Aseptic Necrosis of Hysterorrafia: A Case Report
A 35 years old patient with uncontrolable methrorragia post cesarean section treated with surgical conservative technique.
Not all cases of ANH need an Hysterectomy as a definitive treatment. A conservative approach is succesfull.
Aseptic necrosis of hysterorrafia was described more than 80 years ago as a bleeding syndrome that occur after CS mainly when they are iteratives. Apparently, in some of the CS, the accidental oclussion of one of uterine arteries produce an infarct of the miometrium and as a consequence, the bleeding appears, sometimes scarse and sometimes heavy, affecting the mother´s health. The bleeding does not decrease with conventional treatments, and stop spontaneously, as it started [1-3]. It is red blood, rutilant, abundant, without any pain. The known measures to stop bleeding in puerperium does not work in this cases, neither drugs nor surgical treatments.
A 35 years old patient underwent to second CS because a previous CS. The surgery was uneventfull and she was dischargedfrom Hospital 72 hours after surgery. About 10 days later, she complained of vaginal bleeding, not had seen any damage ofneither vagina nor cervix. It was a methrorragia. She started with nasal oxitocyn every 6 hours and apparently she did well.One week later, she complained again for the same symtoms and was medicated in the same way. But, some days later, shecomplained again, and we started to think in the possibility of ANH. We performed blood tests found an hematocrit of 28%, she was asymptomatic, and the ultrasound informed a cyst over the hysterorrafia with a size of 10cm long and 5cm wide.
With this finding, we decided to perform a laparotomy with presuntive diagnosis of ANH, haematoma or absces. Noteworthy, we left the bladder well down in the vesicouterine space by the time of CS because we did not performed peritonization of the hysterorrafia. When opened the abdomen, we saw the bladder over the hysterorrafia (Figure 1) and when we started to separate the bladder from the uterus, we found the necrotic procces (Figure 1-2).
Figure 1. We can observe the uterus (green arrow), the bladder ocluding the hysterorrafia (red arrow) and the necrotic area (blue arrow).
Figure 2. We descended the bladder (red arrow) and the necrosis is bigger (blue arrow).
Figure 3. The bladder libered from the hysterorrafia (red arrow) and the necrotic area in the uterus (blue arrow).
Figure 4. Observe the bladder moved down (red arrow) and the liberation of the inferior lip of the hysterorrafia (blue arrow).
Figure 5. The bladder completly descended (red arrow) and the uterus ready to be repared (blue arrow).
Figure 6. The uterus repared.
We removed the necrotic tissue and rebuild the hysterorrafia with separate stitches with catgut (Figure 4-5-6). The bladderwas descended and the necrotic procces was bigger (Figure 2-3). With a good uterine retraction and good haemostasia, weclosed the abdomen. The patient did well and was discharged 48 hours after surgery and she remain asymptomatic for morethan a two month. She still does not reassumed her menses because she continue breastfeeding her baby.