Case Report: Emergency resectoscopic management of acute postpartum leiomyoma expulsion presenting as refractory postpartum hemorrhage

Spontaneous postpartum expulsion of a uterine leiomyoma is rare and may present as a diagnostic dilemma when accompanied by postpartum hemorrhage, pelvic pain, necrotic tissue passage, or a protruding vaginal mass. We report a 34-year-old gravida 2, para 1 woman with a known intramural leiomyoma that enlarged to approximately 9 cm during pregnancy. After uncomplicated vaginal delivery at 36 weeks and 6 days of gestation, she developed immediate postpartum hemorrhage with an estimated blood loss of 1,950 mL and received uterotonic therapy, tranexamic acid, and 2 units of packed red blood cells. On postpartum day 3, she returned with severe lumbosacral pain, heavy vaginal bleeding, necrotic tissue passage, and a protruding cervical mass. Hemoglobin declined to 6.9 g/dL. Contrast-enhanced computed tomography in this hemodynamically stable patient demonstrated a large heterogeneous prolapsed mass within the lower uterine segment and cervical canal, an adjacent hemorrhagic component, and preserved uterine contour, supporting prolapsed degenerating leiomyoma rather than uterine inversion. The prolapsed necrotic leiomyoma was manually delivered, followed by resectoscopic excision of the residual pedicle under general anesthesia. Pathology confirmed benign leiomyoma with extensive hemorrhagic infarction. The patient recovered without recurrent bleeding at 6-week follow-up. This case highlights acute postpartum leiomyoma expulsion as an unusual cause of refractory postpartum hemorrhage and supports direct-visualized, uterus-preserving resectoscopic management in selected stable patients.