Keywords : hematometra ● induced abortion
Hematometra is a rare and delayed complication of medical termination of pregnancy. Acquired acute hematometra also termed the postabortal syndrome or the redo syndrome is a rare complication of suction evacuation with incidence ranging from 0.1 to 1 per 100 suction curettage abortion 1. The treatment consists of prompt evacuaion of both liquid and clotted blood leading to rapid resolution. An oxytocic is administered after the repeat evacuation.
A 26 year old literate, P A was admitted on 31st March, 2004 in emergency with the complaint of acute pain in abdomen associated with amenorrhoea of 7 weeks, giddiness, nausea, infrequent spotting, and frequent urge for defecation and micturation. She gave history of colicky pain in the lower abdomen since her inducced abortion on 4th February, 2004. Her symptoms aggravated since the last 2 days. Her urine pregnancy test was negative on 26th March, 2004.
On examination she was hemodynamically stable but was pale. Her pulse was 80/minute and regular, blood pressure 110/80 mm Hg, and temperature 990 celsius. Respiratory and cardiovascular systems were normal. Abdominal examination revealed tenderness in the lower abdomen without any palpable lump. Vaginal and speculum examinations revealed healthy vulva, vagina, and cervix with very scanty dark blood stained discharge. The uterus was tender, retroverted, 7 to 8 weeks size with closed cervical os, and with tender left fornix.
On interrogation, she gave history of induced abortion at 10 weeks gestation at Darbhanga on 4th February, 2004 after which she had no menstruation . Her previous menstrual cycles were of 30 days with 4 days bleeding.
She had a full term delivery by cesarean section for fetal distress 3 years back and laparoscopic appendicectomy 6 months back. She had been admitted to our hospital 3 months back on 2nd December, 2003 for suspicion of ectopic pregnancy which was excluded clinically and by sonography and she was discharged after 5 days with conservative treatment.
Investigations showed hemoglobin 10g/dL, WBC count 10,300/mm3, differential count - P A+ve, nonreactive HIV and HbsAg, no malaria parasites on peripheral smear, and negative urinary pregnancy test. This was confirmed by serum ? hCG. Transvaginal sonography on 1st April, 2004 suggested intrauterine molar pregnancy with retained products of conception. There was no evidence of ectopic pregnancy.
Conservative treatment was started with intravenous fluids and antibiotics. Considering the possibility of molar pregnancy with retained products 5 units of syntocinon in 500 mL of 5% dextrose was given by intravenous drip. Her vital signs remained stable but colicky pain continued which needed injectable analgesic at frequent intervals. As her sonography report was not corresponding with the ? hCG report and she had persistant acute pain in the abdomen, she was reevaluated by abdominal sonography on 2nd April, 2004 which revealed a hematometra.
On 2nd April, 2004 she was taken for D and E. The examination under anesthesia revealed 9 weeks size uterus with uterine cavity measuring 9 cm and a tightly closed os. Cervix was dilated up to 8 mm and dark blood came out in gush followed by about 50 mL of fresh blood. Uterine cavity was curetted. No organised tissue came out. Ten units of syntocinon were given in 500 mL of intravenous drip. She had an uneventful recovery. Pain subsided and her general condition improved. She was discharged on 5th April, 2004.
On follow-up, she had normal menstrual period on 2nd May, 2004 . She has normal cycles.
Acquired cervical stenosis and resulting hematometra are often overlooked as delayed complication of suction evacuation. The incidence is rare and the majority follow voluntary termination of pregnancy. It is more common in the younger age group and in pregnancy termination at 6-7 weeks gestation. The usual mode of presentation is amenorrhoea with colicky pain in the lower abdomen between 31-40 days after suction evacuation and rarely after 61 days 2. The uterus is large, tender and vaginal bleeding is less than expected. Ohara 3 has described a case of acute onset hematometra associated with endometritis and cervical stenosis.
While dealing with a case of amenorrhoea and pain in abdomen with a history of suction evacuation in the recent past, one must consider this as the first possibility. Adequate cervical dilatation and reducing the vaccum pressure to zero before withdrawing the suction cannula during every D and E may help to minimise this complication.
