• Case description:

•A 76 years old patient had Vaginal Colpocleisis operation after an MDT review because of  significant cardiac history of aortic valve replacement and was on permanent pacemaker for the past 5 years . Patient had Vaginal hysterectomy and anterior repair in 2006 and was expereincing recurrent prolapse . Pt was diagnosed to have Stage 3 anterior vault prolapse and stage 2 posterior wall prolapse  with repeated attempts of pessary failure .Pt was on life long warfarin .

•Patient had uneventful colpocleisis operation with noted to have stage 4 complete vaginal vault prolapse .Blood loss at the operation was minimal .Patient was discharged on day 2 post operative day with bridging thromboprophylaxis protocol .

•On 6 th post operative day , pt was admitted with per vaginal bleeding . Streaks of blood noted in vagina with sutures noted to be healing . Patient was managed conservatively with Tranexemic acid and  was discharged home .

•On 10th post operative day , patient re admitted with  another  episode  of  per vaginal bleeding and noted to have oozing from the sutures . Additional haemostatic suture under local anaesthesia  was placed in the edge of vaginal mucosa  with  vicryl 2/0 and  no active  bleeding noted . Patient was discharged home on 12 th post operative day.

•On 14 th post operative day , patient readmitted  with per vaginal bleed and significant drop of Hb. CT abdo pelvis commented  bleeding in the region of right vaginal wall likely right internal iliac artery branch culprit vessel . Patient was managed with IR embolization in bleeding vessel with 1 unit of blood transfusion . Patient was discharged on  15 th  post operative day with commencement of warfarin .

•On 22 nd post operative day , patient readmitted with per vaginal bleeding . CT abdo pelvis  with contrast  reported  bleeding in the region of right vaginal wall . Bilateral iliac artery embolization noted . No active contrast  extravasation  present within the abdominopelvic cavity . IR consultant  opinion was to manage conservatively as regional bleeding likely small with stable Hb of 93. Patient was managed conservatively with warfarin and enoxaparin  and discharged home on 23 rd post operative day  with follow up phone call after 4 weeks noted patient well and no further per vaginal bleeding .

•Discussion :

•The  British Urogynaecological society  colpocleisis  information leaflet  mentions  blood transfusion after colpocleisis opeartion is a rare event . Numerous publications support  the information  with  mentioning bleeding is minimum similar to light period . This case mentions a rare cause of bleeding which is from branch of right internal iliac artery though indeterminate ,   that needed interventional radiology guided embolization  while patient experienced repeated episodes of per vaginal bleeding followed by blood transfusion  and repeated hospital admissions .