Early cesarean section complication — hematoma at the uterine incision

The rates of cesarean sections are increasing globally leading to a rise in intraoperative and long-term surgical complications including obstetrical hemorrhages, malplacentation disorder of placenta accreta spectrum and uterine niche formation [1].The uterine niche is a complex disorder resulting in subfertility, infertility, a decline in the quality of life due to chronic pelvic pain, and prolonged vaginal spotting and bleeding [2].The uterine niche can have life-threatening consequences when placental implantation is disrupted during the following pregnancies, resulting in an ectopic cesarean scar pregnancy, uterine rupture, and placenta accreta spectrum disorder [3].The paper presents a 31-year-old patient in a singleton pregnancy with neurosurgical indications for an elective cesarean section.Her medical history was uncomplicated, except for lumbar disc disease, hypothyroidism and one previous cesarean section performed six years earlier, without any intra-and post-operative complications.Multiple transvaginal and transabdominal ultrasounds conducted throughout the pregnancy revealed an appropriate for gestational age fetus, anterior placenta, and no abnormalities of the lower uterine segment.The woman was a non-smoker with a normal body mass index (BMI) of 24 kg/m 2 .The cesarean section was performed using a low transverse uterine incision, the uterus was closed using continuous, non-locking, double-layer, endometrium-free technique with standard synthetic absorbable Polyglactin sutures, without any intraoperative complications.The surgeon who performed the procedure was a specialist with over 5 years of operative experience.The intraoperative blood loss was estimated at 500 mL.The peri-and postoperative period was uneventful, the patient's hemoglobin and white blood cell count (WBC) remained stable, vaginal bleeding was normal, no fever was noted and the pain management was sufficient using oral acetaminophen and ibuprofen.The patient and the neonate were discharged after three days of hospital observation.At eight weeks post the cesarean section, during a standard postpartum gynecological visit, the ambulatory care gynecologist performed a standard transvaginal ultrasound examination and due to abnormal appearance of the lower uterine segment, the patient was referred to a tertiary centre.At the tertiary centre, a joint consultation with senior obstetricians and gynecologists was conducted and a transvaginal ultrasound revealed a large hematoma measuring 6 × 4 × 4 cm, at the site of uterine incision, separating the lower uterine segment myometrium from body of the uterus, causing uterine dehiscence (Fig. 1).It is important to underline that; the patient had no evident risk factors of hematoma formation as the cesarean section had a standard course with minimal adhesions and blood loss.The patient did not have coagulopathy or other hematological disorder, and she did not suffer from any trauma, or prolonged strain, including coughing, in the post-operative period.Clinically, the patient remained asymptomatic, no symptoms of an infection or pain were reported.Laboratory blood results including hemoglobin, c-reactive protein (CRP) and white blood cell count (WBC) values remained in range.A decision for observation and conservative treatment was made due to asymptomatic presentation and no signs of hematoma infection or abscess formation.