A silent vascular threat: uterine artery pseudoaneurysm in secondary postpartum haemorrhage

Abstract

Secondary postpartum haemorrhage (SPH) is an important cause of postpartum morbidity occurring between 24 hours and 6 weeks after delivery. While retained products of conception and endometritis are common causes, rare conditions such as uterine artery pseudoaneurysm (UAP) can result in life-threatening haemorrhage and diagnostic difficulty. We report a case of recurrent SPH caused by UAP following caesarean section. A postpartum woman presented on the eighth postoperative day with massive vaginal bleeding and haemorrhagic shock after caesarean delivery for second-stage arrest. Initial ultrasonography suggested retained products of conception, and she underwent stabilization with blood transfusion followed by check curettage. Despite treatment, the patient developed two further episodes of recurrent haemorrhage requiring repeated admissions. MRI findings suggested scar hematoma, scar dehiscence, or endometritis, while diagnostic laparoscopy was inconclusive. Repeat Doppler ultrasonography by a senior radiologist raised suspicion of UAP, which was confirmed by CT angiography. Selective angiography revealed a pseudoaneurysm arising from the right uterine artery, and successful uterine artery embolization using NESTER coils achieved immediate control of bleeding. UAP should be considered in recurrent or severe SPH. Early diagnosis and timely uterine artery embolization provide effective, fertility-preserving management with excellent outcomes.