Nonunion of Uterine Incision: A Rare Cause of Secondary Postpartum Haemorrhage: A Report of 2 Cases

Nanda, Smiti; Singhal, Savita Rani; Sharma, Damyanti; Sood, Madhulika; Singhal, Sonal

doi:10.1111/j.1479-828x.1997.tb02466.x

Cited by 10 publications

(7 citation statements)

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“…More importantly, most of the discussion about the hypotheses of CS niche formation in past seems to be focussed on deficient alignment (apposition) of myometrial tissue, but there has been hardly any attention paid to ischemia of tissues or preservation of vascularity of the myometrial edges sutured together. This is particularly surprising given that a number of published case reports of uterine scar dehiscence in the puerperium with massive late PPH predominantly show ischemic necrosis of the uterine scar (hence devascularization) in most cases [ 15 - 19 ]. This also raises a possibility whether lesser degrees of scar dehiscence (smaller complete or large incomplete defects particularly following repeat cesareans) could be the cause of very rare cases of late (4 - 6 weeks) heavy PPH, such cases going undiagnosed or unreported.…”

Section: Ischemia and Mal-apposition Hypothesis For Cs Niche (Techniqmentioning

confidence: 99%

Etiology of Cesarean Uterine Scar Defect (Niche): Detailed Critical Analysis of Hypotheses and Prevention Strategies and Peritoneal Closure Debate

Sholapurkar

2018

J Clin Med Res

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There is an increasing incidence of cesarean scar (CS) defect/niche and its sequelae, probably not entirely explained by better diagnosis or rising cesarean rate. Discussion of possible etiological factors has received scant attention but would be important to formulate preventive strategies. Meaningful informative studies on long-term sequelae of cesarean section are very difficult and none are available for causation of CS defect. Hence, it is crucial to identify key areas in etiology of CS defect for focused research. This practical review proposes an “ischemia and mal-apposition hypothesis for CS niche”, stating that the surgical technique of uterine incision closure is the most important determinant of CS defect formation. Other factors such as cervical location incision, adhesion formation and patient specific factors seem far less important in etiology. Rather than the headline theme of “single versus double-layer closure of uterus”, the finer details of surgical technique which achieve good apposition without inducing tissue ischemia seem more important. Different techniques are discussed and it is proposed that continuous, non-locking absorbable sutures in two layers, without including much of decidua and without undue tight (constricting/devasculaizing) pulling of sutures are likely to result in good healing of uterine scar. Single-layer technique may be best reserved for thin myometrial edges especially during repeat cesareans. Adhesions between uterine isthmus and bladder/abdominal wall seem common associations but not causative for CS niche. It would be desirable to prove these surgical principles by good quality prospective randomized “quantitative” studies but the wait may be very long and this should not hinder the adoption of good surgical principles. Science is much cognitive and not just empirical. To consider a related example, the current recommendation of non-suturing of peritoneal layers during cesarean is mistakenly based on short-term irrelevant surrogate outcomes like analgesic requirements and time-saving, many of which have been already disproven. Evidence is presented recommending simple quick techniques of peritoneal closure to prevent adhesions. More analytical debate in surgical techniques is needed to inspire engaged, critical and insightful practitioners rather than unquestioning dependence on weak evidence/guidance.

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Section: Ischemia and Mal-apposition Hypothesis For Cs Niche (Techniqmentioning

confidence: 99%

Etiology of Cesarean Uterine Scar Defect (Niche): Detailed Critical Analysis of Hypotheses and Prevention Strategies and Peritoneal Closure Debate

Sholapurkar

2018

J Clin Med Res

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“…1,[3][4][5][6] Secondary PPH can be caused by numerous other etiologies the significant among which are , primary subinvolution of placental bed, endometritis, pseudoanuerysm of the uterine artery, non union of uterine incision etc. [6][7][8][9] Other rare causes of PPH have also been reported. 10,11 While there is plenty of data available in world literature regarding primary PPH, secondary PPH has not been studied with similar zeal.…”

Section: Introductionmentioning

confidence: 99%

Secondary postpartum haemorrhage in a tertiary care hospital of North India: a retrospective analysis

Nigeen

Farooq

Afzal

et al. 2017

Int J Reprod Contracept Obstet Gynecol

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Background: Postpartum haemorrhage (PPH) is a very common complication that follows delivery. It is one of the leading causes of maternal mortality both in developing and developed countries. Primary PPH has been studied a lot, but data regarding secondary PPH is sparse. Our objective was to study the clinical characteristics and outcome of patients presenting with secondary PPHMethods: A retrospective descriptive study done at Lalla Ded hospital Srinagar, a tertiary care hospital of North India, between June 2015 and December 2015.Results: Fifty patients with secondary PPH were studied out of whom 36 were delivered outside this hospital and referred. Fourteen patients who delivered in this hospital developed secondary PPH. Mean age of patients was 35±3 years. Retained products of contraception (RPOCs) was the leading cause in 36 (72%) of patients followed by endometritis in ten (20%). Mean hemoglobin concentration was 8.7±1.9grams ranging from 4.4 grams to 12.9 grams. Mean hospital stay was 6.3±1.5 days ranging from 1 day to 20 days. Curettage was done in 40 (80%) of patients including 36 having RPOC s and check curettage in four patients. Fourteen (28%) patients required blood transfusion. One patient required hysterectomy. None of the patients died.Conclusions: Secondary PPH has been studied very little. Our results show retained products of contraception as a leading cause of secondary PPH which is probably related to poor management of third stage of labour. There is crucial role of active management of third stage of labour in preventing secondary PPH. Majority of secondary PPH patients require dilatation and curettage with other supportive measures only. Surgical intervention is rarely required. Blood loss is usually mild to moderate. Prognosis is good if medical intervention is sought early.

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“…13(41%) patients needed Laparotomy and caesarean wound dehiscence was found as the cause. In cases where heavy bleeding occurs 2-3 weeks following caesarean section, either non healing of uterine incision or dehiscence of the scar following infection should be thought of 17 . All the cases were done on emergency and poor quality suture material was found to be used on Laparotomy.…”

Section: Resultmentioning

confidence: 99%

Risk Factors and Maternal Outcome of Secondary Post Partum Haemorrhage in Rangpur Medical College Hospital. - A one year study

Ferdousy¹,

Ferdousi²,

Nahaer³

et al. 2020

Bangladesh J Obstet Gynaecol

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Background: Post partum haemorrhage (PPH) is one of the most common causes ofmaternal mortality worldwide. Primary PPH (which occurs within 24 hours of delivery) hasbeen studied a lot. But data regarding secondary PPH (which occurs 24 hours after deliveryupto to 6 weeks post partum) is sparse. Our aim was to find out the risk factors and maternaloutcome of secondary PPH. Materials and Methods: A cross sectional analytic study of 32 cases admitted with secondaryPPH in Gynae and Obstetric department of Rangpur Medical College Hospital during 1 yearstudy period was carried out. Result: Frequency of secondary PPH was 0.58%. Mean age of the patient was 25.23±2.79years; 22(69%) patients were multi para; 17 (53%) patients had education up to primarylevel. Maximum patients [18 (56%)] were from low socio economic status. Mean time ofpresentation was 13.5±2.78 days after delivery; 14(44%) patients delivered vaginally and18(56%) patients delivered by caesarean section. Most of the vaginal delivery 9 (28%) wereconducted by untrained dai or other family member. Among 32 patients, 31 were referredfrom outside the Hospital. Retained bits of placenta was the leading cause (15,47%) andcaesarean wound dehiscence was the second cause (13,41%); 13 (40%) patients had feveron presentation. All were anemic with mean hemoglobin concentration 7.4±1.4gm and 24(75%) of them required blood transfusion. Four patients was in shock. Antibiotic was givento all patients. DE&C was done in 15(47%) cases and laparotomy followed by total abdominalhysterectomy was done in 12 cases and repair in 1 case. Among 15 patients who underwentsurgical evacuation there was histological evidence of placental tissue in only 6(40%) patients. Conclusion: In present study retained bits of placenta and caesarean wound dehiscenceare found as main cause of secondary postpartum hemorrhage So care should be takenduring active management of third stage of labour (AMTSL). Choosing appropriate suturematerial, maintaining personal hygine of patient and sterility of operation theate, usingappropriate antibiotic to combat microbials and last but not list improving skillness of surgeonare the key to reduce the rate of secondary PPH. Bangladesh J Obstet Gynaecol, 2018; Vol. 33(2) : 107-112

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Nonunion of Uterine Incision: A Rare Cause of Secondary Postpartum Haemorrhage: A Report of 2 Cases

Cited by 10 publications

References 0 publications

Etiology of Cesarean Uterine Scar Defect (Niche): Detailed Critical Analysis of Hypotheses and Prevention Strategies and Peritoneal Closure Debate

Etiology of Cesarean Uterine Scar Defect (Niche): Detailed Critical Analysis of Hypotheses and Prevention Strategies and Peritoneal Closure Debate

Secondary postpartum haemorrhage in a tertiary care hospital of North India: a retrospective analysis

Risk Factors and Maternal Outcome of Secondary Post Partum Haemorrhage in Rangpur Medical College Hospital. - A one year study

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