Episiotomy site hematoma, though uncommon, can be associated with serious maternal morbidity. It arises mostly due to tissue trauma or injury to blood vessels, leading to the formation of a pseudoaneurysm. Sometimes, when surgical management fails, embolization of the bleeding vessel is a lifesaving option. Here, we report two cases of episiotomy site hematoma that required selective arterial embolization for management, following the failure of surgical management. A 28-year-old G6A5 woman underwent forceps delivery following which she developed a 6*6-cm right-sided vulvovaginal hematoma at the episiotomy site. After failed surgical management, arterial embolization was performed and hemostasis was achieved. A 26-year-old P2L2 woman with a history of surgical exploration for episiotomy site hematoma, presented postdelivery on postpartum day seven with profuse vaginal bleeding. Her computed tomography angiogram revealed a pseudoaneurysm of around 2.1*1 cm in length with a vaginal hematoma of 4*5 cm. Selective artery embolization performed and complete hemostasis was achieved with no complications. Selective arterial embolization is a safe therapeutic option for episiotomy site hematoma, especially if surgical management fails.

Chronic ectopic pregnancy is a variant of ectopic pregnancy presenting as chronic lower abdominal pain, menstrual irregularity and pelvic mass. Often, chronic ectopic may pose diagnostic conundrum due to unusual presentations. We are presenting an unusual case of chronic ectopic with negative urine pregnancy test, who presented with pain in right hypochondrium. The patient had bilateral adnexal mass with omental deposit on imaging masquerading adnexal malignancy, leading to decision for surgical management. Intraoperatively blood clots were present in supramesocolic compartment along with bilateral adnexal masses. Total abdominal hysterectomy and bilateral salpingo-oophorectomy with clots evacuation was done and postoperatively, patient had complete relief of her symptoms. Final histopathology came out as ectopic gestation. Culminating point is to keep ectopic pregnancy as differential in all reproductive age group women presenting with pain in abdomen regardless of other symptom particularly with pelvic mass.

Morbidly adherent placenta usually presents with heavy bleeding and difficulty in placental removal in the third stage. Although association of morbidly adherent placenta with previous caesarean section or uterine surgery is well documented the exact pathogenesis of placenta accrete still remains unknown. We hereby report a case of spontaneous second trimester abortion followed by recurrent intermittent hemorrhage leading to hypovolemic shock. Following this hysterectomy was done, which on histopathology revealed placenta increta away from previous uterine scar site. Pathogenesis in this case for morbidly adherent placentation seems to be resembling that in a woman without any previous uterine surgery or scar, which is quite unusual. We report this case with a brief review of the literature.

Objective: To analyse the outcome of patients with symptomatic arterio-venous malformation (AVM), formed following pregnancy and managed by uterine artery embolization (UAE). Materials and Methods: This retrospective study was conducted after ethical approval and included 15 patients presenting with abnormal uterine bleeding following pregnancy, who were suspected to have an AVM which later was confirmed by angiography and managed with UAE. Presenting symptoms, post- UAE complications and subsequent fertility outcomes were noted. Follow-up period ranged from 6 months to 2.5 years. Results: The mean age was 28.4±3.82 years and mean parity was 1.3. Out of 15 cases, 9 (60%) presented after abortion, 4 (26.6%) after normal vaginal delivery and 2 (13.3%) after cesarean delivery; of these 10/15 (66.7%) patients had a history of curettage. The most common presenting symptom was continuous bleeding per-vaginum since the antecedent pregnancy in 9/15 (60%) patients and 6/15 (40%) patients had irregular bleeding. The mean duration of symptoms was 91±85.7 (30-360) days. For UAE, embolic agents used were polyvinyl alcohol (PVA) particles (300-500 μm) in 2 (13.3%), 30% glue injection in 3 (20%), the combination of PVA with glue injection in 4 (26.6%) and PVA with gelfoam in 6 (40%) patients. After UAE, bleeding responded within 3.6±0.97 (3-6) days in all but one patient who required repeat UAE one month later. All women resumed their normal menstrual cycle in 31.3±5.2 (24-42) days. Ten patients desired conception, of whom 5 (50%) conceived within 13.2±5.1 (6-19) months after UAE. Two women carried pregnancy to term, one underwent preterm cesarean for growth restriction with oligohydramnios. One patient had postpartum hemorrhage, which was managed medically. One had spontaneous abortion at 6 weeks gestation and the other is 13 weeks pregnant at present. Conclusion: UAE is an effective treatment modality for the management of symptomatic post-pregnancy AVMs.

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