Hemorrhagic uterine necrosis after surgical vessel ligation and B-Lynch suture in persistent post-cesarean uterine atony: case report and review of literature

Giusti S., Fanti F., Cecchi E., Capriello P., Malacarne E., Marmorato M., Vergine F., Giannini A., Gadducci A., Caramella D., Simoncini T.


Uterine necrosis is a rare life-threatening condition reported in few case reports and series, associated with uterine artery embolization for uterine fibroids or postpartum hemorrhage. We report a hemorrhagic uterine necrosis in a nulliparous 35 years-old woman underwent cesarean section at 40+1 weeks of gestation for obstructed labor, presenting post-partum persisting bleeding and uterine atony and congestion. Bleeding stopped only after placement of two set of compressive sutures, curettage of uterine cavity and placement of Bakri Balloon but the uterine body never contracted and become congested. Notwithstanding an effective antibiotic therapy, the patient developed an intermittent fever and signs of severe anemia. Clinical and radiological diagnosis with CT and MRI scan were compatible with uterine necrosis characterized by hemorrhagic infarction of the uterine wall and decomposition of its muscular tissue. Hysterectomy was discussed with patient and performed on day 32 after C-section. Uterine apoplexy, a rare life-threatening disease, was detected with CT by lack of uterine contrast enhancement and a gas-filled uterine cavity and necrosis was confirmed with MRI by showing fluid degeneration of the myometrium. Failure to recognize a necrotic uterus on imaging can cause delayed hysterectomy, which is mandatory and potentially life-saving.


Case report, CT, MRI, Hemorrhagic infarction, Uterine necrosis

Full Text:



Couvelaire A. Deux nouvelles observations d'apoplexie utero-placentaire (hemorrhagies retro-placentaires avec infiltration sanguine de la pavoi musculaire de l'uterus). Ann Gynecol Obstet. 1912;9:486.

Melenhorst M, Hehenkamp W, de Heer K, Berger F. CT features in uterine necrosis of unknown cause: a case report. Clinical Imaging. 2014; 38:543-6.

Torigian DA, Siegelman ES, Terhune KP, Butts SF, Blasco L, Shlansky-Goldberg RD. MRI of uterine necrosis after uterine artery embolization for treatment of uterine leiomyomata. AJR Am J Roentgenol. 2005;184(2):555-9.

Poujade O, Daher A, Ballout El Maoula A, Aflak N, Bougeois B, Vilgrain V, et al. Uterine necrosis following pelvic arterial embolisation for postpartum haemorrhage: Case report. J Gynecol Obstet Biol Reprod. 2012;41(6):584-6.

Gabriel H, Pinto CM, Kumar M, Nikolaidis P, Miller FH, Weinrach DM, et al. MRI detection of uterine necrosis after uterine artery embolization for fibroid. AJR Am J Roentgenol. 2004;183(3):733-6.

Kitamura Y, Ascher SM, Cooper C, Allison SJ, Jha RC, Flick PA, et al. Imaging manifestations of complications associated with uterine artery embolization. Radiographics. 2005;(Suppl 1):S119-32

Pirard C, Squifflet J, Gilles A, Donnez J. Uterine necrosis and sepsis after vascular embolization and surgical ligation in a patient with postpartum hemorrhage. Fertil Steril. 2002;78:412-3.

Courbiere B, Jauffret C, Provansal M, Agostini A, Bartoli JM, Cravello L, et al. Failure of conservative management in postpartum haemorrhage: uterine necrosis and hysterectomy after angiographic selective embolization with gelfoam. Eur J Obstet Gynecol Reprod Biol. 2008;140:291-3.

Tseng JJ, Ho JY, Wen MC, Hwang JI. Uterine necrosis associated with acute suppuratives myometritis after angiographic selective embolization for refractory postpartum haemorrhage. Am J Obstet Gynecol. 2011;204:e4-6.

Rivlin ME, Carroll CS, Morrison JC. Conservative surgery for uterine incisional necrosis complicating cesarean delivery. Obstet Gynecol. 2004;103(5 Pt 2):1105-8.

Sierra A, Burrel M, Sebastia C, Radosevic A, Barrufet M, Albela S, Buñesch L, Domingo MA, Salvador R, Real I. Utility of multidetector CT in severe postpartum hemorrhage. Radiographics. 2012;32(5):1463-81.

Rodgers SK1, Kirby CL, Smith RJ, Horrow MM. Imaging after cesarean delivery: acute and chronic complications. Radiographics. 2012;32(6):1693-712.

Plunk M, Lee JH, Kani K, Dighe M. Imaging of postpartum complications: a multimodality review. AJR. 2013;200:W143-54.