Teaching Case

A 39-year-old, with 2 prior caesarean sections, underwent premature caesarean delivery of twins at 36 weeks. Severe post-op bleeding from uterine atony necessitated a subtotal hysterectomy. Subsequent CT revealed haemoperitoneum and active arterial bleeding. Digital Subtraction Angiography (DSA) revealed active bleeding from branches of the round ligament artery, which was successfully embolised.

Axial unenhanced CT initially reveals haemoperitoneum (Figure 1a). In the arterial phase (Figure 1b), contrast blush in the left iliac fossa indicates arterial bleeding, intensifying in the portal venous phase (Figure 1c).

Treatment conducted through Digital Subtraction Angiography (DSA) via the right common femoral approach, employing a 5Fr introducer sheath, reveals the process. Left common iliac arteriogram, using a Simons 5Fr catheter (Figure 2a), reveals active bleeding. Subsequent selective internal iliac artery angiography, using a Cobra-curved 5Fr catheter (Figure 2b), finds no source. External iliac artery angiography (Figure 2c) displays ongoing bleeding. Superficial iliac circumflex artery selective microcatheterisation (Figure 2d) confirms the bleeding's origin. Coils 3mm x 6cm (Optima Coil System, Balt, Montmorency, France) were used to embolise the ostium of the round ligament artery (Figure 1e). Recanalisation from superficial epigastric artery branches follows (Figure 2f). Microcatheterisation of superficial epigastric artery and embolisation using EVOH was performed (Figure 2g). The procedure concludes with aortography (Figure 2h), ruling out more bleeding sources.

Primary postpartum haemorrhage (PPH) refers to excessive bleeding in the first 24 hours after birth [1,2]. The most common causes of PPH are atony, trauma, placental disorders, and coagulopathy/bleeding diatheses [3]. In general terms, treatment is based on a combination of factors, including fluid resuscitation, coagulopathy correction, and blood transfusion. Uterine compression and intrauterine balloon tamponade may also be considered [3]. When first-line treatments fail, transcatheter arterial embolisation (TAE) or surgical management may be implemented [4,5].

When TAE is considered, knowledge of the normal anatomy of the female genital tract and its variants is mandatory (Figure 3). Primarily, bleeding originates from uterine artery (UA) branches. However, postpartum haemorrhage (PPH) can also arise from connected collateral vessels—such as those linked to the ovarian, inferior mesenteric, round ligament, and internal pudendal arteries. In the case presented, bleeding emerged from round ligament artery branches, an aspect emphasising their significant participation in the complex uterine blood supply network that should be considered during TAE [4,5].

Another thing to remember is the fact that in cases of PPH stemming from uterine atony, the following strategies merit consideration: (1) use of temporary embolic material; (2) bilateral uterine artery embolisation, irrespective of the presence of active bleeding sources; (3) embolisation of anterior divisions of bilateral internal iliac arteries (IIAs) if accessing the uterine artery proves challenging and haemodynamic instability; (4) addressing other potential bleeding sources through embolisation.

When PPH results from trauma or surgery, as in the presented case, consider: (1) actively identifying contrast medium extravasation, pseudoaneurysms, and abruptly cut-off vessels as indicators of active bleeding sources; (2) employing selective arterial embolisation; (3) consider anastomotic arteries, especially the ovarian and the round ligament artery; and, (4) permanent embolic materials are recommended [4].

In conclusion, a comprehensive grasp of the uterine arterial network is imperative for ensuring successful procedural interventions. The round ligament artery emerges as a significant anastomotic conduit, bridging the internal iliac and external iliac arteries, underscoring its pivotal role as a source of bleeding in PPH.

All patient data have been completely anonymised throughout the entire manuscript and related files.