Rupture of the Uterine Artery Pseudoaneurysm Causing Late Postpartum Hemorrhage: Case Report and Literature Review

PPH remains one of the leading causes of maternal death worldwide and is defined as a blood loss of more than 500 cc. PPH can be classified as primary or secondary depending on the time of onset after partus (24 h up to 6 weeks). Primary PPH is caused by the 4 T’s: tonus (atony), tissue (retentio placenta), trauma (cervical tear, vaginal tear, uterine rupture), and thrombin (coagulopathy), with uterine atony being the most common cause. Secondary PPH is often caused by retained products of conception. Other causes are endometritis, persisting trophoblast, choriocarcinoma, and vascular malformation (hemangioma) [ 1 – 3 ]. A rare cause of late PPH is rupture of an UAP, which is the focus of this case report. UAP is considered a rare condition and its incidence remains unknown as it’s not always symptomatic. Uterine blood supply is mainly provided via the uterine arteries, which are located at the level of the cervix and the lower uterine segment. The uterine artery further branches into the arcuate arteries, which subsequently branch into the radial arteries, and then further into the spiral arteries [ 39 ]. A pseudoaneurysm differs from an ordinary aneurysm in that it is not surrounded by the three layers of blood vessels, being the tunica intima, media and adventitia (shown in Fig. 4 ). Trauma, infection, inflammation creates a connection between the lumen of the vessel and a newly formed blood-filled space. This space is surrounded by adventitia, hematoma or simply by the surrounding tissues (shown in Fig. 5 ). This thin barrier is very fragile and when exposed to higher pressures it breaks easily resulting in exsanguination [ 4 – 6 ]. Possible risk factors include cesarean delivery, uterine curettage, inflammation, myomectomy, conization of the uterine cervix, and excision of cesarean scar [ 4 , 7 – 13 , 15 , 20 , 22 , 25 , 26 , 30 , 32 , 35 ]. Difference between aneurysm and pseudoaneurysm. A pseudoaneurysm results from trauma to the blood vessel wall creating a blood-filled space delineated by either media, adventitia, hematoma or simply by the surrounding tissues. An aneurysm is a dilatation of the blood vessel while preserving the three layers of the vessel, being intima, media and adventitia. Trauma, infection, inflammation creates a connection between the lumen of the vessel and a newly formed blood-filled space. This space is surrounded by adventitia, hematoma or simply by the surrounding tissues. This thin barrier is very fragile and when exposed to higher pressures it breaks easily resulting in exsanguination. Delivery modality varies. Our literature search found twelve studies reporting a rupture of UAP after vaginal delivery [ 4 , 12 – 22 ]. Other studies reported rupture of UAP after caesarian [ 5 , 6 , 12 , 13 , 15 , 17 , 18 , 23 – 29 ] and during pregnancy [ 30 – 38 ]. While most patients with UAP are symptomatic, it may also present as an incidental, asymptomatic finding during pregnancy or after delivery [ 13 , 32 – 34 ]. This supports the hypothesis that PPH due to UAP rupture may result from a pre-existing, asymptomatic lesion, although the lack of comparative imaging remains a diagnostic challenge. Furthermore, the clinical manifestation of UAP is highly variable. Vaginal bleeding is the most prominent symptom in UAP, although this is not an absolute, as demonstrated in our first case [ 13 ]. There was only one case report that described severe hydronephrosis as a complication of UAP. According to the authors, clinical presentation of UAP varied between two types according to underlying connection between UAP and the uterine cavity. When such connection is present, genital bleeding is the main symptom like in our second case. If no connection is present, a large hematoma can be formed with secondary complications like hydronephrosis [ 35 ]. As there is no gold standard for detection of UAP, different imaging modalities were used in the diagnostic workup including CT, TVS, and MRI [ 4 – 6 , 14 , 16 – 38 , 40 ]. In most studies, ultrasound served as the initial modality to raise suspicion, with CT or MRI used for confirmation [ 5 , 14 , 18 , 21 – 25 , 27 – 33 , 35 , 37 , 38 ]. Less frequently ultrasound [ 4 , 6 , 12 , 13 , 16 , 17 , 19 ] or CT/MRI [ 12 , 13 , 15 , 17 , 20 , 26 , 34 , 36 ] were used as standalone diagnostic tools. With sufficient expertise, ultrasound is an invaluable tool in the diagnosis and management of PPH, as highlighted by Mappa et al. [ 41 ] in their POCUS guidelines. On TVS, a pseudoaneurysm appears as an anechoic sac. A pathognomonic sign for pseudoaneurysm with a narrow neck is a to-and-fro sign in the neck of the pseudoaneurysm and yin-yang sign in the body on Doppler. Moreover, a turbulent arterial flow is shown on Doppler [ 23 , 39 – 41 ]. In our first case, TVS showed extensive free fluid, but no other signs indicating UAP, likely due to the obscuring effect of the large hematoma. In our second case, TVS showed indeed an anechoic sac with positive Doppler flow. Subsequent CT may be needed to delineate anatomy, identify culprit vessels and for treatment planning. Multiple studies suggest endovascular embolization to be the treatment of choice in hemodynamically stable postpartum women [ 4 – 6 , 12 – 23 , 25 – 29 , 34 , 39 , 42 ] and during pregnancy reporting good maternal and fetal outcomes [ 30 , 32 , 33 , 36 – 38 ]. While various embolization techniques are described in the literature, the lack of comparative data prevents the establishment of an optimal approach. Nevertheless, technical success was high across the reviewed studies, regardless of the embolic agent selected, with only 5 cases requiring re-embolization [ 12 , 13 , 19 , 21 , 37 ]. Complications after embolization include pelvic pain, fever, infection or swelling at the puncture site, thromboembolic event or ischemic events ranging from uterine necrosis to vesicovaginal fistula [ 12 , 13 , 16 ]. One possible reason for treatment failure is the presence of multiple feeding vessels to the pseudoaneurysm. A comprehensive examination of all feeding arteries warrants adequate embolization [ 21 , 39 ]. Only three studies reported use of laparotomy with ligation of pseudoaneurysm. However, in the first case this was combined with per sectional delivery of the dead fetus in an hemodynamically unstable patient with extensive hemoperitoneum and hemothorax [ 31 ]. The second case described a large hydronephrosis due to an extensive hematoma [ 35 ]. In the third case, embolization was not available [ 24 ]. Given high success rates, low risk of rebleeding, minimal invasive nature requiring no need for general anesthesia, and good fertility outcomes, endovascular embolization may be preferred as first-line treatment of UAP over surgical ligation and hysterectomy [ 7 , 10 , 16 ]. Data regarding the conservative management of asymptomatic UAP remains scarce, as most reported cases involve symptomatic or ruptured presentations. Few cases of conservative treatment in asymptomatic UAP were identified from our review. Three pregnant patients were diagnosed with asymptomatic, unruptured UAPs during a workup for endometriosis-related pain. Two were initially managed conservatively but later required embolization due to increasing aneurysm size [ 32 , 33 ]. In the third case, spontaneous resolution occurred after a failed embolization attempt [ 34 ]. In summary, while spontaneous resolution is possible, the limited data suggest that conservative management is rarely pursued and may carry a risk of aneurysm growth. While intrauterine balloons are vital in managing atonic PPH, they may be ineffective or potentially harmful in cases of UAP, as increased intrauterine pressure could theoretically trigger rupture. Nonetheless, in our second case and two previously reports [ 25 , 26 ], the use of Bakri balloon provided temporary hemorrhage control. Despite this, management should prioritize aggressive resuscitation and urgent embolization over intrauterine tamponade. Eight other cases reported UAP rupture in patients with either a history of or active endometriosis [ 14 , 22 , 30 – 34 , 37 ]. Three had a history of endometriosis-related surgery [ 14 , 22 , 30 ], and one had a prior appendectomy [ 37 ]. In the remaining 4 cases, endometriosis was diagnosed during pregnancy in 2 patients [ 32 , 34 ], with 1 patient requiring surgical intervention [ 34 ]. These findings suggest that surgical procedures, and the associated microtrauma, may represent a potential underlying factor. In cases without prior surgery, it has been proposed that decidualization of endometriotic lesions or the underlying chronic inflammatory state may contribute to the development of an UAP [ 31 , 33 ]. As previously reported other possible risk factors include cesarean delivery, uterine curettage, inflammation, conization of the uterine cervix, myomectomy and excision of cesarean scar [ 4 , 7 – 13 , 15 , 20 , 22 , 25 , 26 , 30 , 32 , 35 ]. Potential risk factors for the development of UAP in our first case could be adhesions due to PID, endometriosis and in vitro fertilization with multiple follicular punctures. In our second case, no potential risk factors could be withheld. In conclusion, UAP is considered a rare but severe cause of late PPH. Therefore, its incidence is unknown and available literature on this topic is limited, as apparent from our literature search. The rarity of UAP may lead to delay in diagnosis and treatment, potentially with devastating outcome. The clinical presentation of UAP may be atypical and have been suggested to manifest in two ways, i.e., with or without vaginal bleeding. TVS is the primary diagnostic modality of choice due to its accessibility and availability. An anechoic sac with turbulent arterial flow on Doppler is the typical feature. However, CT or MRI remains valuable for confirmation, for delineating anatomy, identifying culprit vessels and treatment planning. Endovascular embolization is preferred treatment choice for stable patient given its minimally invasive nature and favorable outcome.

Postpartum hemorrhage (PPH), a leading cause of global maternal morbidity and mortality, is defined as blood loss exceeding 500 mL following childbirth. While quantitative definitions vary, PPH is typically classified as minor (500–1,000 mL) or major (>1,000 mL), with the latter further subdivided into moderate (1,000–2,000 mL) and severe (>2,000 mL). PPH is categorized as either primary – occurring within the first 24 h postpartum – or secondary, which presents between 24 h and 6 weeks after delivery. Primary PPH is most commonly attributed to uterine atony. Secondary PPH is frequently caused by retained products of conception; however, less common etiologies include endometritis, persistent trophoblastic disease, choriocarcinoma, and vascular anomalies [ 1 – 3 ]. One rare but potentially life-threatening cause of secondary PPH is rupture of a uterine artery pseudoaneurysm (UAP). A pseudoaneurysm arises when trauma to the arterial wall leads to the formation of a blood-filled cavity that lacks the typical three-layered vascular structure. Instead, it is contained only by the adventitia, surrounding tissues, or hematoma, rendering it highly susceptible to rupture and massive hemorrhage [ 4 – 6 ]. Risk factors for UAP include cesarean section, pelvic surgery, inflammation, conization, and myomectomy [ 7 – 11 ]. With this case report, we aim to highlight UAP as a cause of late PPH. Although it is a severe condition, it is often not considered in the differential diagnosis and the available literature is limited. We present two cases along with a review of available literature. The case report was written in accordance with the Consensus-based Clinical Case Reporting (CARE) guidelines, the corresponding checklist is provided as online supplementary material (for all online suppl. material, see https://doi.org/10.1159/000553084 ).

The authors have no conflicts of interest to declare.

Figures 4 and 5 were created in https://BioRender.com . Figure 4: created in BioRender. Hoefnagels, L. (2026) https://BioRender.com/6lgupam . Figure 5: created in BioRender. Hoefnagels, L. (2026) https://BioRender.com/kctynip .

This study was not supported by any sponsor or funder.

The first case is a 29-year-old female, who presented to the obstetrics department with abdominal pain and syncope 6 days after vaginal delivery. This was a first pregnancy through in vitro fertilization. Medical history included pelvic inflammatory disease, chlamydia and ASRM stage IV endometriosis with deep rectovaginal nodule. Delivery was induced at 39 weeks due to commodity. Presenting at the obstetrics department, she was syncopal with complaints of diffuse abdominal pain and mictalgia. Clinical examination revealed palpatory pain and muscle tenderness in the lower abdomen. Vital signs were as follows: blood pressure 103/72 mm Hg and heart rate 105 beats/min. The laboratory results showed a decrease in hemoglobin to 8.8 g/dL (compared to 10.6 g/dL 3 days before) and an elevated CRP and white blood cell count. Transvaginal sonography (TVS) showed hemoperitoneum, normal postpartum uterus, absence of blood or residual tissue in the uterine cavity and abnormal pain during TVS. Computed tomography (CT) of the abdomen with intravenous contrast showed a vascular nodule of 1.8 cm in het right pelvic region, suggestive of a pseudoaneurysm. Active contrast extravasation was observed originating from this nodule, along with extensive hemoperitoneum and the presence of blood clots. In addition, right-sided hydronephrosis was noted, which had been absent during pregnancy, and was presumably secondary to a local hematoma (shown in Fig. 1 ). The patient was transferred to undergo embolization. The embolization procedure was performed under local anesthesia and via right femoral artery after insertion of 4 French introducer sheath. Diagnostic angiography of right internal iliac artery confirmed a pseudoaneurysm of the right uterine artery. Selective catheterization into the right uterine artery was performed using a Progreat 2.7 French microcatheter. Since the microcatheter could not be advanced beyond the pseudoaneurysm, embolization of the uterine artery proximal the pseudoaneurysm was carried out using four microcoils (Hilal 18 2/20 mm coils). Angiography performed after embolization revealed no filling of the pseudoaneurysm (shown in Fig. 1 ). She recovered smoothly and was discharged 5 days later. Ultrasound 4 months later showed complete liquification of the hematoma and resolved hydro-uretronephrosis. Case 1: computed tomography (CT) abdomen with intravenous contrast: a vascular nodule of 1.8 cm in the right pelvic region, suggestive of a pseudoaneurysm (arrow; a ). b Selective digital subtraction angiography of the right internal iliac artery using an ipsilateral femoral approach shows opacification of a uterine pseudoaneurysm (arrow). c A check angiogram after microcoil embolization shows no opacification of the pseudoaneurysm (arrow). Our second case is a 27-year-old primigravida with no noteworthy history, who was admitted to the obstetrics department with complaints of heavy painless vaginal bleeding. Five days earlier she underwent caesarean section due to prolonged second stage of labor. Delivery was induced at 39 weeks and 5 days due to macrosomia. Hemoglobin 2 days postpartum was 6.5 g/dL and two units packed cells were administered. She was discharged without incident after an additional 5 days, but readmitted the same day due to heavy painless vaginal bleeding. The bleeding started 1 h prior to presentation at the emergency department. Patient was hemodynamically stable on arrival. Clinical examination revealed no abnormal findings. In speculum examination showed multiple blood clots, these were manually removed resulting to subsequent heavy blood loss. TVS showed an empty cavity and no signs of hemoperitoneum. An echogenic large structure was visualized right to the cervix with positive Doppler flow, suggesting a pseudoaneurysm of the right uterine artery. Shortly after arrival, her conditions deteriorated and she became hemodynamically unstable accompanied by a loss of consciousness. Fluid resuscitation was performed and a Bakri balloon was placed for initial bleeding control until confirmation of pseudoaneurysm. Hemoglobin dropped to 5.8 g/dL for which four units of packed cells were administered. CT abdomen with intravenous contrast showed a pseudoaneurysm measuring 2.7 cm in the right uterine artery and right-sided hydronephrosis secondary to enlarged uterus. No active contrast extravasation was noted (shown in Fig. 2 ). Treatment involved embolization via left femoral artery access. Diagnostic angiography of right internal iliac artery confirmed a pseudoaneurysm of the right uterine artery, which was embolized with histoacryl/lipiodol mixture (ratio 1:3). Additional feeding artery from the anterior division of internal iliac artery was embolized with Gelfoam. There were no other feeding vessels (shown in Fig. 2 ). Empirical antibiotic therapy was initiated because of fever without an identifiable infectious focus. Patient was discharged 2 days after embolization. Case 2: computed tomography (CT) abdomen with intravenous contrast: a pseudoaneurysm measuring 2.7 cm in the right uterine artery with no active contrast extravasation (arrow; a ). b Selective digital subtraction angiography of the right internal iliac artery using a contralateral femoral approach shows opacification of a uterine pseudoaneurysm (arrow). c Postembolization digital subtraction angiography shows occlusion of the pseudoaneurysm (arrow).

To initiate our literature review, we performed a PubMed search using MeSH terms “pseudoaneurysm,” “uterine artery,” and “pregnancy” dating from 1990 up to June 2025, identifying 84 articles. Selection was limited to articles in Dutch, French, and English, excluding 3 articles. One duplicate article was excluded. Only full-text reports reporting UAP during intrauterine pregnancy or after delivery were considered for inclusion. Five relevant articles were also selected of the reference lists of the retrieved publications. A comprehensive summary of the literature search is given in Table 1 and Figure 3 . Eventually, 30 articles were included. Summary of literature review SA, spontaneous abortion with D&C (dilatation and curettage); CD, caesarian delivery; IVF, in vitro fertilization; VD, vaginal delivery; DP, during pregnancy; EUG, extra-uterine gravidity; CT, computed tomography; MRI, magnetic resonance imaging; TVS, transvaginal sonography; TAS, transabdominal sonography; TOP, termination of pregnancy; AAP, abortus arte provocatus; GA, gestational age; PPROM, preterm pre-labor rupture of membranes; vWD, von Willebrand disease; HELLP, hemolysis elevated liver enzymes and low platelets. Summary of literature review. A total of 55 articles did not meet the inclusion criteria. Twenty-five articles were letters to the editor or picture of the month with limited data about the case, patient characteristics and diagnostics. The full-text was not available for 4 articles. Four articles lacked information about the case details or were ongoing cases, while 1 article dated from 1955. Twenty-one articles did report UAP but not during intra-uterine pregnancy or after delivery. In terms of delivery modality, UAP can occur following both after vaginal delivery and cesarian. Twelve studies reported a rupture of UAP after vaginal delivery [ 4 , 12 – 22 ], fourteen studies reported rupture after caesarian [ 5 , 6 , 12 , 13 , 15 , 17 , 18 , 23 – 29 ], and nine studies reported rupture of UAP during pregnancy [ 30 – 38 ]. Gestational age at diagnosis varied from 14 weeks to 42 weeks [ 4 , 6 , 12 – 17 , 19 , 20 , 23 , 25 , 26 , 30 – 38 ]. The time of diagnosis of UAP varied from a few hours to 4 months post-delivery [ 4 – 6 , 12 – 14 , 16 – 29 , 34 ]. Possible risk factors included a history of cesarean delivery, uterine curettage, inflammation, myomectomy, conization of the uterine cervix and excision of cesarean scar [ 4 , 7 – 13 , 15 , 16 , 20 , 22 , 25 , 26 , 30 , 32 , 35 ]. Eight cases reported UAP rupture in patients with either a history of or active endometriosis [ 14 , 22 , 30 – 34 , 37 ]. No specific risk factors associated with the likelihood of UAP rupture could be determined. Different imaging modalities were used across different studies, although not all studies provided details. In several studies, initial ultrasound was followed by confirmation with CT or magnetic resonance imaging (MRI) [ 5 , 14 , 18 , 21 – 25 , 27 – 33 , 35 , 37 , 38 ]. Less frequently, the diagnosis was established on CT [ 12 , 13 , 15 , 17 , 20 , 34 , 36 ] or MRI [ 13 , 26 ] alone. In a few cases, diagnosis was made solely on ultrasound [ 4 , 6 , 12 , 13 , 16 , 17 , 19 ]. In hemodynamically stable postpartum women, endovascular embolization was the treatment of choice in most studies [ 4 – 6 , 12 – 23 , 25 – 29 , 34 ]. In addition, studies reported successful endovascular embolization during pregnancy with good maternal and fetal outcomes [ 30 , 32 , 33 , 36 – 38 ]. A wide range of embolization techniques is used, including gelfoam, different types of coils, n-butyl cyanoacrylate (glue), polyvinyl alcohol (particles), and various combinations [ 4 – 6 , 12 – 23 , 25 – 30 , 32 – 34 , 36 – 38 ]. Only 5 cases across all reviewed studies required re-embolization with an embolic agent different from the initial agent [ 12 , 13 , 19 , 21 , 37 ]. In 1 case, this was due to the presence of an additional feeding artery [ 21 ]. Only three studies mentioned the use of laparotomy with ligation of pseudoaneurysm. Two cases described hemodynamically unstable patient with extensive hemoperitoneum. In the first case ligation of UAP was combined with per sectional delivery of the dead fetus [ 31 , 35 ]. In the third case, embolization was not available [ 24 ]. The use of balloon tamponade in the context of UAP has been described in two articles, where it was used to achieve local compression, resulting in adequate bleeding control in hemodynamically unstable patients and allowing for subsequent imaging and embolization [ 25 , 26 ].

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. The study was conducted ethically in accordance with the World Medical Association Declaration of Helsinki. This study protocol was reviewed and approved by EC Research UZ/KULeuven, approval No. EC S70480.

Lore Hoefnagels, MD: original draft, writing and editing, conceptualization, data curation, formal analysis, investigation, and methodology; Arne Vanhie, MD PhD: review and editing, conceptualization, validation, and supervision; Karin Leunen, MD PhD and Erika Werbrouck MD PhD: review and editing, validation; Siu W. Lam MD PhD: writing, review, and editing, conceptualization, validation, and supervision.