Massive Severe Uteroplacental and Uteropelvic Apoplexy

Case Report

A 31-year-old primigravida in the 37^th week (36+3) of uncomplicated pregnancy was admitted to the obstetric emergency room with abrupt and severe abdominal pain fifteen minutes before. At admission, she was somnolent with uterine tetany and acute abdomen syndrome with a first episode of hypertensive emergency in pregnancy (170/140 mm Hg) without vaginal hemorrhage. The cervical canal was closed. Emergency ultrasound examination suggested massive central total placental abruption with fetal bradycardia of 40/min. Massive placental abruption with fetal asphyxia indicated urgent cesarean section in general endotracheal anesthesia. Following Joel-Cohen laparotomy, 600 mL hemoperitoneum was found with massive uteroplacental and initial vasopelvic apoplexy (UPA, Couvelaire syndrome). A male hypotrophic neonate was born (2340/49) and immediately resuscitated (Apgar score 3,5,7). Laboratory findings showed initial HELLP syndrome (mild thrombocytopenia, hemolysis, and elevated liver enzymes) with intact coagulogram.

Placenta and uterus showed signs of Paget grade III abruption with massive apoplexy of the complete uterine corpus and adnexal blood vessels with adnexal and pelvic intravascular thrombi ([Fig. 1]). During hysterorrhaphy, intravenous oxytocin and intramyometrial carboprost tromethamine were administered because of hypotonic and non-contractible uterus, however without success. Peripartum cesarean hysterectomy was performed due to vital indications of extensive bleeding with hemorrhagic, livid purple, macerated uterus and hemodynamic instability with antihypertensive therapy (labetalol, urapidil), refractory hypertensive emergency, and tachycardia 180/min during cesarean section (RR 170–200/130–140 mm Hg). Hemostatic compressive sutures were not placed because of impossible tightening and risk of lacerations to the macerated Couvelaire uterus.

Fig. 1 Couvelaire uterus.

The postpartum course was complicated by the HELLP syndrome with multiorgan failure (MOF), oliguria, initially disseminated intravascular coagulopathy (grade I) and refractory hypertension, which was managed on postoperative day 10 with intensive treatment, along with good early newborn's outcome. Hypertension is difficult to correct with 2 antihypertensives (labetalol, nifedipine) and diuretics (furosemide). Histopathology of the uterus and placenta indicated recent massive bleeding between myometrial myofibrils and massive total abruptio placentae ([Fig. 2]).

Fig. 2 Massive placental abruption.

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