The usual etiologies of PPH include genital tract laceration, uterus atony, uterine rupture, placenta retention, coagulopathy(3–5). Vascular injury or anomalies such as aneurysm, AVF and AVM are fierce 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 first-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.