Transvaginal Ultrasound-guided Thrombin Injection for the Treatment of Secondary Postpartum Hemorrhage Caused by a Pseudoaneurysm of the Uterine Artery

Postpartum hemorrhage is the most important cause of maternal death worldwide, and the most important cause of maternal morbidity in The Netherlands [1]. Postpartum hemorrhage can be differentiated into a primary (early) hemorrhage and secondary (late) hemorrhage. Primary postpartum hemorrhage develops in the first 24 hours postpartum and is usually caused by one of ‘the four T’s’: Tonus (uterine atony), Tissue (retained pregnancy products), Trauma (rupture), and Thrombin (coagulopathy). Secondary postpartum hemorrhage develops between 24 hours and twelve weeks postpartum. The incidence of secondary postpartum hemorrhage is 2% in developed countries [2]. The most frequent causes are retained pregnancy products, subinvolution of the uterus, coagulopathy, and endometritis. More rare causes of a secondary postpartum hemorrhage are persistent trophoblastic disease, arteriovenous malformation, and a pseudoaneurysm of the uterine artery. We describe a 33-year old patient who presented six weeks postpartum in December 2014 at the emergency department of the Albert Schweitzer Hospital in The Netherlands, with severe vaginal bleeding caused by a pseudoaneurysm of the uterine artery as a rare complication after Caesarean section. The pseudoaneurysm was initially treated by embolization of the uterine artery, unfortunately without adequate effect. Definitive treatment was obtained by transvaginal ultrasound-guided thrombin injection into the uterine artery and pseudoaneurysm.