Abstract

Background: An arcuate uterus is a minor congenital uterine anomaly that is often considered clinically insignificant. However, non‑uniform myometrial contractility may occasionally predispose to obstetric complications, including postpartum hemorrhage (PPH).
Case presentation: A 26‑year‑old primiparous woman had an arcuate uterus incidentally identified on fetal MRI. She delivered vaginally at 39+2 weeks. Immediately after placental delivery, she developed heavy bleeding (~1200mL) despite an apparently satisfactory uterine tone on abdominal palpation (uterine globe). Bedside ultrasound excluded retained products and suggested asymmetric fundal hypocontractility at the site of the fundal indentation. After initial medical management (uterine massage, uterotonics, tranexamic acid) and mechanical measures, bleeding persisted and she was transferred to the operating room. Uterus‑sparing surgery with stepwise uterine devascularization (Tsirulnikov ligatures) combined with a B‑Lynch compression suture achieved hemostasis.
Conclusion: A clinically “good” uterine globe can be misleading in PPH. When examination findings and bleeding are discordant, a structured 4Ts assessment and bedside ultrasound may expedite diagnosis of segmental/asymmetric atony and guide timely escalation to conservative interventions.

Keywords:Arcuate uterus; Postpartum hemorrhage; Uterine globe; Asymmetric uterine atony; Uterotonic agents; Bakri balloon; B-Lynch; Tsirulnikov; Bedside ultrasound

Abbreviations: ASRM: American Society for Reproductive Medicine; EBL: Estimated Blood Loss; ESGE: European Society for Gynaecological Endoscopy; ESHRE: European Society of Human Reproduction and Embryology; MRI: Magnetic Resonance Imaging; NB: Newborn; PROM: Prelabor Rupture of Membranes; GA: Gestational Age; HR: Heart Rate; PPH: Postpartum Hemorrhage; TXA: Tranexamic Acid; 4Ts: Tone, Trauma, Tissue, Thrombin