Hemorrhage is still the commonest cause of maternal mortality in India. Secondary postpartum hemorrhage has
received little attention, however it may sometimes become fatal. In more than half of the cases, etiology is not made out. Uterine
scar rupture is extremely rare cause of secondary postpartum hemorrhage after lower segment caesarean section, occurring in
1in 365 cases.
This is a retrospective analysis of women referred to our hospital with secondary postpartum hemorrhage following
caesarean section, during a period of four years from August 2008 to July 2012.
A total of 36 patients were admitted with secondary postpartum hemorrhage after caesarean section. Out of them four
women presented between four to six weeks postpartum with severe hemorrhage and hypovolemic shock. All the four had
recurrent episodes of postpartum hemorrhage, managed conservatively, with no identifiable cause and referred to our hospital for
further management. Two women who were hemodynamically unstable with continuous profuse vaginal bleed were taken up for
emergency laparotomy. They had uterine scar rupture with unhealthy, necrosed margins and active bleed. Third patient was stable
after resuscitation and pelvic angiography revealed uterine arteriovenous malformation. Right uterine artery was embolized.
Patient was discharged on second day. After two weeks she again presented with profuse vaginal bleed and hypovolemic shock.
On exploratory laparotomy, she had uterine scar rupture. Fourth patient presented with septicemia and purulent discharge
through the abdominal wound and vagina. She developed postpartum hemorrhage in the hospital. On exploration she had plastic
adhesions in the pelvis with pelvic abscess and ruptured uterine scar. All the four patients had hysterectomy.
Secondary postpartum hemorrhage beyond fourth week post delivery is rare and rarer following lower segment
caesarean section. Uterine scar rupture is fortunately rare and many minor occurrences probably go undiagnosed. Significant
morbidity is associated with this complication including the need for emergency surgical intervention. Clinicians must remain
aware of the diagnostic and therapeutic options.
Kiranmai Gottapu, completed her Master of Surgery in Obstetrics & Gynaecology from NTR University of Health Sciences, India in 2008. She is working as Assistant Professor in the Department of OBGY, Alluri Sitaramaraju Academy of Medical Sciences,Eluru. She is also a Visiting Consultant at Varma Hospitals, Bhimavaram. Her area of interest is Endoscopic Gynaecology, Urogynaecology and Infertility.
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