Transvaginal ultrasound-guided direct thrombin injection for the treatment of intramyometrial pseudoaneurysm in a young female with uterine hemorrhage after failed uterine artery embolization

Uterine artery pseudoaneurysm is an uncommon but important cause of severe uterine bleeding in the postpartum or postsurgical setting. The standard treatment options are endovascular uterine artery embolization and bilateral surgical internal iliac artery ligation for uterus conservation or hysterectomy. We report the case of a young female with hemorrhage from an intramyometrial pseudoaneurysm following repeated curettage and hysteroscopic excision of retained products of conception. Uterus preservation was of priority, and the patient underwent uterine artery embolization; however, the pseudoaneurysm persisted due to ovarian artery collaterals. The pseudoaneurysm was subsequently treated with transvaginal ultrasound-guided direct thrombin injection. The case highlights the advantages and disadvantages of the treatment options in such clinically challenging cases emphasizing the seldom employed direct injection of thrombin for the treatment of pseudoaneurysms.