Trans-Arterial Embolization On A Catastrophic Primary Postpartum Hemorrhage Due To Arterial Aneurysm With Arteriovenous Fistula At Bilateral Lower Vagina: A Case Report

Background: Failure of the primary management at controlling the post-partum hemorrhage (PPH) is occasionally encountered. A catastrophic cause of PPH as vagina arterial aneurysms with AVF is rare and not reported in English literature. Case presentations: We present a 34-year-old woman of arterial aneurysms with arteriovenous stulas (AVF) at bilateral lower vagina causing intractable PPH with aggressive bleeding. By trans-arterial embolization (TAE) the bleeding is successfully controlled, and patient then could recover smoothly. Conclusion: These vascular anomalies being erce culprit of the PPH would result in primary management failure. Knowledge of the possible etiology of post-partum hemorrhage is crucial for treatment management. This case report aims to point out a pivotal role of TAE at detecting and treating this unusual cause of PPH.

Of these, the vascular injury and anomalies such as aneurysm, arteriovenous stula (AVF) and arteriovenous malformation (AVM) are erce culprits(6), and vagina arterial aneurysms with AVF in this presented case is rarely seen. Trans-arterial embolization (TAE) is an effective and minimally invasive procedure in managing the PPH (3,4). Here, we present a case of lower vaginal arterial aneurysm with AVF causing aggressive PPH successfully controlled by TAE after failure of the primary management.

Case Report
A 34-year-old woman with obstetric history of G3P0AA2 was 38 + weeks pregnant and otherwise healthy.
She was admitted for vaginal delivery after spontaneous rupture of the amniotic membranes. Primary post-partum hemorrhage (PPH) occurred after delivery; initial medical management was ineffective. After blood transfusion and vaginal packing with surgical pads, she returned to normotensive status temporarily. As vaginal bleeding persisted, angiography was performed by which arterial aneurysms with AVFs ( Fig. 1) fed by the internal pudendal arteries (Fig. 2) were discovered at the bilateral lower vagina.
Hemostasis was achieved by TAE of the aneurysms with metallic coils at each of the distal internal pudendal artery. After 5 days of hospitalization, she recovered well, and a rechecked angiography 3 months later revealed obliteration of the vascular lesions (Fig. 3).

Discussion
The usual etiologies of PPH include genital tract laceration, uterus atony, uterine rupture, placenta retention, coagulopathy (3)(4)(5). Vascular injury or anomalies such as aneurysm, AVF and AVM are erce culprits(6), and vaginal arterial aneurysm with AVF in this presented case is rarely seen. The clinical diagnosis of our presented case is pregnancy-related arterial aneurysms with AVFs at the lower vagina which contributes to the intractable primary PPH. Vaginal arterial aneurysm with AVF as a cause of PPH was not previously reported in English literature, and would render primary treatment methods ineffective.
The diagnosis was made by angiographic picture of arterial aneurysms with early draining veins in the lower vagina. Anatomically, there are some arteries that supply the vagina; the anterior and lateral surfaces of the vagina are fed by the vaginal artery; the middle portion by the inferior vesicular artery; the lower part by the internal pudendal artery; and the posterior surface by the middle rectal artery(4).
The routine primary management for PPH includes resuscitation, blood transfusion, uterus controlling such as administration of uterotonic drugs, uterine compression, and intrauterine balloon tamponade. If the primary management fails, an intervention of TAE or surgical management should be initiated without any delay(6). The TAE was reported to be effective with a high success rate and was recommended to be rst-line therapy to control PPH(3). The most commonly used embolic material in TAE for PPH was gelatin sponge, and bail-out material could be metallic coils or N-butyl cyanoacrylate (4). At this uncommon condition of vaginal arterial aneurysms with AVFs causing PPH, small particle and liquid embolic material should be meticulously used in TAE, as they may increase the risk of IVC and pulmonary embolism owing to embolic material migration through the arterio-venous shunting.  Pelvic angiography shows arterial aneurysms (arrows) with arteriovenous shunting to early draining veins (arrowheads) at both sides of the lower vagina.

Figure 2
A. Selective angiogram of the right internal iliac artery clearly shows arterial aneurysm (arrow) with early drainage veins (arrowheads) fed by the internal pudendal artery. Similar ndings are seen in the left internal iliac arteriogram B. Selective arterial embolization at the distal internal pudendal arteries with coils as presenting in this left internal pudendal artery.