Case report :
The patient is 37 years old, with no notable pathological antecedents. 4th gesture 4 -th part, the three previous deliveries were by low voice. The current pregnancy took place without any abnormality. The patient presented to the maternity hospital at 39 weeks of amenorrhoea + 4 days at the beginning of labour, the evolution of labour was harmonious until a dilatation of the cervix of 5 cm or she presented an acute foetal suffering with severe bradycardia objectified by the recording of the foetal heartbeat. An emergency caesarean section was indicated, which allowed the extraction of a newborn male Apgar 10/10 -th, birth weight: 3800 grams. The patient suffered a delivery haemorrhage during the operation due to uterine inertia. The uterine massage supplemented by oxytocin infusion and the admission of 5 intrarectal misoprostol tablets (due to the non-availability of sulprostone) did not correct the uterine atony. Since the embolisation technique is not available in our centre, we resorted to Tsirulnikov’s triple ligation combined with uterine compression using the B-Lynch technique using a Vicryl 1 absorbable thread. The bleeding stopped and the patient received a transfusion of 2 red blood cells.
The postoperative course was normal until the 4th post-operative day when the patient presented with fever a (39,6◦C) associated with abdominal pain and diffuse abdominal tenderness, the louchia was not fetid and without metrorrhagia. A The haemogram GB = 28.000/mm3 , Hb = 10.1 g/dl and a CRP elevated to 283 mg/L . A pelvic ultrasound was carried out showing a slight haematometry associated with a slightly heterogeneous myometrium especially on the anterior surface of the uterus. The patient was put on a broad-spectrum antibiotic to treat possible endometritis. 48 hours later, the evolution was marked by the installation of a state of septic shock with a tachycardia of 130 beats per minute, a blood pressure of 80/40 mmHg with persistence of a fever a (39,2◦C) and clinically an abdominal contracture. A pelvic CT scan was carried out showing a medium-abundant pelvic effusion and above all gas bubbles in the myometrium in favour of uterine necrosis. An exploratory laparotomy was urgently indicated.
Surgical exploration finds extensive uterine necrosis especially in its anterior surface, a hysterography partially open in the centre and superinfected with the presence of false membranes occupying the entire anterior surface of the uterus (figure 1). Necrosis was definitive despite the removal of the sutures of vascular ligatures previously performed. A total hysterectomy was performed (figure 2) with an abandoned serum lavage of the peritoneal cavity with pelvic drainage, which was removed two days later.
The postoperative course was favourable and the anatomopathological examination confirmed the diagnosis of uterine necrosis