we report a case of a successful embolization of a mycotic aneurysm of the left uterine artery in the puerperium after a neglected perforated appendicitis . a mycotic aneurysm , meaning an infection of the vessel wall which leads to an aneurysmatic dilatation of the vessel , is potentially life threatening if rupture occurs . three hours after delivery the abdominal complaints increased and the patient developed a hypovolemic shock with signs of intra - abdominal bleeding of unknown origin resulting in a diagnostic laparoscopy . the abdominal cavity showed a hemoperitoneum , a subperitoneal hematoma of the uterus , and a purulent , perforated appendix . ct scan showed signs of a leaking mycotic aneurysm in the left uterine artery , which was successfully embolized . we report a successful embolization of a mycotic aneurysm of the left uterine artery in the puerperium . bacterial or fungal inflammation of the vessel wall can lead to aneurysmatic dilatation of the vessel and is potentially life threatening if a rupture occurs 14 . we report a case of an embolization of a mycotic aneurysm of the left uterine artery 2 weeks after a spontaneous vaginal delivery . embolization is a well - known method to occlude the uterine artery in hemorhaghia postdelivery or in the treatment of uterine fibroids . as far as we know , this is the first case report in literature of a mycotic aneurysm of the proximal uterine artery that has been successfully embolized 3,57 . a 26-year - old healthy pregnant woman presented with continuous intermittent lower abdominal pain in the left side at 40 + 1 weeks gestation . the pregnancy was uneventful until 36 weeks of gestation , when the woman experienced two short periods of acute left lower abdominal pain , but consulted neither her midwife nor her general practitioner . at 37 weeks the woman was tender over the left lower abdomen , but without signs of peritonitis . her temperature was normal and laboratory examination showed no signs of infection . because of these unexplained vague complaints , irregular uterine contractions , and a favorable cervix , it was decided to induce labor by artificial rupture of membranes followed by oxytocin augmentation . three hours after delivery the abdominal complaints increased and there were signs of a hypovolemic shock with lowering hematocrit and hemoglobin and transabdominal ultrasound , showed free fluid in the abdominal cavity . after removal of blood and clots , a large subperitoneal hematoma underneath the serosa of the uterus and in the left mesovarium became visible . the appendix was infected , purulent , and possibly perforated since we saw some pus in the abdominal cavity . the appendix was laparoscopically removed and we decided to leave the hemoperitoneum closed , since the size of the subperitoneal hematoma remained stable during surgery . during surgery the patient received a transfusion of three units of packed red blood cells and intravenous cefazoline / metronidazole ( 3000 mg/1500 mg per day ) . due to breastfeeding the antibiotics were switched to amoxicillin / clavulanic acid ( 1200 mg/4 days ) and continued for 10 days . thirteen days after surgery , the patient was readmitted because of acute left lower abdominal pain and peritoneal tenderness . a transvaginal ultrasound showed a round structure on the left side of the uterus with turbulent ( yin - yang sign ) doppler flow ( fig.1 ) with minimal fluid in the rectouterine pouch . the size and shape of this small based saccular aneurysm suggested mycotic infection of iatrogenic origin . transvaginal ultrasound showing a round structure at the left side of the uterus with turbulent ( yin - yang sign ) doppler flow . the endovascular approach revealed that the bleeding was indeed a result of a large saccular aneurysmatic change in the uterine artery ( fig.2 ) . it was possible to bypass the aneurysm and embolize the distal artery to prevent backflow with a 3- and 4-mm tornado coil . since this did not result in complete distal embolization , the aneurysmatic lumen was filled with two 20-cm long interlocking detachable coils . the successful embolization of the aneurysm and his secondary bleeding was achieved after placing a final proximal arterial 4-mm tornado coil ( fig.2 ) . we describe a successful embolization of a mycotic aneurysm of the left uterine artery in a patient in the puerperium with a neglected , undiagnosed , perforated appendicitis . bacterial or fungal inflammation of the vessel wall can lead to aneurysmatic dilatation of the vessel and is potentially life threatening if a rupture occurs . a mycotic aneurysm was first described in 1885 by sir william osler , as an infected dilatation of an arterial wall secondary to septic emboli 1,2 . nowadays the definition of mycotic aneurysms is based on preexisting arterial disease and/or localized infection sources . infection of the artery wall occurs as a result of three possible mechanisms : embolization of bacterial endocarditis , hematogenous spread of micro - organisms in the vasa vasorum ( i.e. septicemia ) , or direct extension from a neighboring source of purulent infection 1,3 . the sudden appearance of an aneurysm in a septic patient is very suspect of a mycotic aneurysm . mycotic aneurysms usually lack intimal calcification . in some cases , which probably occurred in our patient , the inflamed appendix became adherent to the wall of the aneurysm resulting in a wall infection 1,2 . the most common pathogens in mycotic aneurisms are gram - positive cocci , but salmonella and other gram - negative bacteria and also bacteroides fragilis are described 3 . among the fungi a case report was written in 1999 of a pseudo aneurysm of the uterine artery . preexisting arterial aneurysms in general are associated with an increased risk of rupture in pregnancy . rupture of these preexisting arterial aneurysms in pregnancy or in puerperium are associated with significant morbidity and mortality . pregnancy - related rupture of aneurysms of the aorta , cerebral vessels , splenic artery , coronary artery , renal artery , and ovarian artery have been documented . aneurysms occurring in the uterine artery are rare 3,57 . in the literature , only mycotic aneurysms in the aorta , the internal and external iliacal artery , and femoral artery are described 1,3,4 . we suspect that in our case the purulent , perforated appendix caused peritonitis with multiple adhesions around both adnexa and an infection of the wall of the left uterine artery resulting in a mycotic aneurysm . clinically diagnosing appendicitis during pregnancy is difficult because of the variable appendiceal position , limited physical examination of the gravid abdomen , and the nonspecificity of symptoms during pregnancy 6 . in several reports , as in our case , diagnosis earlier in pregnancy our patient experienced this abdominal pain as vague , which was probably due to the appendicitis , peritonitis with secondary the aneurysm of the left uterine artery . as far as we know , this is the first time that a mycotic aneurysm is described in the uterine artery which was successfully embolized .
key clinical messagewe report a case of a successful embolization of a mycotic aneurysm of the left uterine artery in the puerperium after a neglected perforated appendicitis . 
 a mycotic aneurysm , meaning an infection of the vessel wall which leads to an aneurysmatic dilatation of the vessel , is potentially life threatening if rupture occurs .