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This is the case of a 36-year-old woman, para 3, who underwent total laparoscopic hysterectomy and left salpingo-oophorectomy for pelvic pain. Her symptoms developed 12 months after a NovaSure endometrial ablation for menorrhagia. Pre-operatively, she had a trial of 3 months GnRH analogues with complete resolution of pain. Intraoperative findings included a normal-sized uterus, adhesions of the left ovary to the pelvic side wall and extensive adhesions of the bladder to the cervix as a result of three previous caesarean sections. The procedure was uncomplicated with blood loss of 100 ml. A vessel sealing device was used for haemostasis (Gyrus PK, Olympus) and the vagina vault was closed with V-loc 2–0 barbed suture (Covidien). Post-operative course was uneventful and she was discharged home on day 1. She was readmitted 22 days post-operatively with sudden onset of heavy vaginal bleeding with big clots. On admission, there was no abdominal tenderness; she was apyrexial and haemodynamically stable. The admission haemoglobin was 13 g/dl, and inflammatory markers were normal. On speculum examination, there was arterial bleeding from the left angle of the vaginal vault, and further clots were removed from the vagina. The estimated blood loss was 700 ml. Our standard protocol for readmissions usually involves an ultrasound scan and/or CT scan depending on the clinical indication. However, in this case, due to the continuation of brisk bleeding, it was decided to transfer her to theatre before any imaging was performed. In the operative theatre, four figure of eight haemostatic sutures were placed in the vaginal vault achieving complete haemostasis. Due to the complete arrest of vaginal bleeding, we did not consider that a laparoscopy was necessary. A vaginal pack with antiseptic proflavine was inserted in the vagina for 24 h. She was transfused with two units of red blood cells, and the post-transfusion haemoglobin was 9.5 g/dl. Her immediate post-operative course was stable, but the following day after removal of the pack, bleeding resumed with a further 200 ml of fresh vaginal loss. In order to avoid further surgery, she underwent an emergency pelvic angiogram with a view of embolisation of the pelvic vessels. Initial flush angiography did not clearly demonstrated vascular abnormality. Selective angiography of the anterior division of the left internal iliac artery and superselective angiography of the uterine artery demonstrated a pseudoaneurysm arising from the distal residual left uterine artery (Fig. 1). The left uterine artery was cannulated using a Terumo Progreat micro catheter (Terumo Corp. Tokyo, Japan) via a 5 French Sim2 catheter as a guide (Boston Scientific, D. S. Miligkos (*) :K. Louden :R. Behrens Department of Obstetrics and Gynaecology, Royal Hampshire County Hospital, Romsey Road, SO22 5DG Winchester, UK e-mail: dmiligk@doctors.org.uk

Uterine artery pseudoaneurysm following laparoscopic hysterectomy. An unusual cause of delayed heavy vaginal bleeding