Haematometra arising from multiple abortions: a comprehensive case report

Abstract

Haematometra, a rare and delayed complication, can emerge following medical termination of pregnancy, also known as ‘postabortal post-caesarean syndrome’ or ‘redo syndrome’. Treatment requires the immediate evacuation of both liquid and clotted blood for quick resolution, followed by administration of an oxytocic agent to ensure complete recovery. This current report describes a female patient in her mid-30s who presented with colicky lower abdominal pain following a medically-induced abortion at 10 weeks. The case underscores the critical need for vigilance in detecting haematometra after abortion or caesarean delivery. Prompt recognition through symptoms and ultrasound, followed by immediate treatment, is essential to prevent severe complications such as infertility and ensure ongoing reproductive health.

Introduction

Menstruation is a fundamental physiological process for women, signifying the natural shedding of the uterine lining, involving blood and tissue discharge. ¹ This cycle, orchestrated by hormonal signals, sometimes presents symptoms associated with premenstrual syndrome (PMS). Disturbances in this process, such as obstructions in the cervical canal or vagina, lead to haematometra, which is characterized by the retention of blood within the uterus, manifesting in severe abdominal pain, the cessation of menstrual periods (amenorrhoea) and potential infertility challenges. ² The implications of haematometra extend beyond discomfort, posing risks to reproductive health and emphasizing the importance of understanding its aetiology ranging from congenital anomalies to complications following surgical procedures such as abortions or caesarean deliveries. ³ Recognizing haematometra early is crucial for effective management, highlighting its significance in gynaecological care and the broader spectrum of women’s health issues.

Haematometra is notably rare, making each case significant for clinical learning and advancement. This current case report aims to elucidate the complexities and management dilemmas posed by this condition through a detailed analysis of a particularly challenging case. The current case developed haematometra following multiple surgical abortions, which presents unique diagnostic and therapeutic challenges, serving as a segue into the detailed case presentation in the following section.

Case report

In October 2023, a female patient in her mid-30s presented to the Department of Obstetrics and Gynaecology, Rafik Hariri Hospital, Beirut, Lebanon with colicky lower abdominal pain that had started 3 months after a medically-induced abortion at 10 weeks, which was performed by Médecins Sans Frontières. She was gravida 9, para 3, with a history of three live births via caesarean section and six spontaneous abortions. She had previously undergone two dilatation and curettage procedures. The patient experienced typical menstrual cycles until her recent medical abortion, after which she noted amenorrhoea. Despite this absence of menstruation, she began experiencing severe lower abdominal pain 3 months post-abortion, prompting her visit to the hospital.

Initial examination of the patient revealed a tender, retroverted uterus of approximately 7 to 8-week gestational size with a closed cervical os. Laboratory tests including a comprehensive metabolic panel and urinalysis were largely normal, with a notable haemoglobin level of 10 g/dl and a white blood cell count of 10 300 cells/mm³. A negative urine human chorionic gonadotropin test confirmed the absence of an ongoing pregnancy.

Abdominal sonography and pelvic ultrasound revealed an enlarged uterus measuring approximately 10 cm, with mixed echogenic contents within the endometrial cavity, indicative of haematometra and suggesting internal haemorrhage (Figure 1). The ultrasound images were unclear due to the challenges Lebanon is currently facing, as not all necessary equipment is available. To investigate further, haematometra drainage was conducted under ultrasound guidance. Prior to the procedure, an ultrasound was performed to visualize the contents of the uterus, which showed dark blood. During the time of the procedure itself, dilatation and suction were used to remove the blood (Figure 2). The success of the process was confirmed using ultrasound both before and after the procedure in an attempt to ensure complete evacuation. Postoperatively, ultrasound imaging and curettage were used and the results confirmed the successful removal of the contents of the endometrial cavity (Figure 3). Based on the clinical presentation and imaging findings, a diagnosis of haematometra was established.

Figure 1.

Pelvic ultrasound of a female patient in her mid-30s who presented with colicky lower abdominal pain following a medically-induced abortion at 10 weeks showed an enlarged uterus (approximately 10 cm) with mixed echogenic contents within the endometrial cavity.

Figure 2.

Operative images from a female patient in her mid-30s who presented with colicky lower abdominal pain following a medically-induced abortion at 10 weeks: (a) intraoperative image of haematometra drainage and (b) postoperative image of the suctioned blood removed during the procedure. The colour version of this figure is available at: http://imr.sagepub.com.

Figure 3.

Postoperative ultrasound imaging of a female patient in her mid-30s who presented with colicky lower abdominal pain following a medically-induced abortion at 10 weeks showing the successful removal of the contents of the endometrial cavity.

To facilitate the procedure, cervical dilation was attempted using a Hegar dilator. Starting with a size 8 Hegar dilator, the cervix was gradually dilated to allow better access to the uterine cavity, ensuring thorough evacuation and examination.

Following the surgical intervention, postoperative management included the intravenous administration of 10 units of syntocinon in 500 ml. The patient’s recovery was positive, with alleviated pain and the resumption of regular menstrual cycles. Histopathological analysis of the evacuated contents revealed non-specific inflammatory changes and confirmed significant blood retention, but no chromosomal abnormalities were detected. The reference to histopathological analysis pertains to tests conducted on the contents evacuated during the dilatation and curettage procedure performed after the patient’s symptoms post-abortion. This analysis was specifically for evaluating the material removed during this recent intervention, rather than any tests conducted immediately after the abortion 3 months prior. The term ‘significant retention’ aimed to describe the substantial accumulation of blood within the uterus, which was successfully evacuated during the procedure, directly referring to the hematometra addressed during the dilatation and curettage procedure.

Ethical approval to report this case was obtained from the Institutional Review Board Committee of Rafik Hariri Hospital, Beirut, Lebanon on 8 April 2024. The registration and oversight of the approval process were managed by Dr Georges Yared. Due to the ongoing crisis in Lebanon, the Institutional Review Board Committee did not issue a formal approval number for this case report. However, all necessary ethical guidelines and standards to ensure the integrity and ethical compliance of this research were followed. Written informed consent was obtained from the patient for their anonymized information to be published in this article. All patient details were de-identified. The reporting of this study conforms to the CARE guidelines. ⁴

Discussion

This current case report highlights the importance of considering haematometra as a differential diagnosis in patients presenting with post-abortion amenorrhoea, abdominal pain and a negative pregnancy test. The complexities associated with diagnosing and managing this rare condition underscore the necessity for thorough diagnostic and therapeutic approaches. Effective management not only addresses the immediate symptoms but also plays a critical role in preserving future fertility and overall reproductive health. This current case serves as a reminder of the potential challenges associated with haematometra.

Haematometra is a rare and complex condition characterized by the accumulation of blood within the uterus, typically resulting from obstruction in the lower genital tract. It is crucial to understand the various aetiologies and underlying mechanisms that contribute to this condition to ensure effective management and prevent long-term reproductive complications. The development of haematometra can occur post-caesarean or after abortions, and in teenagers, it is often linked to congenital anomalies like a transverse vaginal septum or cervical agenesis. In post-caesarean cases, haematometra may develop due to improper surgical closure of the uterus, which creates a uterine pouch where blood accumulates.^5,6 After an abortion, haematometra generally results from incomplete removal of conception products or acquired cervical stenosis.^7,8

The diagnosis of haematometra involves the measurement of uterine size and assessment of echogenic contents via ultrasound. It is typically suspected in patients presenting with a history of amenorrhea and cyclic abdominal pain. The ultrasound shows a distended uterus filled with echogenic material, confirming the presence of retained blood.^9,10 If left untreated, haematometra can lead to significant complications, including chronic pelvic pain and infertility. The retained blood can cause inflammatory reactions and fibrotic changes within the uterus, potentially leading to adhesions and reduced uterine capacity, which affects future fertility.^11,12

The effective management of haematometra includes both medical and surgical approaches. Oxytocic agents such as syntocinon are used to facilitate uterine contractions and aid in the evacuation of retained blood. In some cases, surgical intervention may be necessary to remove obstructions or retained products. Timing and dosage of these interventions are critical to ensure complete resolution of the condition and prevent recurrence.^13–15

A review of the literature highlights the rarity and complexity of haematometra management. For example, a previous report described an acute onset haematometra associated with endometritis and cervical stenosis following a suction evacuation, emphasizing the need for careful monitoring and potential intervention to prevent such complications. ¹⁵ Other reports include cases where haematometra developed weeks after an abortion, with varying symptoms such as abdominal pain, fever and vomiting, managed successfully with either pharmacological or surgical treatments.^15–17 Indeed, the current body of literature describes how haematometra might originate from a number of different causes such as retained products of conception, cervical stenosis and even anatomical defects. For example, a previous report of a case of recurrent haematometra of unknown aetiology highlighted the difficulty associated with the prognosis and management of this pathology, especially when wide bore catheters fail to drain. ¹⁸ Similarly, another study noted that complications including haematometra might arise from retained products of conception manifesting as chronic abdominal discomfort or abnormal uterine bleeding. ¹⁹

The management of haematometra will often require surgical techniques especially in situations where conservative approaches have not provided relief from the symptoms. In a previous case report, a successful hemihysterectomy was performed on a patient presenting with recurrent haematometra secondary to an anatomical defect. ²⁰ This previous case further demonstrates that surgery might be inevitable especially when other methods have failed. ²⁰ In addition, the case of a postmenopausal woman with cervical stenosis demonstrated the need for surgical treatment in order to relieve the obstructive pathology that caused haematometra. ²¹

Preventive strategies are crucial, particularly ensuring complete removal of conception products and maintaining cervical patency post-procedure. The use of Hegar dilators to confirm the communication between the uterine cavity, cervical canal and vagina is an effective method to prevent accidental cervical closure during surgical procedures. This measure is particularly important in caesarean sections where the risk of improper closure is significant.^1,22

From this perspective, it remains important to consider haematometra during the differential diagnoses for women presenting with post-procedural amenorrhoea and cyclical pain. A comprehensive understanding of the aetiological factors, combined with a vigilant diagnostic and management approach, is essential for preventing long-term adverse outcomes and ensuring optimal reproductive health. This current case and the previously published literature demonstrate the critical need for awareness and expertise in handling such complex gynaecological conditions.

In conclusion, despite its rarity, haematometra should be a consideration in patients presenting with post-abortion amenorrhoea and cyclical pain. Early recognition and appropriate management strategies are critical, especially for women of childbearing age experiencing lower abdominal and pelvic discomfort, to ensure effective treatment and prevention of potential complications.