Vessel Subinvolution of the Placental Implantation Site: A Case Report and Review of Supportive Literature

Subinvolution of the implantation site is a significant contributor to delayed postpartum hemorrhage (PPH). There is immense literature documenting the histologic features, development, and involution of the uteroplacental site; however, practice-oriented literature on subinvolution of the implantation site is sparse. In the present study, we briefly review the physiologic characteristics associated with the normal development and involution of uteroplacental arteries and the proposed pathophysiologic attributes of subinvolution. Furthermore, we engage in a comparison of the condition with preeclampsia. Herein, we report a case of postpartum vaginal bleeding that persisted for two weeks following cesarean delivery. The bleeding was nonresponsive to conservative treatment. Sonography performed revealed that a heterogeneous intrauterine vascular mass measuring 14.6 × 9.2 × 10.4 cm( )was present, distending the uterine cavity. The presence of retained products of conception could not be ruled out. Therefore, to further confirm the condition, the patient underwent an emergency hysterectomy. Gross examination showed an enlarged and boggy uterus with numerous dilated and ecstatic thrombosed blood vessels in the implantation site of the endomyometrium. Histologic and immunohistochemical examination of the implantation site revealed the presence of persistently patent uteroplacental arteries with variable degrees of thrombosis adjacent to normally involuted vessels. Hence, a diagnosis of placental site vessel subinvolution (VSI) was established in this case. We also reviewed the related literature to illustrate the informative histologic findings of subinvolution. Preparing the ground for diagnosing subinvolution is important as this process defines that the cause of delayed postpartum uterine bleeding is idiopathic, rather than iatrogenic.