British Journal of Obstetrics and Gynaecology Aug. 1975. Vol. 82. pp. 682-686.
RECURRENT BLEEDING FROM THE LOWER SEGMENT SCAR -A LATE COMPLICATION OF CAESAREAN SECTION BY
K. S. STEWART,* Senior Registrar in Obstetrics and Gynaecology AND
T. WADEEVANS,Consultant Pathologist United Birmingham Hospitals Summary Hysterectomy became necessary six months after Caesarean section because of recurrent severe haemorrhage from the uterine scar.
CASEREPORT A previously healthy 23-year-old woman, was admitted as an emergency to hospital on the 18th January 1972, anaemic and in severe shock as a result of profuse vaginal bleeding. Her past medical history had been uneventful until June 1971, when her first child was delivered by Caesarean section. Because of suspected minor cephalopelvic disproportion at term, with the head high in the brim and a radiological true conjugate of 10.4 crn, trial of labour had been induced by low amniotomy followed four hours later by an oxytocin infusion. The patient remained in satisfactory condition and apyrexial but because of failure to make satisfactory progress lower segment Caesarean section was performed 24 hours after amniotomy, the uterine incision being closed in two layers with No. 2 chromic catgut. The baby, a 3.36 kg girl, made satisfactory progress. The placenta, which weighed 650 g and was sited on the posterior wall of the upper segment, appeared normal but histological examination showed inflammatory changes in the chorionic plate, membrane and cord. No bacteriological culture was made.
Postoperative recovery was uneventful apart from a pyrexia, not exceeding 37.5 “C over the first five days. The lochia were normal with no evidence of intrauterine infection. Cultures of high vaginal swab and midstream urine were negative. Antibiotics were not prescribed. The patient was discharged home with her baby on the 12th day. The lochia stopped three weeks post partum, but one week later there was a two-day episode of scanty vaginal bleeding. This recurred six weeks post partum but thereafter a normal 28-day menstrual cycle was established. From early December, lynoestrenol 2.5 mg and ethinyl oestradiol 0.05 mg (“Minylin”) was prescribed for contraception. Five-and-a-half months after delivery, a further two-day irregular vaginal loss occurred, the haemoglobin a few days later being 8 . 7 g/dl. Oral iron was prescribed. Two weeks later the vaginal bleeding recurred profusely, necessitating emergency admission to hospital. The pulse rate was 120 per minute, blood pressure 80/30 mm Hg, and the haemoglobin concentration 5 a 0 g/dl. Uterine haemorrhage was estimated as having been 2000 ml. The patient quickly responded to a 3 litre whole blood transfusion. There was a low grade pyrexia with some lower abdominal and uterine tenderness, but pelvic examination
* Present appointment: Consultant Obstetrician, Royal Infirmary, Stirling, Scotland. 682
RECURRENT UTERINE SCAR BLEEDING
was otherwise normal, with only a scanty continuing blood loss. A high vaginal swab, taken on admission, grew staphylococcus pyogenes sensitive to penicillin. An immunological test for human chorionic gonadotrophin was negative. The bleeding time and the one-stage prothrombin, partial thromboplastin and thrombus clotting times were normal, as were the platelet and white blood cell counts. Streptomycin and penicillin by intramuscular injection were prescribed. Three days later, examination under anaesthesia showed no obvious lesion, and curettage produced scanty proliferative endometrium. A gauze pack was inserted for 48 hours and the patient commenced on 15 mg of norethisterone daily by mouth’ In addition a single injection of 250 mg of
683
hydroxyprogesterone caproate was given intramuscularly. A definite diagnosis had not been reached when, on the 24th January, 1972, there was a further loss of about 200 ml, and on the 26th of 300 ml of blood. On the next day, the haemoglobin was 9.5 g/dl and so a further 1500 ml of whole blood was transfused. The final bleeding episode started on the 3rd February 1972, and by the next morning, the loss was estimated at 400 ml. Further surgery was considered indicated. Preliminary curettage again showed no abnormality and so laparotomy was undertaken. The pelvic organs appeared normal. Total hysterectomy was carried out, a further 1500 ml of blood being given during and immediately after the operation. The patient
FIG.1 Anterior wal1 of uterine cavity displayed after the uterus had been opened down the midine of the posterior wall. The slit-like Caesarean section scar is apparent and the spiral thrombus is marked by an arrow.
684
STEWART AND EVANS
was discharged home on the tenth postoperative day with a haemoglobin of 13-4 g/dl. Hysterectomy specimen. The uterus was 9 cm long, 6 cm wide, and 3 cm deep, and had been opened in the midline from the back. Three cm above the squamo-columnar junction, at the site of the Caesarean section scar, was a transverse depression on the inner surface. This was narrow and slit-like on the left but expanded to about 0.5 cm on the right, with a small circular opening (Fig. l), from which projected a smooth spiral mass 1 cm long and uniformly 0.2 cm in diameter. This was shown (Fig. 2) by histological examination to be thrombus, mostly compact and acellular, but in some areas staining as fibrin. Beneath the opening a rounded vascular space 0.5 cm in greatest dimension occupied almost the full thickness of the scar (Fig. 3). Its wall was composed of a convoluted layer of virtually acellular collagen, with a little fresh thrombus on its inner and coarse masses of elastin on its outer aspect. The lumen continued outside the wall of the uterus into a vein of better preserved structure; this had been obliterated and then recanalized. To the right was a group of small arteries but a direct connection between these
and the lumen was not demonstrated (Fig. 4). Elsewhere at this level was well-developed scar tissue with recanalized small arteries. Much haeniosiderin was present and in addition there were a few focal collections of histiocytes and small foreign-body giant cells without demonstrable inclusions ; the inflammation was confined to this area. Below the scar, the cervix was congested but appeared otherwise normal, and above, the endometrium was thinned and inactive. COMMENT The haemorrhage had occurred from a dilated venous space in the Caesarean section scar. Two episodes of slight bleeding had occurred within six weeks of delivery, but the menstrual pattern had been normal for the next four months. It seems likely that the communicating vein had thrombosed during this early phase, and that the recurrent more recent bleeding had followed organization and recanalization at a time when the surrounding fibrous scar prevented collapse and permanent occlusion of the varix. Hysterectomy in this healthy 23-year-old
FIG.2 Section of the spiral mass projecting into the cavity from the inner surface of the scar, showing, from below upwards, zones of deeply staining compact fibrin, red cells and organized thrombus. (Picro-Mallory X 40.)
RECURRENT UTERINE SCAR BLEEDING
FIG.3 Transverse sections of the anterior uterine wall, taken from a posterior aspect, looking (1) immediately above and (2) immediately below the scar.
FIG.4 Section of the full thickness of the right side of the scar showing (A) the cavity, (B) the inner end of the communicating space, and (C) the pedicle containing small vessels connecting it to the outside of the uterus. (PicroMallory x 28.)
685
686
STEWART AND EVANS
primipara was performed as a last resort and most reluctantly. Possible aetiological factors such as blood dyscrasias and obvious intrauterine disease were first excluded. Intrauterine infection and dysfunctional uterine bleeding were considered unlikely in view of the failure to respond to conservative treatment. Pre-operative hysterography or pelvic arterio-
graphy might have helped in the diagnosis, in which case the uterus could have been saved by excision of the lower segment scar. We are aware of no similar report in the literature.
ACKNOWLEDGEMENT We thank Mr. A. L. Deacon for his advice in the preparation of this paper.
RECURRENT BLEEDING FROM THE LOWER SEGMENT SCAR -A LATE COMPLICATION OF CAESAREAN SECTION BY
K. S. STEWART,* Senior Registrar in Obstetrics and Gynaecology AND
T. WADEEVANS,Consultant Pathologist United Birmingham Hospitals Summary Hysterectomy became necessary six months after Caesarean section because of recurrent severe haemorrhage from the uterine scar.
CASEREPORT A previously healthy 23-year-old woman, was admitted as an emergency to hospital on the 18th January 1972, anaemic and in severe shock as a result of profuse vaginal bleeding. Her past medical history had been uneventful until June 1971, when her first child was delivered by Caesarean section. Because of suspected minor cephalopelvic disproportion at term, with the head high in the brim and a radiological true conjugate of 10.4 crn, trial of labour had been induced by low amniotomy followed four hours later by an oxytocin infusion. The patient remained in satisfactory condition and apyrexial but because of failure to make satisfactory progress lower segment Caesarean section was performed 24 hours after amniotomy, the uterine incision being closed in two layers with No. 2 chromic catgut. The baby, a 3.36 kg girl, made satisfactory progress. The placenta, which weighed 650 g and was sited on the posterior wall of the upper segment, appeared normal but histological examination showed inflammatory changes in the chorionic plate, membrane and cord. No bacteriological culture was made.
Postoperative recovery was uneventful apart from a pyrexia, not exceeding 37.5 “C over the first five days. The lochia were normal with no evidence of intrauterine infection. Cultures of high vaginal swab and midstream urine were negative. Antibiotics were not prescribed. The patient was discharged home with her baby on the 12th day. The lochia stopped three weeks post partum, but one week later there was a two-day episode of scanty vaginal bleeding. This recurred six weeks post partum but thereafter a normal 28-day menstrual cycle was established. From early December, lynoestrenol 2.5 mg and ethinyl oestradiol 0.05 mg (“Minylin”) was prescribed for contraception. Five-and-a-half months after delivery, a further two-day irregular vaginal loss occurred, the haemoglobin a few days later being 8 . 7 g/dl. Oral iron was prescribed. Two weeks later the vaginal bleeding recurred profusely, necessitating emergency admission to hospital. The pulse rate was 120 per minute, blood pressure 80/30 mm Hg, and the haemoglobin concentration 5 a 0 g/dl. Uterine haemorrhage was estimated as having been 2000 ml. The patient quickly responded to a 3 litre whole blood transfusion. There was a low grade pyrexia with some lower abdominal and uterine tenderness, but pelvic examination
* Present appointment: Consultant Obstetrician, Royal Infirmary, Stirling, Scotland. 682
RECURRENT UTERINE SCAR BLEEDING
was otherwise normal, with only a scanty continuing blood loss. A high vaginal swab, taken on admission, grew staphylococcus pyogenes sensitive to penicillin. An immunological test for human chorionic gonadotrophin was negative. The bleeding time and the one-stage prothrombin, partial thromboplastin and thrombus clotting times were normal, as were the platelet and white blood cell counts. Streptomycin and penicillin by intramuscular injection were prescribed. Three days later, examination under anaesthesia showed no obvious lesion, and curettage produced scanty proliferative endometrium. A gauze pack was inserted for 48 hours and the patient commenced on 15 mg of norethisterone daily by mouth’ In addition a single injection of 250 mg of
683
hydroxyprogesterone caproate was given intramuscularly. A definite diagnosis had not been reached when, on the 24th January, 1972, there was a further loss of about 200 ml, and on the 26th of 300 ml of blood. On the next day, the haemoglobin was 9.5 g/dl and so a further 1500 ml of whole blood was transfused. The final bleeding episode started on the 3rd February 1972, and by the next morning, the loss was estimated at 400 ml. Further surgery was considered indicated. Preliminary curettage again showed no abnormality and so laparotomy was undertaken. The pelvic organs appeared normal. Total hysterectomy was carried out, a further 1500 ml of blood being given during and immediately after the operation. The patient
FIG.1 Anterior wal1 of uterine cavity displayed after the uterus had been opened down the midine of the posterior wall. The slit-like Caesarean section scar is apparent and the spiral thrombus is marked by an arrow.
684
STEWART AND EVANS
was discharged home on the tenth postoperative day with a haemoglobin of 13-4 g/dl. Hysterectomy specimen. The uterus was 9 cm long, 6 cm wide, and 3 cm deep, and had been opened in the midline from the back. Three cm above the squamo-columnar junction, at the site of the Caesarean section scar, was a transverse depression on the inner surface. This was narrow and slit-like on the left but expanded to about 0.5 cm on the right, with a small circular opening (Fig. l), from which projected a smooth spiral mass 1 cm long and uniformly 0.2 cm in diameter. This was shown (Fig. 2) by histological examination to be thrombus, mostly compact and acellular, but in some areas staining as fibrin. Beneath the opening a rounded vascular space 0.5 cm in greatest dimension occupied almost the full thickness of the scar (Fig. 3). Its wall was composed of a convoluted layer of virtually acellular collagen, with a little fresh thrombus on its inner and coarse masses of elastin on its outer aspect. The lumen continued outside the wall of the uterus into a vein of better preserved structure; this had been obliterated and then recanalized. To the right was a group of small arteries but a direct connection between these
and the lumen was not demonstrated (Fig. 4). Elsewhere at this level was well-developed scar tissue with recanalized small arteries. Much haeniosiderin was present and in addition there were a few focal collections of histiocytes and small foreign-body giant cells without demonstrable inclusions ; the inflammation was confined to this area. Below the scar, the cervix was congested but appeared otherwise normal, and above, the endometrium was thinned and inactive. COMMENT The haemorrhage had occurred from a dilated venous space in the Caesarean section scar. Two episodes of slight bleeding had occurred within six weeks of delivery, but the menstrual pattern had been normal for the next four months. It seems likely that the communicating vein had thrombosed during this early phase, and that the recurrent more recent bleeding had followed organization and recanalization at a time when the surrounding fibrous scar prevented collapse and permanent occlusion of the varix. Hysterectomy in this healthy 23-year-old
FIG.2 Section of the spiral mass projecting into the cavity from the inner surface of the scar, showing, from below upwards, zones of deeply staining compact fibrin, red cells and organized thrombus. (Picro-Mallory X 40.)
RECURRENT UTERINE SCAR BLEEDING
FIG.3 Transverse sections of the anterior uterine wall, taken from a posterior aspect, looking (1) immediately above and (2) immediately below the scar.
FIG.4 Section of the full thickness of the right side of the scar showing (A) the cavity, (B) the inner end of the communicating space, and (C) the pedicle containing small vessels connecting it to the outside of the uterus. (PicroMallory x 28.)
685
686
STEWART AND EVANS
primipara was performed as a last resort and most reluctantly. Possible aetiological factors such as blood dyscrasias and obvious intrauterine disease were first excluded. Intrauterine infection and dysfunctional uterine bleeding were considered unlikely in view of the failure to respond to conservative treatment. Pre-operative hysterography or pelvic arterio-
graphy might have helped in the diagnosis, in which case the uterus could have been saved by excision of the lower segment scar. We are aware of no similar report in the literature.
ACKNOWLEDGEMENT We thank Mr. A. L. Deacon for his advice in the preparation of this paper.
