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Postpartum haemorrhage due to a laceration in the endocervical canal; three case reports
European Journal of Obstetrics & Gynecology and Reproductive Elsevier
Biology, 30 (1989) 183-185
183
EIO 00698
Postpartum haemorrhage due to a laceration in the endocervical canal; three case reports N.W.E. Department
Schuitemaker
and M.R. Mackenzie
of Gynaecology and Obstetrics, Bronwo Hospital, The Hague, The Netherlands Accepted for publication 21 June 1988
Three cases of severe postpartum haemorrhage due to a laceration in the endocervical canal at the level of the internal OS are described. The cause of the laceration differed in all cases. Whenever postpartum haemorrhage occurs the possibility of a laceration in the internal OSmust be considered. Postpartum haemorrhage; Laceration, internal OS
Mroductlon
Postpartum haemorrhage is one of the major causes of maternal morbidity. Whenever postpartum haemorrhaging occurs, the source must be localized and treated as quickly as possible. To date no reports have appeared in literature on bleeding from a laceration at the level of the internal OSin the endocervical canal. It seemed worthwhile therefore to describe three patients with severe postpartum haemorrhage due to such a laceration.
J.S., a 35-year-old patient who had previously given birth to two children, was admitted to hospital in labour in her 40th week of pregnancy. No problems had occurred during pregnancy. At the time of hospitalisation, the membranes had already ruptured and the amniotic fhtid contained meconium. Since there were no contractions, an oxytocin drip (2 IU per 6 hours) was started. The foetus was placed under intrauterine control. Within 1 hour she had progressed from 3 cm to full Correspondence: N.W.E. Schuitemaker, Department of Gynaecology and Obstetrics, Bronovo Hospital, Bronovolaan 5, 2597 AX, The Hague, The Netherlands.
0028-2243/89/$03.50
0 1989 Elsevier Science Publishers B.V. (Biomedical Division)
184
dilatation. The second stage lasted 5 min and proceeded without complications; an episiotomy was required. The baby weighed 3530 g; Apgar score 1’8, 5’9. The placenta was expelled 10 min later; 100 ml of blood were lost at that time. After delivery and examination of the placenta 0.15 mg ergometrine were administered intravenously as part of our routine procedure. The oxytocin drip was continued for another 14 hours. Two hours after delivery pronounced haemorrhaging occurred. Since contraction of the uterus was slow, the oxytocin drip was started up again. Inspection of the cervix revealed a rupture at 3 h; it was sutured. The vagina was intact. Since haemorrhaging continued, the uterine cavity was explored manually under general anaesthesia. Moreover, again the cervix and vagina were inspected carefully. No explanation for the loss of blood could be found. An injection of prostaglandin F,, [l] into the myometrium did not help. Consumption coagtdopathy developed. The fibrinogen concentration was 0.7 g/l. Fresh whole blood transfusions were administered. An hysterectomy was performed. Subsequent inspection of the uterus revealed a severe laceration in the internal OSat 9 h which was undoubtedly the source of the bleeding. In total the patient received 34 units of blood. Recovery was satisfactory. case II H.S., a 25-year-old primigravida, was hospital&d in labour in her 40th week of pregnancy. The pregnancy had been uneventful. The first stage took 13 hours. The second stage lasted 39 min; an episiotomy was required. During delivery 3 IU oxytocin were injected intramuscularly as part of our routine procedure. The baby weighed 3470 g; Apgar score 1’9, 3’10. After delivery of the infant there was heavy blood loss (1300 ml). Since, according to the Sign of Kiistner, the placenta was still attached to the uterus it was decided that the placenta should be removed manually under general anaesthesia. The unterine cavity was then explored and found to be intact. A routine injection of 0.15 mg ergometrine was given intravenously. In view of the continuing haemorrhage an oxytocin drip was started. Subsequently the cervix was inspected and found to be intact. In the vagina, however, there was a tear that extended high up into the right for-nix. This laceration and the episiotomy were sutured. To compensate for the blood loss a plasma expander and packed cells were administered. Haemorrhaging continued. The fibrinogen level was 2.2 g/l. The patient was re-examined under general anaesthesia. Inspection of the endocervical canal revealed a superficial laceration at 6 h. When this laceration was sutured, bleeding stopped. Total blood loss was 4.5 litre. Recovery was uneventful. case III E.L., a 27-year-old primigravida, underwent amnioscopy when she was 41 4/7 weeks pregnant. After the procedure marked bleeding occurred. Vaginal inspection revealed dark blood coming from the external OS. The tone of the uterus was normal; foetal heart rate remained within the normal range. The membranes were ruptured in order to stop the haemorrhage. Bleeding decreased considerably but not entirely. As a result it was decided that a Caesarian section should be carried out.
185
Inspection of the uterus after birth of the child (weight 3720 g; Apgar score 1’7, 5’10) revealed two bleeding veins at 6 h in the internal OS that had probably been damaged during the amnioscopic procedure. After these veins were sutured haemorrhaging stopped. The postoperative course was without complications. Discussion A laceration in the endocervical canal at the level of the internal OS can develop in various ways, In our first case the laceration is probably attributable to rapid dilatation. In the second case the cause of the laceration is unknown, while in the third it was iatrogenic in origin. These case histories illustrate, however, that when postpartum haemorrhaging occurs, the possibility of a laceration in the internal OS must also be considered. Acknowledgements The authors wish to thank Professor J. Bennebroek Gravenhorst, M.D. (Department of Gynaecology and Obstetrics, Academic Hospital, Leiden, the Netherlands) for his advice. Reference 1 Takagi S, Yoshida T, Togo Y, Tochigi H, Abe M, Sakata H, Fujii TK, Talcahashi H, Tochigi B. The effects of intramyometrial injection of prostaglandin F2., on severe postpartum haemorrhage. Prostaglandins. Vo1.12, No.4, 1976:565-579.
Biology, 30 (1989) 183-185
183
EIO 00698
Postpartum haemorrhage due to a laceration in the endocervical canal; three case reports N.W.E. Department
Schuitemaker
and M.R. Mackenzie
of Gynaecology and Obstetrics, Bronwo Hospital, The Hague, The Netherlands Accepted for publication 21 June 1988
Three cases of severe postpartum haemorrhage due to a laceration in the endocervical canal at the level of the internal OS are described. The cause of the laceration differed in all cases. Whenever postpartum haemorrhage occurs the possibility of a laceration in the internal OSmust be considered. Postpartum haemorrhage; Laceration, internal OS
Mroductlon
Postpartum haemorrhage is one of the major causes of maternal morbidity. Whenever postpartum haemorrhaging occurs, the source must be localized and treated as quickly as possible. To date no reports have appeared in literature on bleeding from a laceration at the level of the internal OSin the endocervical canal. It seemed worthwhile therefore to describe three patients with severe postpartum haemorrhage due to such a laceration.
J.S., a 35-year-old patient who had previously given birth to two children, was admitted to hospital in labour in her 40th week of pregnancy. No problems had occurred during pregnancy. At the time of hospitalisation, the membranes had already ruptured and the amniotic fhtid contained meconium. Since there were no contractions, an oxytocin drip (2 IU per 6 hours) was started. The foetus was placed under intrauterine control. Within 1 hour she had progressed from 3 cm to full Correspondence: N.W.E. Schuitemaker, Department of Gynaecology and Obstetrics, Bronovo Hospital, Bronovolaan 5, 2597 AX, The Hague, The Netherlands.
0028-2243/89/$03.50
0 1989 Elsevier Science Publishers B.V. (Biomedical Division)
184
dilatation. The second stage lasted 5 min and proceeded without complications; an episiotomy was required. The baby weighed 3530 g; Apgar score 1’8, 5’9. The placenta was expelled 10 min later; 100 ml of blood were lost at that time. After delivery and examination of the placenta 0.15 mg ergometrine were administered intravenously as part of our routine procedure. The oxytocin drip was continued for another 14 hours. Two hours after delivery pronounced haemorrhaging occurred. Since contraction of the uterus was slow, the oxytocin drip was started up again. Inspection of the cervix revealed a rupture at 3 h; it was sutured. The vagina was intact. Since haemorrhaging continued, the uterine cavity was explored manually under general anaesthesia. Moreover, again the cervix and vagina were inspected carefully. No explanation for the loss of blood could be found. An injection of prostaglandin F,, [l] into the myometrium did not help. Consumption coagtdopathy developed. The fibrinogen concentration was 0.7 g/l. Fresh whole blood transfusions were administered. An hysterectomy was performed. Subsequent inspection of the uterus revealed a severe laceration in the internal OSat 9 h which was undoubtedly the source of the bleeding. In total the patient received 34 units of blood. Recovery was satisfactory. case II H.S., a 25-year-old primigravida, was hospital&d in labour in her 40th week of pregnancy. The pregnancy had been uneventful. The first stage took 13 hours. The second stage lasted 39 min; an episiotomy was required. During delivery 3 IU oxytocin were injected intramuscularly as part of our routine procedure. The baby weighed 3470 g; Apgar score 1’9, 3’10. After delivery of the infant there was heavy blood loss (1300 ml). Since, according to the Sign of Kiistner, the placenta was still attached to the uterus it was decided that the placenta should be removed manually under general anaesthesia. The unterine cavity was then explored and found to be intact. A routine injection of 0.15 mg ergometrine was given intravenously. In view of the continuing haemorrhage an oxytocin drip was started. Subsequently the cervix was inspected and found to be intact. In the vagina, however, there was a tear that extended high up into the right for-nix. This laceration and the episiotomy were sutured. To compensate for the blood loss a plasma expander and packed cells were administered. Haemorrhaging continued. The fibrinogen level was 2.2 g/l. The patient was re-examined under general anaesthesia. Inspection of the endocervical canal revealed a superficial laceration at 6 h. When this laceration was sutured, bleeding stopped. Total blood loss was 4.5 litre. Recovery was uneventful. case III E.L., a 27-year-old primigravida, underwent amnioscopy when she was 41 4/7 weeks pregnant. After the procedure marked bleeding occurred. Vaginal inspection revealed dark blood coming from the external OS. The tone of the uterus was normal; foetal heart rate remained within the normal range. The membranes were ruptured in order to stop the haemorrhage. Bleeding decreased considerably but not entirely. As a result it was decided that a Caesarian section should be carried out.
185
Inspection of the uterus after birth of the child (weight 3720 g; Apgar score 1’7, 5’10) revealed two bleeding veins at 6 h in the internal OS that had probably been damaged during the amnioscopic procedure. After these veins were sutured haemorrhaging stopped. The postoperative course was without complications. Discussion A laceration in the endocervical canal at the level of the internal OS can develop in various ways, In our first case the laceration is probably attributable to rapid dilatation. In the second case the cause of the laceration is unknown, while in the third it was iatrogenic in origin. These case histories illustrate, however, that when postpartum haemorrhaging occurs, the possibility of a laceration in the internal OS must also be considered. Acknowledgements The authors wish to thank Professor J. Bennebroek Gravenhorst, M.D. (Department of Gynaecology and Obstetrics, Academic Hospital, Leiden, the Netherlands) for his advice. Reference 1 Takagi S, Yoshida T, Togo Y, Tochigi H, Abe M, Sakata H, Fujii TK, Talcahashi H, Tochigi B. The effects of intramyometrial injection of prostaglandin F2., on severe postpartum haemorrhage. Prostaglandins. Vo1.12, No.4, 1976:565-579.