Placental Site Subinvolution Leading to Secondary Postpartum Hemorrhage - A Rare Case

Abstract

G4P1L1A2 with polyhydramnios underwent Elective LSCS. Intraoperatively dense adhesions noted. On pod-8, the patient presented with increased bleeding p/v. On examination, a uterus of 24 weeks’ size, intermittently relaxing. Her coagulation profile was deranged [PT-45.3, APTT-93, INR-4.04]. Portable ultrasound suggested a probability of retained products of conception.

The patient was stabilized with blood and blood products. USG-guided suction and evacuation were attempted, but the procedure was abandoned as the uterine cavity enlarged and no products obtained.

Emergency Subtotal Hysterectomy with B/L internal iliac artery ligation performed. The patient withstood the procedure well. Post-operatively she was managed with blood and blood products. Histopathology report-grossly postpartum uterus measuring 15x15x5 cm without cervix and adnexa. The endometrial cavity appears shaggy brown and the right posterior aspect shows adherent dark brown hemorrhagic tissue measuring 1.5 cm in thickness adherent to the myometrium. Microscopically, the endometrium has large ectatic blood vessels which display scattered trophoblasts within the wall. Many of these vessels show a lack of endothelial lining.

Some of the vessels show fibrin thrombi; chorionic villi are not seen. Consistent with placental site vessel sub involution. There is no evidence of retained products of conception. Risk factors in this patient are previous LSCS with dense adhesions, and inflammation affecting blood vessels. Conservative management like uterine artery embolization can be done where facilities are available.

Placental site subinvolution is a rare form of secondary PPH that has always been underdiagnosed. Incidence of postpartum haemorrhage from subinvolution is most common in the second week postpartum. Diagnosis confirmed by histopathology.