JMCR: Clinical Minute
Published in Biomedical Research
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Delayed rupture of vaginal wall haematoma causing secondary postpartum haemorrhage—successful management with bilateral uterine artery embolisation: a case report
The Case
A 32-year-old primiparous woman underwent forceps-assisted vaginal delivery with mediolateral episiotomy. On postpartum day 4, ultrasound demonstrated an approximately 8-cm right vaginal wall haematoma. Because she was asymptomatic and haemodynamically stable, conservative management and surveillance were chosen.
The Turn
On postpartum day 11, she developed sudden massive vaginal bleeding—approximately 1,000 mL within minutes—with dizziness, diaphoresis, transient loss of consciousness, and haemodynamic instability. Her haemoglobin was 74 g/L. The uterus was well contracted, and ultrasound showed no obvious retained products of conception.
The Diagnosis
The known vaginal wall haematoma had ruptured in a delayed fashion, producing secondary postpartum haemorrhage. Emergency angiography demonstrated active arterial contrast extravasation from branches supplying the vaginal wall.
The Intervention
Emergency bilateral uterine artery embolisation was performed. Post-embolisation angiography demonstrated complete cessation of extravasation, and the vaginal bleeding stopped immediately. Subsequent ultrasound showed gradual resorption of the haematoma, with no recurrent bleeding reported during follow-up.
Clinical Pearl
Secondary postpartum haemorrhage is not always uterine. In a patient with late postpartum bleeding after instrumental delivery, episiotomy, or known genital-tract trauma, consider delayed rupture of a concealed vaginal wall haematoma. When the bleeding source is deep, arterial, and difficult to access surgically, angiography can both localize the lesion and permit rapid, minimally invasive haemostasis with uterine artery embolisation.
JMCR Clinical Minute: An initially stable postpartum vaginal haematoma can become a delayed, life-threatening haemorrhage. Recognition, imaging, and timely embolisation can be lifesaving while avoiding more invasive surgery.
Richard Alan Rison is the interim Editor-in-Chief of Journal of Medical Case reports. He is also an associate neurology editor (editorial board) for BMC Neurology, and the former lead editor for case reports of BMC Research Notes (currently on the editorial board). His scholarly work focuses on medical case reporting, reporting standards, and editorial methodology. Dr. Rison participated in the development and dissemination of the CARE guidelines for clinical case reporting and has authored numerous publications addressing both neurological disorders and the role of case reports in advancing medical knowledge. Dr. Rison practices general neurology and served as the founding medical director of the PIH Health Hospital-Whittier Stroke Program and the PIH Health Hospital-Whittier Non-Invasive Vascular Laboratory, is a clinical assistant professor of neurology at the University of Southern California Keck School of Medicine and Los Angeles County Medical Center, and is a Fellow of the American Academy of Neurology, the American Neurological Association, and the American Association of Neuromuscular and Electrodiagnostic Medicine. Dr Rison is board-certified by the American Board of Psychiatry and Neurology in neurology and vascular neurology, and neurocritical care and neuroimaging by the United Council of Neurologic Subspecialties. He is also board-certified by the American Board of Electrodiagnostic Medicine in electrodiagnostic medicine. Dr. Rison is a former president of the Los Angeles Neurological Society.
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Journal of Medical Case Reports
This journal will consider any original case report that expands the field of general medical knowledge, and original research relating to case reports.
