July 2008.indd ABSTRACT Uterine cavity occlusion following caesarean section for central placenta praevia culminating in haematometra and thereby amenorrhoea is one of the rarest long term complications of lower segment caesarean section. We report a case of 28 year old primigravida with Grade 4 placenta praevia who underwent elective caesarean section at 35 weeks gestation. She presented at Nizwa Hospital, Sultanate of Oman, after 7 months with cyclical lower abdominal pain and amenorrhoea. She was treated by hystero- scopic adhesiolysis and an in utero Foley’s catheter. She had complete resolution of her condition within 2 months and resumption of menstrual cycles. Multiple haemostatic sutures at caesarean section for placenta praevia can be an causative factor for such a com- plication along with other risk factors like multiple caesarean sections, chorioamniotis etc. Recognition of these factors, meticulous surgical technique and appropriate post operative care can effectively prevent it. Keywords: Placenta previa; Adhesions, intrauterine; Occlusion; Genital tract; Case report, Oman. Occlusion of Upper Genital Tract Following Lower Segment Caesarean Section for Placenta Praevia *Mini B Poothavelil, Ilham Hamdi, Geeta Zunjurwad SULTAN QABOOS UNIVERSITY MEDICAL JOURNAL JULY 2008, VOLUME 8, ISSUE 2, P. 215-218 SULTAN QABOOS UNIVERSITY© SUBMITTED - 20TH JANUARY 2008 ACCEPTED - 15TH APRIL 2008 Department of Obstetrics and Gynaecology, Nizwa Hospital , Nizwa, Sultanate of Oman *To whom correspondence should be addressed. Email: drminibenny@hotmail.com ةِ عَ طْ القِ رِيَّةُ يْصَ قَ عملية بعد التناسلي اجلهاز من العلوي اجلزء إنسداد لِيَّة فْ السُّ زينجوارد جيتا حمدي، إلهام بوثافيليل، بي ميني وانقطاع الرحم داخل دموي جتمع إلى مركزية والذي يؤدي منزاحة عملية قيصرية ملشيمة إجراء عن الناجت الرحمي التجويف امللخص: يعتبر انسداد ــيمة بها مش 28 عاما األولى عمرها للمرة حامل امرأة حالة هنا ــتعرض نس . ــفلية الس القطعة قيصرية تلي التي املضاعفات املديدة من أندر احليض سلطنة عمان في نزوى مستشفى املريضة راجعت . احلمل من اخلامس والثالثني األسبوع في قيصرية اختيارية لها أجريت الرابعة الدرجة من منزاحة م تَنْظيرُ الرَّحِ طريق عن بإزالتها الرحم داخل االلتصاقات من عوجلت . ــهر أش ــبعة س ملدة انقطاع احليض مع البطن ــفل أس دورية آالم من وهي تعاني اجلراحية اخلياطة تكون أن املمكن من بانتظام. ــهرية الدورة الش إليها وعادت ــهرين ش خالل املريضة ــفيت .ش الرحم داخل بولية ــطرة مع تثبيت قس االختطار عوامل إلى باإلضافة ، املضاعفات لهذه املسببة العوامل أحد ــيمة املنزاحة للمش القيصرية العملية إجراء أثناء إليقاف النزيف ــتعملة املس الدقيق والرعاية اجلراحي اإلجراء املسببة مع العوامل على هذه التعرف إن . أخره إلى لَى. السَّ و َشيماءِ امل والتهاب القيصرية العمليات تعدد األخرى مثل املضاعفات. هذه متنع ميكن أن العملية املالئمة بعد الصحية عمان. ، حالة تقرير ، التناسلي ، اجلهاز إنسداد ، الرحم جتويف داخل ، التصاقات ، املنزاحة الكلمات: املشيمة مفتاح WHEN THE PLACENTA IS IMPLANTED partially or completely over the relative-ly noncontractile lower uterine segment, it is termed placenta praevia.1 In an attempt to achieve haemostasis during caesarean section, a number of in- novative techniques have been tried apart from the usual method of oversewing the open bleeding sinuses on the lower segment.2, 3, 4 None of the methods have been known to cause postoperative intrauterine adhe- sions, haematometra or amenorrhea. In our unique case, there was absence of any other risk factors like previous caesarean section, placenta accreta or per- creta, multiparity, post partum endometritis, intra uterine fibroids or polyps. C A S E R E P O R T A 28 year old primigravida woman presented at Nizwa Hospital, Oman, in November 2005 at 32 weeks ges- tation with Type 4 placenta praevia. She was admit- ted for observation and underwent an elective lower segment caeserean section at 35+ week’s gestation after attaining satisfactory fetal lung maturity. Intra- operative findings included a lower segment not well formed with varicosities, the placenta being anterola- C A S E R E P O R T M I N I B P O O T H AV E L I L , I L H A M H A M D I A N D G E E TA Z U N J U R WA D 216 teral and extending posteriorly covering the cervical internal os. Multiple haemostatic sutures were made with polyglactin 910 number 0 in the posterior uter- ine wall in view of the multiple bleeding vessels from the placental bed. A small vertical extension around 1.5cm at the right side of the anterior lower segment was sutured with polyglactin 910 number 0. The inter- nal os was digitally checked. The postoperative period was uneventful and the patient was discharged on the third postoperative day. The patient returned after 7 months to Nizwa Hos- pital Outpatient Department with complaints of cycli- cal lower abdominal pain and amenorrhoea. Detailed ultrasonography revealed a distended uterine cavity with hypoechoic shadows resembling haematometra with biloculated endometrium in between [Figure 1]. The patient underwent cervical dilatation and di- agnostic hysteroscopy with adhesiolysis. Intraopera- tively, the cervix was pinpoint dilated gradually with Hegars dilator until no. 9 under ultrasound guidance. During the process, flimsy adhesions around the in- ternal os area were broken followed by drainage of the haematometra. Hysteroscopy revealed flimsy ad- hesions around the internal os and the lower uterine cavity, the cavity being filled with dark altered blood [Figure 2]. Foleys catheter no.16 was introduced into the uter- ine cavity and the bulb dilated till 10cc to facilitate Figure 1: Ultrasonography revealing haematometra and intrauterine adhesions Figure 2: Hysteroscopy under ultrasonographic guidance helped in diagnosis and appropriate management Figure 3: Post procedure: near complete drainage of the haematometra O C C L U S I O N O F U P P E R G E N I TA L TR A C T F O L L O W I N G L O W E R S E G M E N T C A E S A R E A N S E C T I O N F O R P L A C E N TA P R A E V I A 217 the drainage of the intrauterine blood, the procedure being uneventful [Figure 3]. The patient was admin- istered intravenous antibiotics and discharged on the third postoperative day after removal of the intrauter- ine Foley’s catheter. After 2 weeks, she resumed her menstrual cycle with a normal flow of 5 days with minimal dysmenorrhoea. A follow up ultrasonography revealed complete resolution of the haematometra and no evidence of any intrauterine adhesions [Figure 4]. The patient was followed up for 10 months after the procedure and found to have continued regular menstrual cycle with normal flow. Ultrasonography confirmed no persist- ent cervical stenosis. D I S C U S S I O N Intrauterine adhesions following lower segment cae- sarean section are one of the rare complications with few case reports available in the literature. Our patient was a primigravida with no previous history of uterine surgery, no other antepartum events suggesting chorioamnionitis, no postpartum evidence suggesting endometritis-like fever, uterine tenderness, offensive lochia or absence of lochia. A normal amount of lochia was observed in the postpartum period. She was asymptomatic for approximately 5 to 6 months thereafter. Our investigations of the patient led to the diagnosis of intrauterine synchiae and haematometra as result of the multiple hemostatic sutures that were made in the raw surface of the lower segment in an at- tempt for quick haemostasis. These adhesions were flimsy and could be easily broken during slow gradual dilatation, followed by hysteroscopy. Insertion of a Foley’s catheter served two purposes: first, easy and complete drainage of the hematometra and second, preventing apposition of the uterine walls and allowing the regeneration of the endometrium. Lower segment caesarean section for placenta preavia will eventually lead to bleeding from open sinuses of the relatively noncontractile lower seg- ment that can be catastrophically heavy. Such events can be severe in the presence of a morbidly adherent placenta or placenta accreta or percreta. After the de- livery of the placenta, the bleeding vessels are over- sewn by haemostatic sutures usually polyglactin 910 or daxon. When we are confronted with a patient experi- encing placenta praevia with massive haemorrhage in cesarean delivery, haemostasis is first attempted using uterotonic drugs, uterine massage, and intrauterine packing. However, if these manoeuvres fail, a number of surgical techniques to control severe bleeding at ce- sarean delivery have been proposed, such as uterine artery ligation, hypogastric artery ligation, and uter- ine compression suturing.5 Perhaps these procedures alone or in combination can successfully control the haemorrhage. Every obstetrician must be familiar with these simple methods in order to avoid having to per- form a hysterectomy and thus preserving the repro- ductive capability, as well as diminishing the operative morbidity. There are a few other techniques such as the isth- micocervical apposition, an intrauterine balloon or a B-Lynch uterine brace suture.6 Women with multiple previous cesarean deliveries risk the development of uterine synechiae and ventral fixation of the uterus to the abdominal wall.7 Hysteroscopic treatment of in- Figure 4: Postoperative follow-up ultrasound reveals complete resolution of the haematometra and a thin endometrial echo trauterine adhesions is a safe and effective treatment for the restoration of normal menstruation.8 C O N C L U S I O N Although rare, the occurrence of intrauterine adhe- sions and haematometra/pyometra can be a long- term sequel of caesarean section.9 The associated risks factors include placenta praevia, placenta accreta, percreta, chorioamonitis with prolonged rupture of membranes, multiple caesarean sections or a scarred uterus, postpartum endometritis and iatrogenic oc- clusion of the posterior uterine wall. Manual removal of the placenta can contribute significantly to these complications.10 The use of multiple sutures through the uterus is effective to control postpartum hemor- rhage, but may lead to uterine synechiae. R E F E R E N C E S 1. Badawy SZ, Orbuch L, Khurana KK. Secondary amen- orrhea with severe intrauterine adhesions and chronic uterine torsion after Cesarean section in a teenage girl. J Pediatr Adolesc Gynecol 1998; 11:93-96. 2. Ferrazzani S, Guariglia L, Triunfo S, Caforio L, Caruso A. Successful treatment of post-cesarean hemorrhage related to placenta praevia using an intrauterine bal- loon. Two case reports. Fetal Diagn Ther 2006; 21:277- 280. 3. Li YT, Yin CS, Chen FM, Chao TC. A useful technique for the control of severe cesarean hemorrhage: report of three cases. Chang Gung Med J 2002; 25:548-552. 4. Das C, Mukherjee P. Isthmico cervical apposition su- ture-an effective method to control PPH during cae- sarean section for placenta praevia. J Obstet Gynaecol India 2005; 55:322-324. 5. Wu HH, Yeh GP. Uterine cavity synechiae after hemo- static square suturing technique. Obstet Gynecol 2005; 105:1176-1178. 6. Muge H, Nese G, Adil O. B-Lynch uterine compres- sion suture for postpartum haemorrhage due to pla- centa praevia accrete, Aust N Z J Obstet Gynaecol 2005; 45:93-95. 7. Mathelier AC. Unusual late complications after two previous cesarean deliveries: a case report. Int J Fertil Womens Med 2003; 48:70-73. 8. Pabuccu R, Atay V, Orhon E, Urman B, Ergun A. Hys- teroscopic treatment of intrauterine adhesions. Fertil Steril 1997; 68:1141-1143. 9. Ochoa M, Allaire AD, Stitely ML. Pyometra after hemo- static square suture technique. Obstet Gynecol 2002; 99:506-509. 10. Golan A, Raziel A, Pansky M, Bukovsky I. Manual re- moval of the placenta - its role in intrauterine adhesion formation. Int J Fertil Menopausal Stud 1996; 41:450- 451. M I N I B P O O T H AV E L I L , I L H A M H A M D I A N D G E E TA Z U N J U R WA D 218