부산대학교 도서관

A 37-year-old nulliparous woman with no notable medical history had a diamniotic dichorionic pregnancy. At 33+1 weeks, she underwent cesarean section because of preeclampsia and was referred to our hospital because of severe postpartum hemorrhage. Emergency bilateral uterine artery embolization（UAE）was performed using a gelatin sponge. She was treated with Sulbactam/Ampicillin as prophylactic antimicrobial after UAE. Postoperatively, she presented with fever and abdominal pain and had increased white blood cell count. We suggested intrauterine infection, antibiotics was switched to Tazobactam/Piperacillin. Additionally, general malaise, foul-smelling lochia, and uterine restoration failure were observed. The general condition deteriorated gradually, antibiotics was switched to Imipenem/Cilastatin. On postoperative day 23, T2-weighted magnetic resonance imaging（MRI）images showed an enlarged myometrium, and gadolinium T1-weighted images showed that the myometrium had poor contrast enhancement, suggesting myometrium necrosis. However, conservative treatment with antibiotic therapy was continued because a temporary embolic agent was used, and she hoped to conceive a second child. Nonetheless, the symptoms did not improve. On postoperative day 26, she had leukopenia（WBC 1800/μL）with shivering. Total hysterectomy was performed because of septic shock caused by uterine infection. The postoperative course was uneventful, and the patient was discharged. Pathological examination revealed endometrium inflammation and myometrium necrosis from the fundus to the uterine body. Therefore, considering uterine necrosis as a potential differential diagnosis in patients with prolonged fever, abdominal pain, foul-smelling lochia, and intrauterine infection that does not respond to antimicrobial therapy after UAE is important. Contrast-enhanced MRI should be performed in such cases to facilitate early diagnosis and timely intervention.