Two unusual cases of secondary postpartum haemorrhage.

The patient, aged 29 years, was admitted under our care on her twelfth postpartum day with moderately severe vaginal bleeding. Her first pregnancy and labour had been five years previously. Thereafter she had had three abortions. Consequently when her fifth pregnancy was confirmed a Shirodkar suture of tantalum wire was inserted. At 24 weeks she was admitted to hospital because of intermittent vaginal bleeding. At 34 weeks regular uterine contractions began and the cord was found to be prolapsed down the cervical canal, despite the Shirodkar suture. A male child weighing 2,000 g was delivered by lower segment caesarean section. The operation showed no apparent abnormality, the puerperium was uneventful, and the patient went home after nine days. Our hospital flying squad was called three days later because the patient had had vaginal bleeding for 24 hours, which had become worse. The uterus was the size of a 12 weeks' pregnancy, but the cervix barely admitted a finger owing to the presence of the Shirodkar suture. There was little pelvic tenderness. Vaginal bleeding continued after admission despite a slow infusion of oxytocin (syntocinon), and an ultrasonogram showed a uterus of almost 18 weeks' size full of blood clot with an area at the level of the lower segment which was thought could represent a retrovesical haematoma. The Shirodkar suture was removed under premedication, and obviously much blood and clot had been dammed back in the uterine cavity. Despite further intravenous oxytocin bleeding increased. Examination under anaesthesia revealed a dehiscence of the entire caesarean section scar with a large haematoma cavity behind the bladder. The uterus, now of about 14 weeks' pregnancy size, was lying backwards. At laparotomy immediately afterwards 250 ml of altered blood was found in the peritoneal cavity. When the clot was removed from a large retrovesical haematoma the gaping lower segment of the uterus was defined and brisk bleeding was seen coming from the angles of the lower segment wound. The tissues were very friable and infected, and the old lower segment scar was gaping widely with slough on the wound edges. Bleeding was eventually arrested by subtotal hysterectomy and oversewing the cervical stump. At the completion of the operation the patient had received 14 units of blood and her general condition was good. Convalescence was uneventful and she went home after 17 days. Histological examination of the uterus showed extensive infection but no malignancy. Six weeks later she was well. The cervix was healthy and mobile and there was no evidence of residual inflammation in the wound or pelvis.