Macedo Silva Carlos; Domingos Pestana Cristina; Gomes Leiria Rita; Pina Zeferino; Dias Fátima Maria
Gynecology and Obstetrics Department, Hospital Dr. Nélio Mendonça, Funchal, Ilha da Madeira, Portugal
Ceska Gynekol 2021; 86(5): 335-338
Postpartum haemorrhage is a major cause of maternal morbidity and mortality worldwide. Early diagnosis and treatment are essential to prevent sequelae or even death. We describe a rare case of early postpartum haemorrhage with hemoperitoneum due to a laceration of the uterine serosa with exposure of a uterine vessel solved by laparotomy.
Postpartum haemorrhage is a major cause of maternal morbidity and mortality worldwide. Although there are established risk factors, it is in many cases an unpredictable event . There isn’t always an increase in vaginal blood loss; in some cases the bleeding can be intra-abdominal, and health professionals should be aware of other signs and symptoms of significant blood loss. Early recognition is essential for a timely and effective intervention .
We describe a case of a 31-year-old healthy woman, 40 weeks and 4 days pregnant, admitted in labour. From the medical history, she had a previous eutocic delivery without complication, and the present pregnancy was uneventful. After initial assessment, she was admitted to the delivery room in active labour. At her request, epidural analgesia was performed to control pain. Labour went on uneventfully, with eutocic delivery three hours after admission, giving birth to a healthy female baby weighing 3,295 grams and an Apgar score of nine at the first minute and 10 on the fifth minute. The delivery was not instrumental nor was Kristeller’s manoeuvre used. A grade I median perineal laceration was identified without need for suturing. Although not quantified, blood loss during delivery was considered normal. After delivery, 10 IU oxytocin was administered as recommended to reduce the risk of postpartum haemorrhage, and the new-born was breastfed in the first hour of life.
Half an hour after delivery, she was transferred to the postpartum unit and at that time she had good uterine tone with normal vaginal blood loss and without pain. Three hours after delivery, the obstetrician emergency team was called due to a feeling of malaise, dizziness, and nausea. Upon evaluation, she was conscious and oriented with no pain complaints, had discoloured mucous membranes, blood pressure 80/32 mmHg, heart rate of 82 bpm, and slight vaginal blood loss. No changes were identified upon physical examination, and a blood count was requested. Intravenous metoclopramide and a perfusion of hydroxyethylstarch at 6% were prescribed. The haemoglobin value was 5.1 g/dL with a haematocrit of 17.1%, so two units of erythrocyte concentrate (UEC) were requested. The pre-labour haemoglobin value was 9 g/dL, one month before.
The transfusion of the first UEC was uneventful, after which the patient reported improvement in symptoms, presenting a blood pressure of 103/54 mmHg with a heart rate of 80 bpm. Five hours after delivery, due to the onset of abdominal pain with pain upon deep palpation of the lower abdomen and no signs of peritoneal irritation, intravenous acetaminophen was prescribed, with partial relief of the complaints. After two hours, due to worsening of the abdominal pain, and at this point, she had a distended abdomen tympanized with intense pain upon superficial palpation; although there were no changes upon vaginal examination, an abdominal CT scan was requested, because ultrasound was not available.
The urgent CT scan without intravenous contrast revealed a large hemoperitoneum with blood in all quadrants of the abdomen, and a higher density at the periuterine level with probable active bleeding at this location. With these findings, an exploratory laparotomy was proposed to the patient who accepted it. A midline incision was made, abdominal cavity was filled with blood, 700 mL of blood were aspirated, and organized clots were removed. On the posterior surface of the uterus, there was a superficial laceration of the uterine serosa in the lower half of the uterine body, on the left. This one had approximately a 10 by 5 centimetre extension without reaching the broad ligament, exposing a vessel with active bleeding at the level of the insertion of the uterine vessels in the uterus; it was probably a branch of the uterine artery (Fig. 1, 2). The homolateral fallopian tube and ovary were intact. The blood loss was stopped with a Vycril 1.0 X suture, and an absorbable haemostatic mesh was placed on the surface (Fig. 3). After checking the entire abdominal cavity as well as the haemostasis, the abdomen was closed in layers. There was no evidence of endometriosis or adhesions. During surgery and post-surgical recovery, four more UECs were administered.
The postoperative period was uneventful, and she was discharged on the fourth postpartum day, medicated with oral iron and analgesics. At the puerperal follow-up appointment five weeks after delivery, she presented with no complaints and had good healing of the surgical wound.
During labour and for vaginal delivery,in addition to other factors, regular contractions are necessary, which will generate mechanical forces so the foetus is expelled, thus the uterine walls are subjected to a series of mechanical forces. In this way it is possible that lacerations of the uterine tissues can occur, which are generally of lesser severity and are asymptomatic. In certain situations, these mechanical forces can cause tissue damage of greater severity, especially when there are predisposing factors predominantly the presence of uterine scars .
Total disruption of the uterine wall, a uterine rupture, is considered as an obstetric emergency, which can be life--threatening for both mother and baby. Although rare, this is a well-known condition, but partial disruption of the uterine wall is a less characterized situation . As in uterine rupture, these can also lead to an increase in vaginal blood loss, as the case of internal myometrial laceration; however, when the rupture occurs on the external surface of the uterus, as this condition does not communicate with the endometrial cavity, it usually does not cause an increase in vaginal blood loss .
In these situations, in which the haemorrhage is confined to the abdominal cavity, as in the case described without increased vaginal blood loss, the deterioration of vital signs and the increase in abdominal volume are the main clinical findings that should raise suspicion of a postpartum hemoperitoneum. In view of this hypothesis, an abdominal and pelvic ultrasound is recommended [5,6]. As previously described, ultrasound was not available at the moment, which is why a CT scan was requested.
Whether in the total rupture of the uterine wall or in a partial rupture, there are well described risk factors highlighting the presence of uterine scars, which are points of greater fragility to the mechanical forces generated by uterine contractions [2,3]. The cases of partial uterine rupture with hemoperitoneum described in the literature, endometriosis lesions or a history of abdominal surgery with postoperative adhesions to the uterus are frequently identified [3,6,7]. In addition to this, others have also described other risk factors for uterine rupture, such as abnormal placentation, multiple pregnancy, obstetric manoeuvres or use of uterotomic drugs, and others [3,7]. In the case described, no risk factor was identified, which is why it is a rare and unpredictable case, and it was not possible to identify what motivated this partial uterine wall laceration. The rupture in a non-scar uterus is rare with some studies reporting incidences from 0.7/10,000 to 1/22,000 pregnancies; however, they don’t mention partial ruptures or serosal lacerations. Although they may be more frequent, most cases are not diagnosed as they do not have any symptoms [8,9]. In this case, intraoperative inspection of the uterine surface did not show any lesion suggestive of endometriosis or presence of adhesions.
Thus, we describe a case of an incomplete rupture of the uterine wall, a superficial laceration, that evolved into a severe hemoperitoneum, which is usually associated with less severe cases or is only discovered accidentally. In these patients with no risk factors, a high index of suspicion is necessary since it is a rare and unexpected event.
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Gynaecology and obstetrics