A 41-year-old Japanese female homemaker, gravida 1, para 0, with no remarkable medical, surgical, family, social, environmental, smoking, or alcohol history, was referred to our hospital at 9 gestational weeks after in vitro fertilization. During the gestational period, she was diagnosed with subchorionic hemorrhage in an emergency examination at 15 gestational weeks and hospitalized for treatment of a threatened premature delivery with oral ritodrine hydrochloride at 33–34 gestational weeks. At 40 weeks and 3 days of gestational age, she was hospitalized for labor induction, and after 3 days of oxytocin administration, she had a live birth; the neonate was female, weighed 3140 g, had Apgar scores of 9 and 10, and was delivered via a combination of midline episiotomy, vacuum extraction, and the Kristeller maneuver. However, while removing the placenta, a large mass, including the uterus and placenta, emerged, and uterine inversion was diagnosed by vaginal examination and abdominal ultrasonography (Fig. 1).

Fig. 1
figure 1

The uterine fundus (arrow) passes through the cervical ring, though this is not clear in the image

Massive bleeding from the stripped uterine cavity continued, and she presented with a shock index of over 2, a pulse rate of 134 beats per minute (bpm), and a blood pressure of 41/19 mmHg. The patient had a decreased level of consciousness, with a Japan Coma Scale score of 10 [8], namely this patient could be easily aroused by being spoken to, and she had cold extremities. Since laboratory tests revealed minimal hemoglobin, platelet, and fibrinogen levels of 6.6 g/dl, 5.4 × 104/μl, and 102 mg/dl, respectively, we started rapid blood transfusion and systemic management in the intensive care unit (ICU). The patient’s liver and renal function were not abnormal; her serum alanine aminotransferase, aspartate aminotransferase, and creatinine levels were 15 units/l, 15 units/l, and 0.48 mg/dl, respectively. Uterine replacement was performed with intravenous nitroglycerine (100 mg), and vaginal bleeding was controlled by Bakri balloon insertion into the recovered uterine cavity, with an iodoform gauze inside the vagina and with sutures of the perineal and vaginal lacerations. However, disseminated intravascular coagulation (DIC) had developed, and the Japanese obstetrical DIC score was 15 points [9], with a platelet count of 5.4 × 104/μl, a fibrinogen level of 102 mg/dl, a prothrombin time (PT) of 16.8 seconds, an activated partial thromboplastin time (APTT) of 47.5 seconds, a fibrin degradation product (FDP) level of 97.8 μg/ml, and d-dimer of 42.0 μg/ml. Then, we performed contrast-enhanced computed tomography (CT; Fig. 2) and uterine artery angiography to detect another source of bleeding related to uterine atony. After these procedures, we decided to perform UAE instead of surgical management to preserve future fertility and avoid the risk of perioperative hemorrhaging secondary to DIC. Finally, transcatheter right-sided UAE was performed to control the pseudo-aneurysmal sac and tortuous vessels of the right uterine artery (Fig. 3). On the day of delivery, we rapidly performed blood transfusion, Bakri balloon tamponade, and UAE to control the massive bleeding. Two days later, her condition stabilized, and she was transferred from the ICU to the general ward. We detected a hematoma that was 10 cm in diameter in the left vaginal wall on the same day, so surgical removal with an indwelling catheter in place was performed under general anesthesia on the following day after confirming no active bleeding by contrast-enhanced CT (Fig. 4) and explaining the procedure to the patient and her husband. The administration of antibiotics was also needed for 18 days, including 5 days of intravenous administration of cefmetazole (2 g/day) and 13 days of oral cefcapene pivoxil (300 mg/day); however, this catheter was removed, and the vaginal wall hematoma had almost disappeared before discharge.

Fig. 2
figure 2

A The uterus was enlarged and deviated to the right. A pseudo-aneurysm-like cyst (arrow) and dilated blood vessel (arrowhead) were detected in a branch of the right uterine artery. B The uterine cavity was remarkably enlarged over the size of the Bakri balloon (arrow). Enlarged tortuous vessels were detected, and continuous active extravasations were suspected

Fig. 3
figure 3

A pseudoaneurysm-like cyst (arrow) arising from a branch of the right uterine artery and enlarged tortuous vessels were detected

Fig. 4
figure 4

A Hematoma in the uterine cavity (arrow) remained, but active bleeding was not detected. B A large hematoma existed in the left vaginal wall (arrow), but active extravasations were not detected

Overall, we measured approximately 4500 ml of blood loss and performed transfusion of 44 units of red blood cell concentrate (approximately 6160 ml), 30 units of fresh frozen plasma (approximately 3600 ml), and 20 units of platelet concentrate (approximately 400 ml), yet she was able to be discharged 13 days after delivery. Iron agents were needed for 22 days, including 3 days of intravenous saccharated ferric oxide (40 mg/day) and 19 days of oral sodium ferrous citrate (100 mg/day). Placental histopathological examination revealed placenta accrete, including increased syncytial knot, necrosis, and smooth muscle adhesion. In the outpatient department, we detected a thick endometrium approximately 4 months after UAE without difficulty, and no abnormality was detected for over 1 year.

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