An exceptional outcome from a rare cause of postpartum haemodynamic collapse

We present a case of a 26-year-old woman presenting with haemorrhagic shock without any overt bleeding on postpartum day 2. Work up revealed intra-abdominal haemorrhage from an unclear source in the pelvis. She was intubated, resuscitated with mostly crystalloids, and started on norepinephrine and dopamine, in a rural hospital with limited resources. She was then transferred to the closest tertiary care centre 3 h away by air. On arrival, she was hypothermic (34.9°C) and had developed severe metabolic acidosis (pH 6.89). A massive transfusion protocol was initiated. She underwent an emergency laparotomy and the origin of the active bleeding was believed to be a branch of the right internal iliac artery. Haemostasis was achieved with packing. She was subsequently taken to interventional radiology for angioembolisation of the right uterine artery as an alternative to haemostatic hysterectomy. Her final diagnosis was rupture of an extrauterine uterine artery pseudoaneurysm.