Delayed rupture of vaginal wall haematoma causing secondary postpartum haemorrhage—successful management with bilateral uterine artery embolisation: a case report

Abstract

Secondary postpartum haemorrhag (PPH), defined as excessive bleeding occurring between 24 hours and 6 weeks after delivery, is less common than primary PPH but may cause substantial maternal morbidity if diagnosis or intervention is delayed. Vaginal wall haematomas are usually recognised in the early postpartum period and are rarely implicated in delayed haemorrhage. Delayed rupture of a concealed vaginal wall haematoma is exceptionally uncommon. A 32-year-old Han Chinese primiparous woman presented to the Emergency Department of the New District Branch of Gansu Provincial Hospital on postpartum day 11 with sudden-onset profuse vaginal bleeding. She had undergone forceps-assisted vaginal delivery with mediolateral episiotomy approximately 11 days earlier and delivered a healthy male infant weighing 3800 g. On postpartum day 4, pelvic examination and ultrasonography identified a right vaginal wall haematoma, which was initially managed conservatively because she was haemodynamically stable. On postpartum day 11, the haematoma ruptured abruptly, causing massive vaginal bleeding, transient loss of consciousness, and haemodynamic instability. Emergency angiography demonstrated active contrast extravasation from branches supplying the vaginal wall region. Bilateral uterine artery embolization (UAE) was performed successfully, and haemostasis was achieved immediately. Delayed rupture of a concealed vaginal wall haematoma should be considered in women presenting with secondary postpartum haemorrhage after instrumental delivery, episiotomy, or documented vaginal wall trauma. Early imaging assessment and close surveillance are important when a postpartum vaginal haematoma is identified. UAE is a safe, effective, and fertility-preserving treatment option when bleeding arises from deep pelvic or vaginal wall vessels and surgical access is difficult.