A 37-year-old, Gravida 4 Para 3 living 3 at 19 weeks' gestation age with three previous caesarean scars, a known patient with chronic hypertension. She presented at our facility with complain of vaginal bleeding for 4 h prior to arrival, which was characterized by minimal bleeding with clots, she changed two pads. This was accompanied by lower abdominal pain that was intermittent and cramping in nature. It was non progressive with no specific periodicity. She had no preceding vaginal discharge or leakage. She did not report of awareness of heartbeat, loss of consciousness, or dizziness. On review of other system was uneventful. She has no known drug or food allergy.
She booked at 12 weeks and was prescribed methyldopa 500 mg thrice daily for her chronic hypertension, which she has been using with good compliance and her blood pressure was well controlled. The pregnancy was uneventful until the time of admission. She is a non-smoker and reports no alcohol use during pregnancy.
On examination: she was ill looking, alert, afebrile, not pale, not dyspnoeic with no lower limb oedema. Her vitals on admission were a blood pressure reading of 139/86 mmHg, a pulse rate of 86 beats per minute, a temperature of 36.6  C saturating 99 % on room air.
Her abdominal examination revealed a gravid abdomen, had an old sub-umbilical midline incision scar, fundal height was 20 cm, with variable lie. The abdomen was not tense, and mild tenderness was elicited. Foetal heart rate was 168 beats per minute. Sterile speculum examination was done a healthy cervix was visualized which was closed with fresh blood oozing from the cervical OS. Review of other systems was unremarkable.
Obstetric ultrasound was performed initially, showed a single viable foetus with estimate weight of 330 g, foetal heart rate were 172 beats per minutes, posterior placenta with a heterogenous echotexture extending to anterior aspect (Fig. 1, Fig. 2).
Initial blood work up revealed a Haemoglobin level of 11.5 g/dl, Haematocrit of 36 %, Platelets count of 161 x 109/l. Our provisional diagnosis at this point was threatened abortion at 19 weeks and chronic hypertension with differential diagnosis of low-lying placenta.
She was initiated on Progesterone (ethyl oleate progesterone) 100 mg intramuscular, intravenous Tranexamic acid 1000 mg, Intravenous paracetamol 1 g.
7 h post admission, she was reviewed once more by a resident of Obstetrics and Gynaecology reported she had developed per vaginal bleeding, with soaked one maternity pad and accompanied with awareness of her heartbeat. On examination: she was pale, tachycardic with a heart rate of 120.
Foetal heart rate was not picked on doppler assessment, other vital signs were stable.
Per abdominal exam revealed fundal height had significantly increased from 20 cm to 30 cm and tenderness elicited over the uterus.
Hemoperitoneum of about 200 ml with fresh blood and clots
Uterus found measuring about 30 cm fundal height
Uterus had a distinct white and blueish discoloration resembling that of a Couvelaire uterus (Fig. 5)
Ovaries and fallopian tubes appeared normal
The urinary bladder was normal, but the bladder peritoneum was adhered to the lower part of the uterus.
Repeat Full blood picture showed Haemoglobin of 8.8 g/dl, Haematocrit of 25.7 % and Platelets count of 47 x 109/l. She was transfused with two units of packed red cells and four units of platelets. Our current diagnosis at this point was an Abruptio placenta. She consented for emergency exploratory laparotomy and was taken for surgery. Intra-operative under aseptic technique abdominal incision was made through old sub-umbilical midline incision scar and findings were
Hysterotomy performed and delivery of a 260 g foetus with no signs of life. There were multiple heavy clots in the uterus, about 1000 ml of clots were evacuated.
Uterine muscles were lax and there was intractable bleeding despite administration of 40 IU oxytocin in 500 ml of Normal Saline.
Given that the levels of Platelet count pre-operatively was 57 and the continued bleeding seen at the incision site the decision was made for subtotal hysterectomy. Subtotal hysterectomy was done, the uterine stump sutured, and haemostasis achieved. There was significant bleeding from the left ovarian vessels therefore left oophorectomy was done as well. The abdomen was then closed in layers.
Patient was the sent to the Intensive Care Unit for close monitoring whilst receiving two units of packed red cells, four units of Platelets and two units of fresh whole blood. On day four post operation she was discharged in good condition. Her outpatient follow up was uneventful.