Dr. Geetika Thakur is working as Research Associate at PGIMER Sector 12 Chandigarh with eleven years of clinical and research experience with a special interest in maternal near miss morbidity and high risk pregnancies.
Delayed postpartum haemorrhage caused by partial or complete dehiscence of uterine scar is extremely rare. A case, hereby, is presented of delayed severe postpartum haemorrhage presenting as late as 44 days following LSCS. Patients with delayed postpartum haemorrhage should evaluated for uterine scar dehiscence. If missed, the consequences can be catastrophic with prolonged severe maternal morbidity.
Delayed postpartum hemorrhage (PPH) is defined as any abnormal or excessive bleeding that occurs 24 h after delivery and up to 12 weeks postpartum [1]. The exact prevalence of secondary PPH is difficult to estimate as only severe cases of secondary PPH who require blood transfusion or surgical intervention get reported, rest are managed on an outpatient basis. According to the largest historical cohort, the frequency of secondary PPH ranges between 0.2 and 3% of deliveries [2]. Retained placenta is the commonest cause for secondary PPH followed by subinvolution, endometritis, and pseudoaneurysm. Scar dehiscence is one of the rarest causes of secondary PPH. We are describing a case of scar dehiscence who reported on day 44 with life-threatening severe hemorrhage.
We are discussing a para 2 living 2 patient. In her present pregnancy, she was booked in our institute since early gestation. Her pregnancy was uncomplicated except for the development of gestational diabetes mellitus at 26 weeks of gestation which was controlled on oral hypoglycemic agents and insulin. She was planned for induction for the same at 37 + 4 weeks. The patient refused induction of labor as she had a repaired complete perineal tear in her first delivery. The patient underwent an Elective LSCS with bilateral tubal ligation. Her postoperative period was uneventful, the patient had no fever and she was discharged 48 h after LSCS. Suture removal was done on day 8 and sutures were healthy. She had her postpartum visit at 6 weeks. Two days after that, i.e., 44 days postpartum, she presented to the emergency with severe bleeding per vaginum with the passage of a big clot and soakage of one complete pad in half an hour. There was no history of local trauma, fever, foul-smelling vaginal discharge, per vaginal or per speculum examination, intercourse, or antiplatelet/anticoagulant intake.
On examination, she was anxious, although, well-oriented. She had tachycardia of 120 beats per minute, BP was 100/70 mm of Hg and the patient was pale. Her uterus was well retracted. On per speculum examination, 500 cc clots were removed from her vagina, cervix was irregular and pulled up, os was closed and minimal active bleeding was seen. Hemogram, coagulogram, LFT, RFT were within normal limits. On transvaginal USG with color Doppler, no evidence of residual placental tissue was found in the uterine cavity. Although a 2 * 2 cm hypoechoic lesion was found in the isthmic region with no color flow. I/V antibiotics, I/V Tranexamic acid was started and patient was planned for Digital subtraction angiography (DSA). While she was being shifted for DSA, she had the second bout of torrential bleeding per vaginum. She was shifted for exploratory laparotomy. Intraoperatively, it was found that the cesarean scar was necrosed and the scar site was bleeding profusely. Total abdominal hysterectomy was done. The patient received 5 packed red blood cells (PRBC), (1) fresh frozen plasma (FFP), (2) platelet concentrate, and (3) cryoprecipitates intraoperatively. The patient was stable postoperatively (no fever or malaise) except for the fact that she had a urinary tract infection on day 2 which was managed according to culture sensitivity. She was discharged in stable condition on her 10th postoperative day. Suture removal was done on day 10 and sutures were healthy. The histopathology of the uterus was suggestive of benign proliferative endometrial glands with the myometrium showing extensive loss of myometrial fibers and replacement by fibrosis as shown in Fig. 1.
Delayed postpartum hemorrhage is not a well-studied condition as the incidence is very less. Amongst the patients who develop delayed PPH, the proportion of cases being reported is further less as most of the cases are managed on an outpatient basis. Even the ones who reach emergency pose a diagnostic dilemma as there is no specific definition to quantify delayed PPH into mild, moderate, or severe. Severe secondary PPH due to scar dehiscence is very rare and the bleeding occurs commonly due to the shearing of vessels on the margins of the uterine scar. The risk factors reported for scar dehiscence are multiparity, diabetes, emergency surgery, infection, and incision placed too low in the uterine segment [2]. Two out of these, i.e., multiparity and diabetes were present in our patient. Uterine scar dehiscence with infection requires a high index of suspicion as a rare cause for postpartum localized/generalized peritonitis with sepsis. Severe abdominal wound infection after cesarean section may be associated with uterine wound dehiscence, which poses a grave risk to the mother in her future pregnancy.
Most commonly the patients present between 1 and 4 weeks postoperatively [3]. Sometimes the patient has an irregular bleeding pattern and the patient may have several bleeding episodes separated by days [3]. This was, however, not the case in our patient as she had a postpartum check just 2 days back and she was asymptomatic at that time. One case was found where the bleeding was as late as 10 weeks post-operatively.
While evaluating a case of secondary PPH a pelvic ultrasound with Doppler is very important as it can help exclude common causes like retained placental fragments, endometritis, and subinvolution of the placental bed [3]. Pelvic angiography helps in identifying pseudoaneurysms as a cause of severe secondary PPH [3]. In our case the patient was planned for DSA; however, the procedure could not be carried out as the patient had torrential bleeding warranting immediate exploratory laparotomy. On laparotomy, the cesarean scar tissue was necrotic.
Once the diagnosis of dehiscence of cesarean scar is made, the approach to management can be conservative or surgical. Conservative modalities were not an option for our patient as the patient was bleeding profusely from an eroded uterine artery. Surgical management includes refreshing the edges of the scar, ligation of internal iliac arteries, and hysterectomy [4]. The decision in our patient was hysterectomy as her bleeding was life-threatening which required multiple blood units and product transfusions intraoperatively (Table 1).
Conflict of interest The authors declare that they have no conflict of interest statement.
Ethical Approval Informed consent of the patient has been taken before submitting the case report for publication.
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