A 30-Year-Old Female Found to Have a Couvelaire Uterus With Placenta Accreta During Planned Cesarean Delivery

Abstract

A case of Couvelaire uterus with placenta accreta found during scheduled repeat low transverse Cesarean section will be discussed within this article. First described in the 1900s, Couvelaire syndrome, also known as uteroplacental apoplexy, is a rare form of nonfatal placenta abruption complication. The case involves a 30-year-old gravida 3 para 2 otherwise healthy female with an uncomplicated pregnancy and two previous cesarean deliveries without complication. She received routine prenatal care. During her pregnancy, she did not experience any symptoms such as vaginal bleeding or abdominal pain. After delivering a healthy female, there were several unsuccessful attempts to remove the placenta from the uterus. Upon inspection, the uterus was found have dark purple patches with ecchymosis and indurations, diagnostic of Couvelaire uterus. Furthermore, there was high clinical suspicion for placenta accreta as the 30-minute mark approached without placenta detachment. A telephonic emergency review with the wet desk radiologist of the 18-week ultrasound revealed high suspicion for placenta accreta. A Cesarean hysterectomy was performed for prevention of significant hemorrhage. This case report may be the first documented association of Couvelaire uterus with placenta accreta. Providers should be vigilant in monitoring for antenatal bleeding, timing of placenta separation, and postpartum hemorrhage.

Massive Severe Uteroplacental and Uteropelvic Apoplexy

“…Uteroplacental apoplexy or Couvelaire syndrome is a rare, a priori nonfatal complication of placental abruption, invasive malplacentation (placenta accreta) or, very rarely, malignoma. Couvelaire uterus is caused when hemorrhage from placental blood vessels seeps into basal decidua causing placental separation, followed by myometrium infiltration [1][2][3][4]. The diagnosis of UPA is made by direct visual inspection during cesarean section or by histopathologic biopsy.…”

“…In milder forms of focal UPA, it is not an indication for primary obstetric hysterectomy in case of good contractility and stable vital maternal function; indeed, some cases pass totally innocently. Urgent obstetric cesarean hysterectomy was once the option for solving UPA, whereas today it is reserved only for severe and massive UPA forms with progression to uteropelvic apoplexy, with severe and refractory bleeding, as described in the literature [1,3,7,8].…”

Uterus couvelaire after caesarean section: A challenging case report

“…2 The incidence of this case is difficult to ascertain, and the estimated incidence is between 5% and 20%. 1 The profile of this case is the extravasation of extensive blood into the uterine muscle and down the surrounding tissue. 3 Distinctive appearance is bluish or purple, speckled by ecchymosis.…”

“…3 Distinctive appearance is bluish or purple, speckled by ecchymosis. 1 The pathophysiology of this case is bleeding in the layer between the decidua-placenta, which then develops and infiltrates into the uterine wall. Characteristically it shows the appearance of ecchymosis on the surface of the uterine serosa.…”

“…Uterus couvelaire, also known as uteroplacental apoplexy, is a condition that results from complications from placental abruption. 1 It was first described by a French obstetrician named Alexandre Couvelaire in 1911. 2 The incidence of this case is difficult to ascertain, and the estimated incidence is between 5% and 20%.…”