without flow measuring 14 mm was identified as a residual image. Right uterine artery was identified, and it showed normal arterial flow. In the left uterine artery, normal arterial flow was not observed but a redistribution flow was present. Currently, the patient is asymptomatic with normal menses, and the residual image has disappeared at sonography. DISCUSSION False or pseudoaneurysm is an uncommon complication of pelvic surgery. They can be acquired in association with
FIGURE 1 Intrauterine vascular image: a hematometra is seen next to the sutures of the myomectomy.
Higón. Uterine pseudoaneurysm after myomectomy. Fertil Steril 2007.
417.e6 Higón et al.
Uterine pseudoaneurysm after myomectomy
Vol. 87, No. 2, February 2007
FIGURE 2 Selective study of the anterior division of the left hypogastric arteries demonstrated a false aneurysm of the left uterine artery.
cause distal embolization (3). In our patient, the initial symptom(s) was three intermitent episodes of severe bleeding without pain or neurovascular symptomatology. The first imaging technique to apply when having a patient with metrorrhagia is transvaginal ultrasound. A pseudoaneurysm appears as a hypoechoic, well-defined structure with clear boundaries on gray-scale imaging with or without associated pelvic hematoma or free fluid (1, 6). In our case, a cystic and well-defined hypoechoic structure was easily identified near the myomectomy sutures. A well-organized hematoma was also seen next to the lesion beating in consonance with the heartbeat. Free pelvic fluid was not detected. CDDUS has a 94% sensitivity and 95% specificity detecting pseudoaneurysms (1, 5, 6). Doppler flow is then crucial in order to obtain the diagnosis. This imaging technique is able to see a central arterial-like turbulent blood flow surrounded by thrombus. Typically, the analysis of the neck of the pseudoaneurysm shows a classic to-and-fro pattern. This pattern means that immediately after the systole, the velocity of flow is very high and then becomes slow or reversed in the diastole. We were unable to identify the neck of the pseudoaneurysm. The CDDUS showed a fast arterial flow in the myometrium. This pattern and the clinical appearance of intermittent episodes of hemorrhage, typically described when there is an arteriovenous fistula, suggests an association of both entities in our patient.
Higón. Uterine pseudoaneurysm after myomectomy. Fertil Steril 2007.
trauma, previous surgery, trophoblastic disease, neoplasm, infection, or diethylstilbestrol exposure. The mechanism that plays a role in the formation of the arterial pseudoaneurysm is probably due to local trauma with vascular injury. When a punctured or lacerated artery does not seal completely, blood may escape and dissect the adjacent tissues, collecting in perivascular areas. If this collection mantains communication with the parent vessel, a pseudoaneurysm could result. The difference between a false and a true aneurysm is that in the former the boundaries of the lesion are formed by a thrombus and not by three arterial layers as in the second case (2, 5, 6). In our case, the origin of the uterine artery pseudoaneurysm formation was probably the uterine artery injury at the time of the myomectomy because the lesion appeared near the suture of the myomectomy. Because we take special care to avoid the vessels during decapsulation of the myomas, it is presumed that the origin of the injury was the suture. Additionally, the status after vasopressin injection could also help the injury to bleed. The clinical appearance of a pseudoaneurysm is variable. It can be asymptomatic, cause pain, exert mass effect on the adjacent neurovascular bundle, bleed, rupture, thrombose, or Fertility and Sterility姞
Arteriography and even surgery are sometimes necessary for a definitive diagnosis (1, 5). It helps to localize the bleeding site with the use of contrast material, which permits a selective embolization of the lesion (7). Advantages over surgery are that it is more elegant, less invasive, it identifies easily the source of bleeding with a quick control of the hemorrhage, has low incidence of rebleeding, and has success rates of 97% (3, 7–9). It also obviates the need and risks associated with general anesthesia, and hospitalization is frequently shorter (6). In conclusion, this case illustrates a rare but serious complication of gynecologic surgery. It is the first reported case of pseudoaneurysm after a myomectomy. The US study was crucial for the diagnosis of this entity, which was confirmed later with arteriography. The treatement of this complication with selective artery embolization is a very good option in the management of this pathology. It is safe, with a high rate of success and few complications, and it usually has no effect on the obstetrical future of the patient. REFERENCES 1. Hidar S, Bibi M, Atallah R, Essakly K, Bouzakoura C, Hidar M. Pseudoaneurysm of the uterine artery. J Gynecol Obstet Biol Reprod 2000;29:621– 4. 2. Descargues G, Douvrin F, Gravier A, Lemoine JP, Marpeau L, Clavier E. False aneurysm of the uterine pedicle: an uncommon cause of postpartum haemorrhage after cesarean section treated with selective arterial embolization. Eur J Obstet Gynecol Reprod Biol 2001;97(1):26 –9.
417.e7
3. Lee WK, Roche CJ, Duddalwar VA, Buckley AR, Morris DC. Pseudoaneurysm of the uterine artery after abdominal hysterectomy:radiologic diagnosis and management. Am J Obstet Gynecol 2001;185:1269 –72. 4. Langer JE, Cope C. Ultrasonographic diagnosis of uterine artery pseudoaneurysm after hysterectomy. J Ultrasound Med 1999;18:711–14. 5. Zimon AE, Hwang JK, Principe DL, Bahado-Singh RO. Pseudoaneurysm of the uterine artery. Obstet Gynecol 1999;94(5 Pt 2):827–30. 6. Wald DA. Postpartum hemorrhage resulting from uterine artery pseudoaneurysm. J Emerg Med 2003;25:57– 60.
417.e8 Higón et al.
7. Pelage JP, Soyer P, Repiquet D, Herbreateau D, Le Dref O, Houdart E, et al. Secondary postpartum hemorrhage: treatment with selective arterial embolization. Radiology 1999;212(2):385–9. 8. Sergent F, Clavier E, Rachet B, Marpeau L. Late post-partum hemorrhage after cesarean section due to rupture of a false aneurysm of the uterine pedicle. J Gynecol Obstet Biol Reprod 1997;26:641– 4. 9. Vedantham S, Goodwin SC, McLucas B, Mohr G. Uterine aertery embolization: an under used method of controlling pelvic hemorrhage. Am J Obstet Gynecol 1997;176:938 – 48.
Uterine pseudoaneurysm after myomectomy
Vol. 87, No. 2, February 2007
Department of Obstetrics and Gynecology, and b Department of Radiology, Hospital Universitario Dr Peset, Valencia, Spain
Objective: To study a case of uterine artery hemorrhage after laparotomic myomectomy in a 40-year-old woman. Design: Retrospective clinical case. Setting: Tertiary clinical care university hospital. Patient(s): A 40-year-old woman, 1 month after a laparotomic myomectomy presenting sudden metrorrhagia. Intervention(s): The diagnosis of uterine artery pseudoaneurysm was made by color and duplex Doppler ultrasonography (CDDUS) and confirmed by arteriography. The angiographic study showed an intramyometrial uterine artery pseudoaneurysm. Main Outcome Measure(s): Clinical response to treatment. Result(s): The uterine artery pseudoaneurysm was successfully treated by embolization. The patient’s recovery was extraordinary, and now she has normal menses. Conclusion(s): CDDUS is a useful imaging technique in the diagnosis of arterial pseodoaneurysms. Transcatheter arterial embolization is a good alternative for management. It has the advantage that it is a less invasive technique and also is able to preserve the reproductive function. (Fertil Steril威 2007;87:417.e5– 8. ©2007 by American Society for Reproductive Medicine.) Key Words: Pseudoaneurysm, aneurysm, embolization, uterine artery
A pseudoaneurysm is the result of an incomplete laceration of the arterial wall that enables blood flow to perivascular tissues. In a pseudoaneurysm, there is persistent blood flow that communicates the lesion with the parent vessel (1). The main difference with a true aneurysm is that the boundaries of a pseudoaneurysm are formed by a peripheral thrombus and are not surrounded by three arterial layers as in a true aneurysm (2). Some cases have been described related to uterine surgery. Cesarean section is the most frequent antecedent found in these patients. Uterine artery pseudoaneurysm is a rare but reported complication of pelvic surgery (3). The incidence of this complication after uterine surgery is not very well known. Although the diagnosis is usually made after a pelvic hemorrhage, some cases may go unnoticed if they do not have a clinical repercussion, reducing the actual incidence of this complication. Typically, the lesion is discovered because the patient has symptoms related to delayed rupture causing an important hemorrhage (4). The most frequent clinical manifestation at the diagnosis is abnormal uterine bleeding. Ultrasonography (US) is the most commonly perfomed initial imaging examination for uterine hemorrhage. Color and duplex Doppler US (CDDUS) may be a useful imaging technique in the Received February 13, 2006; revised and accepted April 25, 2006. Reprint requests: Antonio Pellicer, M.D., Department of Obstetrics and Gynecology, Hospital Universitario Dr Peset, Av. Gaspar Aguilar 90, 46017 Valencia, Spain (FAX: 34-96-3861916; E-mail: pellicer_ant@ gva.es).
0015-0282/07/$32.00 doi:10.1016/j.fertnstert.2006.04.056
diagnosis. It also allows convincing detection and diagnosis of these vascular abnormalities and helps differentiate vascular abnormalities that require embolization from nonvascular abnormalities. Radiology has an important role in the early diagnosis and primary management of the uterine artery pseudoaneurysm. Embolization of the uterine artery is a technique introduced some years ago and employed in gynecology to treat uterine hemorrhages, mainly myomas, but also to treat uterine pseudoaneurysms (3). The elective management is transcatheter arterial embolization, which has the advantage of being less invasive and also able to preserve the reproductive function. We report a case of uterine artery pseudoaneurysm after a laparotomic myomectomy in a 40-year-old woman. A MEDLINE search of English-language medical literature using keywords “aneurysm,” “pseudoaneurysm,” “embolization,” and “uterine artery” found some cases of pseudoaneurysm after pelvic surgery. A cesarean section was the most common surgery done in all cases. To our knowledge, it is the first reported case of pseudoaneurysm after a myomectomy. CASE REPORT A 40-year-old woman, gravida 1, with a cesarean section a year previously was diagnosed as having an intramural myoma in the posterior side of the uterus that measured 7 cm in diameter and deformed the endometrial cavity causing hypermenorrheas and abdominal pain. After discussing with
Fertility and Sterility姞 Vol. 87, No. 2, February 2007 417.e5 Copyright ©2007 American Society for Reproductive Medicine, Published by Elsevier Inc.
the patient the treatment alternatives, she underwent a laparotomy in our hospital on October 29, 2004. Intramyoma injection of vasopressin was used in order to provoke a vasoconstriction of the myoma vessels. At the time of the myomectomy, an entrance to the endometrial cavity was made. A reconstruction of the uterus was made by two-layer reabsorbable suture. There were no complications after surgery, and the patient was released from the hospital 5 days later. Forty days after surgery, the patient came to the emergency service because of a sudden and abundant episode of metrorrhagia. Active bleeding from the uterine cavity in more quantity than a menstruation was evidenced. Transvaginal gray-scale US showed a suspicious image of hematometra and an echodense cyst with turbulence structure measuring 30 ⫻ 18 ⫻ 20 mm in the myometrium. This image was near the suture of the previous myomectomy, and it appeared as an intramyometrial hematoma. It had a perfectly defined and slender wall without excrescences. The clot of the hematometra was pulsing with the heartbeat, and no myometrial tissue was observed between the hematometra and the pseudoaneurysm (Fig. 1). CDDUS showed vascular flow and an arterial typical wave. The patient was stable from a hemodynamic point of view, with a normal blood pressure and cardiac frequency. A blood analysis showed a hemoglobin of 12.3 g/dL and a hematocrit of 37.3%. Because of the stable situation of the patient, an expectant attitude was decided. Twenty-four hours later, hemoglobin dropped to
9.6 g/dL and hematocrit to 28.6%. Because of the non– self-limited hemorrhage, it was decided then to perform an angiography. Under the effect of local anesthesia, the right common femoral artery was located and punctured. A selective left internal iliac angiogram was obtained. It showed a markedly opacified vascular tangle and a pseudoaneurysm in the myometrium (Fig. 2). After embolization with absorbable gelatin sponge pledgets and four 3-mm-diameter coils, the vascular image and the pseudoaneurysm disappeared. A contralateral angiogram showed no communication with the lesion. Follow-up US showed no evidence of pseudoaneurysm. One month after surgery, the patient was asymptomatic and had a normal menstruation. At sonography, an heterogeneous intrauterine image without flow measuring 14 mm was identified as a residual image. Right uterine artery was identified, and it showed normal arterial flow. In the left uterine artery, normal arterial flow was not observed but a redistribution flow was present. Currently, the patient is asymptomatic with normal menses, and the residual image has disappeared at sonography. DISCUSSION False or pseudoaneurysm is an uncommon complication of pelvic surgery. They can be acquired in association with
FIGURE 1 Intrauterine vascular image: a hematometra is seen next to the sutures of the myomectomy.
Higón. Uterine pseudoaneurysm after myomectomy. Fertil Steril 2007.
417.e6 Higón et al.
Uterine pseudoaneurysm after myomectomy
Vol. 87, No. 2, February 2007
FIGURE 2 Selective study of the anterior division of the left hypogastric arteries demonstrated a false aneurysm of the left uterine artery.
cause distal embolization (3). In our patient, the initial symptom(s) was three intermitent episodes of severe bleeding without pain or neurovascular symptomatology. The first imaging technique to apply when having a patient with metrorrhagia is transvaginal ultrasound. A pseudoaneurysm appears as a hypoechoic, well-defined structure with clear boundaries on gray-scale imaging with or without associated pelvic hematoma or free fluid (1, 6). In our case, a cystic and well-defined hypoechoic structure was easily identified near the myomectomy sutures. A well-organized hematoma was also seen next to the lesion beating in consonance with the heartbeat. Free pelvic fluid was not detected. CDDUS has a 94% sensitivity and 95% specificity detecting pseudoaneurysms (1, 5, 6). Doppler flow is then crucial in order to obtain the diagnosis. This imaging technique is able to see a central arterial-like turbulent blood flow surrounded by thrombus. Typically, the analysis of the neck of the pseudoaneurysm shows a classic to-and-fro pattern. This pattern means that immediately after the systole, the velocity of flow is very high and then becomes slow or reversed in the diastole. We were unable to identify the neck of the pseudoaneurysm. The CDDUS showed a fast arterial flow in the myometrium. This pattern and the clinical appearance of intermittent episodes of hemorrhage, typically described when there is an arteriovenous fistula, suggests an association of both entities in our patient.
Higón. Uterine pseudoaneurysm after myomectomy. Fertil Steril 2007.
trauma, previous surgery, trophoblastic disease, neoplasm, infection, or diethylstilbestrol exposure. The mechanism that plays a role in the formation of the arterial pseudoaneurysm is probably due to local trauma with vascular injury. When a punctured or lacerated artery does not seal completely, blood may escape and dissect the adjacent tissues, collecting in perivascular areas. If this collection mantains communication with the parent vessel, a pseudoaneurysm could result. The difference between a false and a true aneurysm is that in the former the boundaries of the lesion are formed by a thrombus and not by three arterial layers as in the second case (2, 5, 6). In our case, the origin of the uterine artery pseudoaneurysm formation was probably the uterine artery injury at the time of the myomectomy because the lesion appeared near the suture of the myomectomy. Because we take special care to avoid the vessels during decapsulation of the myomas, it is presumed that the origin of the injury was the suture. Additionally, the status after vasopressin injection could also help the injury to bleed. The clinical appearance of a pseudoaneurysm is variable. It can be asymptomatic, cause pain, exert mass effect on the adjacent neurovascular bundle, bleed, rupture, thrombose, or Fertility and Sterility姞
Arteriography and even surgery are sometimes necessary for a definitive diagnosis (1, 5). It helps to localize the bleeding site with the use of contrast material, which permits a selective embolization of the lesion (7). Advantages over surgery are that it is more elegant, less invasive, it identifies easily the source of bleeding with a quick control of the hemorrhage, has low incidence of rebleeding, and has success rates of 97% (3, 7–9). It also obviates the need and risks associated with general anesthesia, and hospitalization is frequently shorter (6). In conclusion, this case illustrates a rare but serious complication of gynecologic surgery. It is the first reported case of pseudoaneurysm after a myomectomy. The US study was crucial for the diagnosis of this entity, which was confirmed later with arteriography. The treatement of this complication with selective artery embolization is a very good option in the management of this pathology. It is safe, with a high rate of success and few complications, and it usually has no effect on the obstetrical future of the patient. REFERENCES 1. Hidar S, Bibi M, Atallah R, Essakly K, Bouzakoura C, Hidar M. Pseudoaneurysm of the uterine artery. J Gynecol Obstet Biol Reprod 2000;29:621– 4. 2. Descargues G, Douvrin F, Gravier A, Lemoine JP, Marpeau L, Clavier E. False aneurysm of the uterine pedicle: an uncommon cause of postpartum haemorrhage after cesarean section treated with selective arterial embolization. Eur J Obstet Gynecol Reprod Biol 2001;97(1):26 –9.
417.e7
3. Lee WK, Roche CJ, Duddalwar VA, Buckley AR, Morris DC. Pseudoaneurysm of the uterine artery after abdominal hysterectomy:radiologic diagnosis and management. Am J Obstet Gynecol 2001;185:1269 –72. 4. Langer JE, Cope C. Ultrasonographic diagnosis of uterine artery pseudoaneurysm after hysterectomy. J Ultrasound Med 1999;18:711–14. 5. Zimon AE, Hwang JK, Principe DL, Bahado-Singh RO. Pseudoaneurysm of the uterine artery. Obstet Gynecol 1999;94(5 Pt 2):827–30. 6. Wald DA. Postpartum hemorrhage resulting from uterine artery pseudoaneurysm. J Emerg Med 2003;25:57– 60.
417.e8 Higón et al.
7. Pelage JP, Soyer P, Repiquet D, Herbreateau D, Le Dref O, Houdart E, et al. Secondary postpartum hemorrhage: treatment with selective arterial embolization. Radiology 1999;212(2):385–9. 8. Sergent F, Clavier E, Rachet B, Marpeau L. Late post-partum hemorrhage after cesarean section due to rupture of a false aneurysm of the uterine pedicle. J Gynecol Obstet Biol Reprod 1997;26:641– 4. 9. Vedantham S, Goodwin SC, McLucas B, Mohr G. Uterine aertery embolization: an under used method of controlling pelvic hemorrhage. Am J Obstet Gynecol 1997;176:938 – 48.
Uterine pseudoaneurysm after myomectomy
Vol. 87, No. 2, February 2007