Uterine Necrosis following Uterine Artery Embolization for PPH

A 30-year-old woman was hospitalized for labor induction at 40 weeks and 6 days gestation. She had a history of three prior uncomplicated vaginal deliveries. 

Following unsuccessful induction with Dinoprostone due to persistent category 2 fetal heart rate tracing, a cesarean section was performed, resulting in an intraoperative blood loss – nearly 1000 ml.

Postoperatively, the patient experienced increased vaginal bleeding (postpartum hemorrhage) due to uterine atony, unresponsive to various uterotonic agents and tranexamic acid. Attempts to control bleeding with a Bakri balloon were unsuccessful. 

Consultation with interventional radiology led to bilateral uterine artery embolization (UAE) using tris-acryl gelatin microspheres. Postoperatively, the patient developed symptoms, including foul-smelling discharge, abdominal pains, fever, and chills, prompting an abdominopelvic CT scan on day 28. The scan revealed an enlarged uterus with unenhanced areas of the endometrium and myometrium, as well as internal gas foci, indicative of uterine necrosis with approximately 50% of the normal residual myometrial thickness. 

Empiric broad-spectrum antibiotics were initiated. Despite adjustments, the patient's symptoms persisted, leading to examination under anesthesia, dilation, and curettage (D&C) with direct ultrasound guidance. 

Pathological evaluation revealed acute and chronic endometritis, with Streptococcus anginosus and Prevotella species identified in tissue cultures. Culture-directed antimicrobial therapy resulted in symptom improvement, and the patient was discharged on day 7 with a 14-day antibiotic course. 

At follow-up, she showed no abnormalities, denied discomfort or abnormal discharge, and expressed satisfaction at retaining her uterus. She opted for an etonogestrel subdermal implant for contraception. 

Although hysterectomy is typically recommended for uterine necrosis, this patient desired fertility preservation, which was successfully avoided in this case. Hence, tailored treatment approaches are essential while managing PPH cases.

Source: Chlela M, Dawkins J, Lewis G. Case Reports in Obstetrics and Gynecology. 2023 Jul 19;2023.