Couvelaire uterus resulting in haemoperitoneum

Abstract

First described by Dr Alexandre Couvelaire in 1911, a Couvelaire uterus is a rare complication of severe placental abruption (PA), which is diagnosed by the direct visualization of the uterus. There has been only one case report thus far that reported of an intraperitoneal bleed due to PA resulting in a poor outcome. We present a rare and serious case of Couvelaire uterus resulting in haemoperitoneum with a good outcome (live healthy infant, uterus preservation and total blood loss of 800 ml) in a primigravida with no prior risk factors and low-risk pregnancy other than a complete placenta praevia diagnosed during anatomy scan, which subsequently was reported as clear of cervix in third trimester ultrasound scan. She was diagnosed with placenta abruption and pre-eclampsia post-partum. Most cases of PA cannot be predicted or prevented. However, in some cases, close monitoring and timely decision-making can prevent adverse maternal and foetal outcomes.

Incidence, risk factors, and clinical outcomes of placental abruption in a tertiary hospital in Hong Kong: a retrospective case-control study

“…16 of our patients with placental abruption were found to have a Couvelaire uterus intraoperatively (Figure 2), which occurs when a ruptured decidual spiral artery causing bleedings into the decidua basalis and the myometrium during a severe placental abruption. As blood permeates into the uterine serous layer, a blue-violet ecchymosis occurs 25 . The Couvelaire uterus is atonic and very prone to postpartum haemorrhage and thus aggressive and timely management of atony may prevent further worsening of conditions such as disseminated intravascular coagulation and exsanguination.…”

The main features of placental abruption: Clinical presentation and treatment

“…In such cases, hysterectomy is often necessary due to uterine atony and resilience to standard procedures, uterine tamponade and uterine artery ligation. Due to massive hemorrhage, the loss of more than 1000 ml of blood, interruption of circulation in the umbilical vein, severe fetal asphyxia and intrauterine death may occur [20][21][22].…”

“…U takvim slučajevima, često je neophodna histerektomija zbog atonije i refraktornosti na standardne procedure, tamponade uterusa i podvezivanje ilijačnih arterija. Zbog masivne hemoragije, gubitka više od 1000 ml krvi, i prekida cirkulacije u veni umbilikalis, može da nastupi teška asfiksija ploda i intrauterina smrt [20][21][22].…”

Report of a Complicated Case of Couvelaire Uterus

“…CU manifests when a ruptured decidual spiral artery causes hemorrhage and bleeds into the decidua basalis and myometrium, followed by blood penetration into the uterine serous layer causing a blue-violet ecchymosis [ 3 ]. A hysterectomy may be the only way as a life-saving measure if hemostasis cannot be achieved adequately in view of disseminated intravascular coagulopathy.…”