Uterine artery pseudoaneurysm presenting as delayed post-partum hemorrhage: A rare emergency department presentation

Uterine artery pseudoaneurysm (UAP) is a rare but potentially life-threatening cause of secondary postpartum hemorrhage (PPH). Prompt recognition is essential as traditional management of PPH, such as curettage, can precipitate inadvertent rupture of the pseudoaneurysm which can lead to life or fertility threatening hemorrhage. We report the case of a 33-year-old female, G1P1, with a history of in vitro fertilization (IVF) and subchorionic hematoma, who presented on post-partum day 25 after NSVD with acute vaginal bleeding. Point of care ultrasound (POCUS) did not reveal retained products of conception. Therefore, a comprehensive Doppler study was performed, which showed a high-flow uterine vascular lesion with differential diagnosis including uterine artery pseudoaneurysm (UAP) versus arteriovenous malformation (AVM). CT angiography (CTA) confirmed abnormal intrauterine vascular structures. Pelvic arteriography performed after admission identified a 1.8 × 1.2 cm multilobulated pseudoaneurysm and the patient underwent successful bilateral uterine artery gel foam embolization. Follow up CTA imaging three weeks post embolization showed resolution of abnormal vascularity. UAP should be considered in the differential of patients presenting to the Emergency Department (ED) with delayed PPH. Doppler ultrasound and confirmatory CTA are key for early diagnosis, and uterine artery embolization with interventional radiology offers a fertility-preserving therapeutic option. Timely recognition of UAP in the emergency setting, coupled with early interventional radiology involvement, is critical to achieving hemostasis and minimizing morbidity in secondary postpartum hemorrhage.