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A 23-year-old primiparous woman with 37 weeks of amenorrhoea was admitted to the Obstetric ward with symptoms of severe abdominal pain and non-progression of labour past 20 h. The patient was registered for antenatal care at a peripheral health centre (PHC). She had two previous antenatal visits at the PHC. Her last visit was 15 days prior to admission, during which her blood pressure was found to be normal. In her second trimester visit, her blood group was B positive, haemoglobin was found to be 8.5 g/100 mL, urine routine showed no pathological findings and the tests for venereal disease research laboratory (VDRL) and HIV were non-reactive. She had no history of diabetes mellitus or hypertension and had not undergone any surgeries in the past.
On admission, she was afebrile, heart rate 130/min, blood pressure 94/60 mm Hg in supine position in the left upper limb and respiratory rate was 20/min. Significant pallor was noted (haemoglobin of 8.5 g/100 mL). The total leucocyte count was 12.5×109/L (reference range 4–11×109/L) with neutrophilia 9.1×109/L (reference range 2.5–7.5×109/L). Her coagulation profile was normal, bleeding time 4 min (reference range 3–10 min), clotting time 3 min (reference range 2–6 min) and prothrombin time 12 s (reference range 1–18 s).
On per abdomen examination, there was uterine tenderness and the uterus did not relax between contractions. On admission, the fetal heart rate was 160 bpm but significant decelerations (<100 bpm) were noted within 30 min of admission. Per vaginal examination revealed fresh bleeding from the uterine cavity. The cervix was 3 cm long and 2 cm dilated. Partial placental detachment from the lower uterine cavity was noted. The placenta was completely covering the internal os, a finding suggestive of central placenta praevia. A clinical diagnosis of cephalopelvic disproportion was also made. An emergency lower segment caesarean section was performed for non-progression of labour due to cephalopelvic disproportion with central placenta praevia with significant fetal distress.
On entering the uterine segment, a complete abruption of placenta was noted. A male child weighing 2.6 kg was delivered. The baby cried immediately after birth. On inspection, the uterus was found to have dark purple patches with ecchymosis and indurations diagnostic of Couvelaire uterus or uteroplacental apoplexy (figure 1aA,B).1–3 The haemorrhage is seen to infiltrate the lateral portions of uterus. A retroplacental clot with estimated blood loss of 2 L was also noted. The patient was transfused 200 mL of packed cells during the surgery and two more transfusions of 200 mL of packed cells were given in the postoperative period. She was given cefazolin 1 gm every 8 hours for 5 days in view of leucocytosis. The rest of her postoperative stay was normal.
Couvelaire1 first described the entity in 1911. It is a rare non-fatal complication of severe abruption.2 ,3 It is estimated to complicate 5% of all cases of abruption.2 The entity is infrequently reported and the incidence is difficult to estimate because the diagnosis is made by direct visualisation or biopsy.2 ,3
Couvelaire uterus is caused when haemorrhage from placental blood vessels seeps into decidua basalis causing placental separation, followed by infiltration in the lateral portions of the uterus.3 Occasionally, the infiltrations reach the peritoneal cavity. Couvelaire uterus is managed conservatively.3 Hysterectomy is not required and should be discouraged.
Acknowledgments
The authors thank Dr JK Sharma, the Dean of RD Gardi Medical College, Ujjain, Madhya Pradesh, India and Medical Director Dr VK Mahadik for giving permission to publish this case.
Footnotes
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Contributors MR and SKR collected the clinical details and photographs. AP performed the literature review, wrote the draft and revised the manuscript. MR, SKR, MP and AP verified the diagnosis and other scientific facts. All authors are responsible for clinical follow-up of the case and read and approved the final version of the manuscript.
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Competing interests None.
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Patient consent Obtained.
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Provenance and peer review Not commissioned; externally peer reviewed.