Secondary life-threatening postpartum hemorrhage – Case report

A 35 year old primigravida had delivered a healthy live born infant on term. Her medical and surgery history was unremarkable. 14 days after the delivery she started feeling unwell and having dizziness. 4 days later she started feeling heavy abdominal pain and pre shocked. There was no abnormal vaginal bleeding. She was admitted to the emergency department at our hospital. A abdominal ultrasound scan was performed that revealed a lot of free fluid in the abdomen and she underwent a diagnostic laparoscopy. We found 2,5 l of fresh and partially clotted blood in the abdomen. The inspection oft he abdominal cavity showed intact gastrointestinal organs. The uterus, the tubes were intact. In the cul-de-sac we found large adhesions and also the ovarys were covered with endometrial like tissue. The left ovary presented a ruptured endomertriosis-like cyst with diffuse hemorrage. Biospies were taken. Bleeding was stopped.

The histopathology examination of the specimen showed endometriosis with pseudodezidualized Stroma.

We suggest that this patient my have had ovarian endometriosis and under the influece of pregnancy, the endometriosis my have transformed to decidual tissue which became more vascular and led to the rupture of the cyst causing the extensive hemorrage.

Hemorrhage from decidual tissue associated with pregnancy is rare and only few cases have been discribed. Most cases of internal bleeding result from obstetric causes such as ruptured uterus or ruptured vessels.

In cases of unexplained postpartum shock with an intact uterus, cervix and vagina hemorrage resulting from this condition must be considered.