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Couvelaire Uterus Cell Count, 23.7Xl03 (6.5 to 11.0XI03); Hemoglobin, 11.7 Mg/Dl (12.7 to 14.7 JAMES L

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Couvelaire Uterus Cell Count, 23.7Xl03 (6.5 to 11.0XI03); Hemoglobin, 11.7 Mg/Dl (12.7 to 14.7 JAMES L IUFD workup, as well as laboratory stud­ + Case repotts continued ies for preeclampsia, was ordered. Laboratory studies showed the fol­ lowing values (reference laboratory nor­ mal range in parentheses): white blood Couvelaire uterus cell count, 23.7xl03 (6.5 to 11.0XI03); hemoglobin, 11.7 mg/dL (12.7 to 14.7 JAMES L. HUBBARD, DO mg/dL); hematocrit, 32.2% (37.9% to STEPHAN B. HOSMER, DO 43.9%); and platelets, only 55 XI03 (140 to 450 X 103). The prothrombin time was 15.7 seconds (11 to 13 seconds); partial Uteroplacental apoplexy is a rare but nonfatal complication of severe forms of pla­ tlu'omboplastin time, 30.8 seconds (20 to cental abruption. It occurs when vascular damage within the placenta causes 30 seconds); fibrinogen, 40 mg/dL (170 hemorrhaging that progresses to and infiltrates the wall of the uterus. It is a syn­ to 410 mg/dL); and fibrin split products, drome that can only be diagnosed by direct visualization or biopsy (or both). For 640 mg/dL «10 mg/dL). Results of liver this reason, its occurrence is perhaps underreported and underestimated in the lit­ function tests were within normal limits erature. The subject of this report is a 24-year-old pregnant woman who had a except for the lactate dehydrogenase level placental abruption and in whom classic uteroplacental apoplexy was diagnosed of 3428 UIL (313 to 618 UIL) and the at the time of her cesarean section. uric acid level of 8.2 mg/dL (2.5 to 6.2 (Key words: Couvelaire uterus, uteroplacental apoplexy, placental abruption, mg/dL). Urine dipstick reaction to protein decidual basalis, tubal serosa) was 4+ (negative). The diagnosis based on these labora­ tory results was preeclampsia; hemolysis, ouvelaire uterus is a complication previously, at which time her only prob­ elevated liver studies, low platelets Cseen in some severe forms of abrup­ lem was an elevated I-hour glucose tol­ (HELLP) syndrome; and disseminated tio placentae. The incidence of Couvelaire erance test (161 mg/dL). The patient'S intravascular coagulation (DIC). Intra­ uterus is diliicult to determine. Some esti­ past medical, past surgical, social, and venous infusion of prophylactic magne­ mate its occurrence as high as 20%1; gynecologic histories were otherwise sium was started, and blood products others estimate it as low as 5%.2 unremarkable. were ordered. A second series of At physical examination, the patient's preeclampsia laboratory tests were also Report of case blood pressure was labile, with systolic ordered. ~ 1 A 24-year-old healthy Hispanic woman, pressure ranging from 120 mm Hg to The patient was given 6 units of ( gravida 1 para 0 with an estimated date 150 mm Hg and diastolic pressure rang­ platelets and 4 units of fresh/frozen plas­ of confinement of December 26, arrived ing from 80 mm Hg to 110 mm Hg. She ma. Little to no cervical changes occurred 1 at the labor and delivery department at was afebrile. Her heart rate was regular tllfoughout the course of the day; how­ midnight on December 3 (36 weeks and with no murmurs appreciated; lungs were ever, her laboratory test values wors­ 5 days gestational age), complaining of clear to auscultation bilaterally; her ened. By 5 o'clock that night, the decision abdominal pain starting earlier that abdomen was soft and nontender with was made to take tlle patient to the oper­ evening and no fetal movement for 2 positive bowel sounds; and fundal height ating room for a cesarean section. days. The patient denied any vaginal was 36 cm. Extremities showed only + 1 A primary low transverse cesarean bleeding or discharge, spontaneous rup­ pitting edema but brisk deep-tendon section was performed via a Pfanninstiel ture of membranes, headaches, blurred reflexes at + 3/4. No clonus was noted. skin incision. As the peritoneum was vision, chills, or night sweats. The patient Vaginal examination revealed the cervix opened, the uterus was found to be dark had been seen regularly at the clinic for to be 2 cm dilated, 25% effaced with purple, ecchymotic, and indurated. The prenatal care. Her last visit was 1 week the fetus in the vertex position and at diagnosis of Couvelaire uterus was made. zero station. An abdominal ultrasound The uterus was transected, and a nonvi­ examination showed a nonviable fetus able male infant was delivered. The esti­ in a vertex position. The amniotic fluid mated blood loss was 2000 mL. A com­ From the University of Medicine and Dentistry of New Jersey-School of Osteopathic Medicine, Stratford, index was zero, and no gross abnormal­ plete abruption-of the placenta was NJ. ities were seen. It was decided at that noted. Dr Hubbard is a resident in obstetrics and gyne­ cology, and Dr Hosmer is obstetrics/gynecology res­ time to admit the patient to the labor The patient tolerated tlle procedure idency program director and attending physician at and delivery suite with a diagnosis of well and received 6 units of packed red Kennedy Memorial Hospital, Stratford, NJ. Correspondence to James L. Hubbard, DO, Uni­ intrauterine fetal demise (IUFD). An infu­ blood cells postoperatively. The infusion versity of Medicine and Dentistry of New sion of intravenous oxytocin was started of prophylactic magnesium was contin­ Jersey-School of Osteopathic Medicine, 18 E Laurel Rd, Stratford, NJ 08084-1504. for induction of labor, and a routine ued for 24 more hours. Her DIC .. - 536 • ]AOA • Vol 97 • No 9 • September 1997 Hubbard and Hosmer· Case reports resolved, and her postoperative course Comment 5. Pratola D, Wilkin P: The placenta, umbilical was uncomplicated. She was discharged cord, and amniotic sac, in Gompel C, Silver­ Despite the unusual appearance of Cou­ berg SG (eds) : Pathology in Gynecology and to home 5 days postoperatively with fo l­ velaire uterus, no treatment is required. Obstetrics, ed 3. Philadelphia, Pa, JB lippin­ low-up at the clinic. The condition often resolves sponta­ cott Co, 1985, P 498. neously.? These myometrial bleeds sel­ Discussion 6. Pernoll ML: Third trimester hemorrhage, in dom interfere with uterine contractions Pernoll ML (ed): Current Obstetrical and Gyne­ The phenomenon of uteroplacental enough to cause significant postpartum cological Diagnosis and Treatment, ed 7. Nor­ apoplexy, first described by Couvelaire hemorrhage. The uterus usually responds walk, Conn, Appleton & Lange, 1991 , P 392. early in this century, is now often referred well to intravenous oxytocin. It is impor­ 7. Beckmann CR, Ling FW, Barzansky BM, et , ... to as Couvelaire uterus.l Surprisingly, a tant to remember that Couvelaire uterus al (eds): Obstetrical hemorrhage, in Obstetrics literature search on the topic revealed should not be used as an indication for and Gynecology, ed 2. 1995. Baltimore, Md , no studies on the subject and only a few hysterectomy. Williams & Wilkins, 1995, p 122. " mentions in studies on abruptio placen­ tae.2,3 Searches in the textbooks also References revealed little. 1. Cunningham FG, MacDonald PC, Gant NF, Couvelaire uterus is a complication et al (eds): Obstetrical hemorrhage, in William's of more severe forms of placental abrup­ Obstetrics, ed 20. Stamford, Conn, Appleton & Lange, 1997, pp 751-752. tion. In early stages of hemorrhage result­ ing from pathologic vascular damage 2. AI-Sibai MH , Rahman J, Butalack F, Rah­ within the placenta itself, blood seeps man MS, et al : Emergency hysterectomy in into the decidua basalis, ultimately caus­ obstetrics. A review of 117 cases. Aust NZ J Obstet Gyneco/1987;27(3):180-184. ing a separation of the placenta.s The hemorrhage often progresses, and the 3. Monteiro AA, Inocencio AC , and Jorge CS: walls of the uterus, usually in the lateral Placental abruption with disseminated intravas­ portions, may become infiltrated with cular coagulopothy in the second trimester of pregnancy with fetal survival. Br J Obstet blood.4 Occasionally, such effusions of ....... Gynaeco/1987;94(8):811-812 . blood extend beneath the tubal serosa, into the connective tissue of the broad lig­ 4. Pauerstein CJ: Abnormalities and diseases of aments, and into the substance of the the placenta and apendages, in Novak ER , Woodroff JD (eds): Novak's Gynecologic and ovaries, as well as free in the peritoneal Obstetric Pathology, ed 8. Philadelphia, Pa, WB cavity.1 The uterus assumes the appear­ Saunders Co, 1979, p 622. ance of a purplish or copper-colored ecchymotic, indurated organ that some­ times loses its contractile power.6 Histologically, blood is found between muscle bundles, in perivascular tissue, and in the subserosa. The decid­ ual spiral arterioles may show acute atheromatous processes, with foamy macrophages present.4 It is impossible to know the precise incidence of Couvelaire uterus because it can only be demonstrated conclusively by laparotomy, but conservative estimates t put the number at 5% or fewer of all cases of abruptio placentae.4 Hu bbard and Hosmer • Case reporrs JAOA • Vol 97 • No 9 • September 1997 · 537 .
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