Couvelaire uterus - A case report

Couvelaire uterus ISSN: 2394-0026 (P)Case Report ISSN: 2394-0034 (O)Couvelaire uterus - A case reportMahendra G1*, Ravindra S. Pukale2, Vijayalakshmi S3, Priya41Assistant Professor, 2Associate professor, 3Professor and Head, 4Junior ResidentDepartment of Obstetrics and Gynecology, Adichunchanagiri Institute of Medical Sciences, B.G. Nagara, India *Corresponding author email: [email protected] to cite this article: Mahendra G, Ravindra S. Pukale, Vijayalakshmi S, Priya. Couvelaire uterus -A case report. IAIM, 2015; 2(3): 142-145.Available online at www.iaimjournal.comReceived on: 03-01-2015 Accepted on: 16-01-2015Abstract“Couvelaire uterus” or “Utero-placental apoplexy” is a rare complication of severe forms of placentalabruption. It occurs when vascular damage within the placenta causes hemorrhage that progressesto and infiltrates the wall of the uterus. We presented here rare case of 23 years old female withCouvelaire uterus.Key wordsCouvelaire uterus, Utero-placental apoplexy, Placental abruption.Introduction pregnancy induced hypertension (PIH) in previous pregnancy. Her personal and family“Couvelaire uterus” or “Utero-placental history was not significant.apoplexy” is a rare complication of severe formsof placental abruption. It occurs when vascular General examinationdamage within the placenta causes hemorrhage • Pallor +++that progresses to and infiltrates the wall of the • BP - 116/80 mmHg in the supine leftuterus [1]. It is a syndrome that can only be lateral positiondiagnosed by direct visualization or biopsy (or • Pulse rate - 108/minboth). For this reason, its occurrence is perhapsunderreported and underestimated in the Per abdomen findingsliterature [2]. • Abdomen was tense, corresponding to 32-34 weeks size.Case report • Fetal parts were not palpable. • Clinically fetal heart sound (FHS) couldA 23 years old female, third gravid, second para not be localised.and one living child (G3P2L1) with 29 weeks ofgestation, came to our hospital with complaintof pain in abdomen since 4 hours. History ofInternational Archives of Integrated Medicine, Vol. 2, Issue 3, March, 2015. Page 142Copy right © 2015, IAIM, All Rights Reserved.

Couvelaire uterus ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)Per vaginum findings • Dead female fetus weighing 900 gm was • Cervix was soft, partially effaced extracted. • Os was 2 cm dilated • Bleeding from muscle, skin incision site • Membranes - present was present. • One unit of whole blood and one unit ofRelevant investigation packed RBC were transfused intra- • Hemoglobin - 5.8 gm% operatively. • Blood group – ‘’O’’ positive • The patient was transferred to the • Platelet count – 67000 cells/ cumm surgical intensive care unit after the • Urine routine - albumin 3+ procedure. • Bleeding time (BT): 12 min • Patient was stabilised with one unit of • Clotting time (CT): 10 min packed RBC, two units of fresh frozen • Prothrombin time (PT): 22 sec plasma and two units of platelet • Activated partial thromboplastin time concentrates. After a slow recovery, she (aPTT): 52 sec did well. Patient was discharged on post operative day 12. Patient was followedLiver function tests up after 1 month post operative period • Bilirubin-marginally elevated was uneventful. • SGOT – raised • SGPT - raised Intra-operative finding suggested Couvelaire • Renal function tests: Normal uterus. (Photo – 2, Photo – 3)Ultrasonography (USG) suggested retroplacental Photo – 1: Ultrasonography (USG) suggestedclot and intrauterine death (IUD). (Photo – 1) retroplacental clot and intrauterine death (IUD).Diagnosis of abruptio placentae grade III, withIUD, in latent phase of labour was made.ManagementArtificial rupture of membrane (ARM) was done.Blood stained liquor was drained. Breechpresentation was noted.After giving antibiotics and starting blood, Discussionlabour was accelerated. After 2-3 hours ofwatchful observation for the progress of labour, “Couvelaire uterus” or “Utero-placentalcesarean section was planned with adequate apoplexy” is a pathological entity where thearrangement of blood as patient was retroplacental blood may penetrate through thedeteriorating. thickness of the wall of the uterus into theIntra-operative findings • 1000 gm of blood clots noted in uterine cavity.International Archives of Integrated Medicine, Vol. 2, Issue 3, March, 2015. Page 143Copy right © 2015, IAIM, All Rights Reserved.

Couvelaire uterus ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)peritoneal cavity. It was first described by Photo – 3: Couvelaire uterus.Couvelaire in the early 1900s as utero-placentalapoplexy, later it was termed as Couvelaire For decades, the standard of care for Couvelaireuterus on the name of the scientist. The uterus was hysterectomy. The traditionalhemorrhage that gets into the decidua basalis concern - myometrial bleeding interfering withultimately splits the decidua, and the hematoma uterine contractility, resulting in atony andmay remain within the decidua or may postpartum hemorrhage - is no longer justifiedextravasate into the myometrium. The today; hysterectomy is usually not requiredmyometrium becomes weakened and may because the condition resolves spontaneouslyrupture due to the increase in intra uterine [5].pressure associated with uterine contractions[3]. Although the exact etiology of Couvelaireuterus is unknown, it has been associated with • Placental abruption • Placenta previa • Coagulapathy • Preeclampsia • Ruptured uterus from a transverse lie • Amniotic fluid embolism [4]Photo – 2: Couvelaire uterus. Abruption is a life threatening condition which hardly gives time to the obstetrician to decide for the management. There is no role of conservative management in Abruptio placenta and delivery is the definitive treatment.Originally it was thought to be caused by a toxin The myometrial hematoma present inproduced by the placenta during abruption or Couvelaire uterus rarely interferes with uterinecaused by an obstruction to venous outflow, contraction following delivery. Thus theresulting in pervasion of the uterine wall by presence of Couvelaire uterus as observedblood. The most current etiologic theory during cesarean section is not an indication persuggests that blood from the retroplacental se for hysterectomy.hemorrhage invades the myometrium,separating the muscle bundles, and extends to Early intervention will reduce maternal and fetalthe serosal surface [5]. mortality and morbidity. Abruption is most commonly associated with hypertension in pregnancy. Proper antenatal visit is required, as haemorrhage is one of the leading causes of maternal mortality. The occurrence ofInternational Archives of Integrated Medicine, Vol. 2, Issue 3, March, 2015. Page 144Copy right © 2015, IAIM, All Rights Reserved.

Couvelaire uterus ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)Couvelaire uterus can be prevented by 3. Waugh ES, Grace HK. Uterus Couvelaire.prevention of abruptio placenta. This includes J Am Med Womens Assoc, 1947; 2(10):proper management of hypertensive states of 451.pregnancy and prevention of trauma during 4. Pitaphrom A, Sukcharoen N. Pregnancypregnancy. Mothers should also avoid smoking Outcomes in Placental Abruption. J Medor consumption of alcohol during pregnancy [6]. Assoc Thai, 2006; 89(10): 1572-8. 5. Eskes TK. Abruptio placentae. A “classic”References dedicated to Elizabeth Ramsey. Eur J Obstet Gynecol Reprod Biol., 1997; 1. Hubbard JL, Hosmer SB. Case Report: 75(1): 63–70. Couvelaire uterus. J Am Osteopath 6. Speert H. Obstetric-gynecologic Assoc, 1997; 97: 536. eponyms; Alexandre Couvelaire and uteroplacental apoplexy. Obstetrics and 2. Donaldson IA, Bismillah AH. Life from a Gynecology, 1957; 9(6): 740–743. Couvelaire Uterus. Postgrad Med J, 1963; 39(452): 356-8.Source of support: Nil Conflict of interest: None declared.International Archives of Integrated Medicine, Vol. 2, Issue 3, March, 2015. Page 145Copy right © 2015, IAIM, All Rights Reserved.