Postpartum hemoperitoneum due to avulsion of pelvic uterine adhesion band.

Abstract: A 31-year-old nulliparous woman presented in labor with preterm rupture of membranes at 35 weeks of gestation. The ensuing intrapartum course was uneventful, and she delivered a healthy infant (birth weight, 2,850 g) vaginally. Four hours after delivery, the patient had a syncopal episode due to hypovolemic shock. At laparotomy, a fibrous band between the right fallopian tube and uterus was found to be avulsed and actively bleeding, confirming preoperative findings obtained with multidetector row computed tomographic angiography.

Key Words: hemoperitoneum, puerperium, adhesion band, multi-detector row computed tomography

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Hemoperitoneum during pregnancy or the puerperium is a rare but potentially life-threatening complication. A hemoperitoneum may follow rupture of various pelvic structures including the uterus, uterine vessels, spleen, ovarian vessels, or pelvic endometrial implants. We report a case of hemoperitoneum with hypovolemic shock occurring four hours after vaginal delivery. The source of hemorrhage was precisely identified before exploratory laparotomy using multidetector row computed tomographic angiography as an avulsed adhesion between the right fallopian tube and uterus.

Case Report

A 31-year-old nulliparous woman presented to the hospital in labor and with ruptured membranes at 35 weeks' gestation. She had no known systemic diseases, disclosed no prior surgeries, and had a benign prenatal course before admission. The patient declined a trial of tocolytic therapy after a thorough discussion regarding risks and potential benefits. The intrapartum course, 7 hours 16 minutes in length, was uneventful, and a 2,850 g girl with Apgar scores of 7 and 9 at one and five minutes, respectively, was delivered vaginally. The blood loss was estimated at 400 mL. Four hours postpartum, the patient had a sudden onset of tachycardia, became hypotensive, and had a syncopal episode. IV fluids were promptly and vigorously administered, and her condition improved within five minutes. Postpartum hemoglobin was 8.3 mg/dL, compared with an admission hemoglobin level of 11.7 mg/dL. Four units of packed red blood cells were given. The amount of lochia was verified as moderate. An abdominal ultrasonogram revealed massive ascites without a retained placenta or fluid in the uterus. Although the combination of clinical signs and ultrasonographic findings were highly consistent with intra-abdominal hemorrhage, the patient's prompt response to fluid resuscitation and transfusion and the amount of time elapsed since delivery raised the possibility that the patient was no longer actively bleeding; thus, expectant management rather than exploratory laparotomy was an alternative. For this reason, multidetector row computed tomographic angiography was obtained, which showed active bleeding points at the right cornu of the uterus (Fig. 1). An emergent laparotomy was performed. During the laparotomy, small lacerations at the right uterine cornu and the base of the right fallopian tube were confirmed (Fig. 2). Approximately 2000 mL of fresh blood and clots were dispersed in the abdominal cavity.

Exploration of the uterus with a probe revealed a superficial linear defect, similar in length to the defect involving the fallopian tube, both of which were repaired with continuous chromic sutures. Right subovarian adhesions and complete obliteration of the cul-de-sac were also noted. The remainder of the pelvis was anatomically normal. Representative biopsies from the uterine defect and adjacent tissues were obtained for histologic evaluation. The histologic examination disclosed fibrin and fibrous bands lined by mesothelial cells. The postoperative period was uneventful, and the patient and her newborn daughter were discharged on the eleventh postoperative day.

Discussion

Pelvic adhesions most often arise from infections, endometriosis, and prior surgery. (1) As expected, the biopsies obtained from the described patient did not disclose an etiology for the adhesive band. Nevertheless, this case has documented that a previously formed fibrous band can be avulsed during the normal course of labor, delivery, and/or postpartum involution of the uterus and can lead to an obstetric emergency. An event like this, however, is so extraordinarily rare that it cannot be predicted.

Having eliminated common causes of postpartum hemorrhage and given the patient's hemodynamic stability after fluid resuscitation, it was considered in the best interest of the patient to demonstrate continued active bleeding and localize it before proceeding with major surgery. An interventional radiologist was therefore consulted, who recommended computed tomographic angiography. Some controversy exists whether computed tomographic angiography is more sensitive than traditional angiography, but multidetector row computed tomographic angiography is preferred for imaging emergent abdominal vascular cases because it enables the acquisition of high spatial-resolution volumetric image data during a single held breath. Indeed, multidetector row computed tomographic capabilities have dramatically improved, such that a very high spatial-resolution image can be achieved for the entire abdominal vasculature, including small, distal submillimeter visceral branches. (2) Unlike catheter angiography, multidetector row computed tomographic angiography not only depicts the relevant vessels, but it also facilitates assessment of perfusion in adjacent organs. (3) High speed and good image resolution increasingly allow for replacement of invasive diagnostic procedures. (2) With our patient, contrast agent extravasation was demonstrated at the right cornu of the uterus. Blood clots in proximity were depicted as areas of heterogeneous density. During emergent laparotomy, we demonstrated that contrast-enhanced computed tomographic images correctly indicated the anatomic source of the bleeding.

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In conclusion, pelvic adhesions may be disrupted during labor and delivery. In the hemodynamically stable patient, multi-row computed tomographic angiography is of enormous benefit in completely defining a persistent source of the bleeding. To the best of our knowledge, this is the earliest documentation of such a case in the literature.

References

1. Liakakos T, Thomakos N, Fine PM, et al. Peritoneal adhesions: etiology, pathophysiology, and clinical significance: recent advances in prevention and management. Dig Surg 2001;18:260-273.

2. Wintersperger BJ, Nikolaou K, Becker CR. Multidetector-row CT angiography of the aorta and visceral arteries. Semin Ultrasound CT MR 2004;25:25-40.

3. Frauenfelder T, Wildermuth S, Marincek B, et al. Nontraumatic emergent abdominal vascular conditions: advantages of multi-detector row CT and three-dimensional imaging. Radiographics 2004;24:481-496.

Hung-Chung Fu, MD, Sheung-Fat Ko, MD, Chia-Yu Ou, MD, and Te-Yao Hsu, MD

From the Departments of Obstetrics and Gynecology and Roentgenology, Chang Gung Memorial Hospital Kaohsiung Taiwan.

Reprint requests to Te-Yao Hsu, MD, Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Kaoshiung 123, Ta-Pei Road, Niao Sung Hsiang, Kaohsiung Hsien, Taiwan. Email: [e-mail]

Accepted March 24, 2006.

RELATED ARTICLE: Key Points

* Rare case, hemoperitoneum was found after vaginal delivery.

* Multirow computed tomographic angiography is very helpful to identify source of hemoperitoneum.

* Pelvic adhesions may be disrupted during vaginal delivery.