Uterine necrosis and hysterectomy in a postpartum hemorrhage patient who underwent repeated uterine artery embolization

Abstract

A 19-year-old nulliparous female in the 28th week of her first pregnancy, a monoamniotic monochorial twin pregnancy, was transferred to our hospital after she presented with watery vaginal discharge and lower abdominal pain. Soon after admission to our hospital, the patient was managed conservatively; her condition stabilized without significant clinical events. Approximately 1 month later, she developed vaginal bleeding with fresh blood, suggesting premature membrane rupture requiring emergency cesarean delivery. The estimated blood loss during cesarean delivery was approximately 1000 mL. The patient showed continued vaginal bleeding after cesarean delivery in the operating room. Vital signs and laboratory data were: blood pressure 1⁄4 122/ 73 mmHg, pulse rate 1⁄4 111 times/minute, hemoglobin 1⁄4 8.5 g/dL, and hematocrit 1⁄4 25.3%. The patient was managed by conservative methods including uterine massage, fluid loading, intravenous administration of oxytocin, and vaginal packing. Uterine atony was considered as the cause of postpartum bleeding because the patient had no abnormal findings of the placenta and no particular event occurred during cesarean delivery. Emergency uterine artery embolization (UAE) was performed for massive postpartum hemorrhage (PPH). The anterior divisions of both the right and left internal iliac arteries were embolized using gelfoam particles (Cutanplast, Mascia Brunelli, Milan, Italy). The next morning, massive vaginal bleeding was again evident. The vital signs were blood pressure 1⁄4 80/60 mmHg and pulse rate 1⁄4 125 times/minute. The hemoglobin level was 6.6 g/dL. Emergency UAE was performed once more. A pelvic angiogram showed active bleeding in the