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| Days after surgical uterine evacuation | Events and Images |
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| Day 22 | (i) Ultrasound showed persistent retained placental tissue with significant vascularity and extension into bladder with no overlying myometrium, suggestive of placenta percreta with bladder involvement |
| (See Figure 3) |
| (ii) Multidisciplinary discussion between gynaecologist, urogynaecologist, maternal fetal medicine specialist, and patient |
| (iii) The options of management discussed included expectant management, abdominal hysterectomy, or uterine artery embolisation |
| (iv) Uterine artery embolisation was decided |
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| Day 33 | (i) Initial angiogram showed very large, tortuous, abnormal uterine arteries, particularly on the left side; thus it was decided to proceed with initial embolisation with the view that multiple procedures would be required to adequately devascularise the retained placental tissue |
| (ii) This decision was based on attempting to minimise undue ischemia and pain to the patient, and therein any hospital admissions, as well as minimising the radiation exposure to this young patient by spreading the embolisation over multiple session |
| (iii) Left sided arterial embolisation performed via microcatheter, using Boston Scientific Helical pushable metal coils (4 mm + 6 mm) and Boston scientific contour embolisation particles (250–350 microns) |
| (See Figures 4, 5, and 6) |
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| Day 36 | (i) Ultrasound showed persistence of retained placental tissue with significant vascularity |
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| Day 54 | (i) Pelvic angiogram showed persistent uterine vascular abnormality with some regression since the initial embolisation procedure |
| (ii) Further embolisation of two arterial branches of the left internal iliac artery |
| (iii) Regression of persistent PV bleeding and return of regular menses |
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| Day 57 | (i) Serum beta HCG 7 |
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| Day 107 | (i) Angiogram showed further improvement of the uterine vascular abnormality |
| (ii) Further embolisation of a branch of the right internal iliac artery |
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| Day 177 | (i) Pelvic angiogram showed a single abnormal feeding vessel to the vascular anomaly off the right internal iliac artery, which was successfully embolised |
| (ii) No further abnormal vessels, including intraperitoneal feeding vessels, were identified |
| (See Figure 7) |
|
| Day 241 | (i) Ultrasound showed persistent uterine mass (16 × 15 × 10 mm); however this was avascular and significantly reduced in size as compared to earlier ultrasound images |
| (See Figure 8) |
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| Day 248 | (i) Hysteroscopy was performed which showed no evidence of residual placental tissue over the anterior uterine wall. Endometrium overlying possible remnant placental tissues could not be ruled out. A uterine septum was identified which was divided with scissors |
| (See Figure 9) |
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| Day 283 | (i) Patient was well, continuing to have regular menstrual periods with no abnormal bleeding |
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