C. Rincón, MD1;J. Cubillos, MD2; C. Arzola, MD, MSc3
(1) Department of Anesthesia, Pontificia Universidad Javeriana. Hospital Universitario San Ignacio. Cra 7 No 40. Bogotá, Colombia. 110231.
(2) Department of Anesthesia. London Health Sciences Center. Western University. London, Ontario, Canada
(3) Department of Anesthesia, Mount Sinai Hospital, University of Toronto, 600 University Avenue, Room 19-104, Toronto, Ontario M5G 1X5, Canada
Postpartum hemorrhage is the leading cause of maternal death around the world according to World Health Organization . While cesarean delivery is a risk factor, uterine atony is the main etiology . Cesarean delivery and concomitant tubal sterilization are a known risk of postoperative intra-abdominal bleeding, which can be insidious and difficult to diagnose in the recovery period. Furthermore, a late diagnosis can lead to a less than optimal management. Point-of-care ultrasonography is an available technique that can contribute to a prompt diagnosis and accurate decision-making . We present a case of a patient in postoperative care after cesarean delivery and tubal sterilization who developed hypovolemic shock symptoms, without any sign of uterine atony or vaginal bleeding. Focused assessment with sonography for obstetrics (FASO) was quickly performed in the recovery room to diagnose intra-abdominal bleeding and decision-making to perform an emergency surgical intervention.
The diagnosis and management of the Postpartum Hemorrhage (PPH) must be carried out in a multidisciplinary approach including the participation of gynecologists/obstetricians, anesthesiologists and nursing care. The evaluation of the hemodynamic status, as well as establishing a cause of hypovolemic shock, must be performed in a timely fashion, to provide early hemostatic control and adequate maternal resuscitation .
Within the field of emergency medicine, the intra-abdominal bleeding caused by trauma is initially diagnosed with point-of-care ultrasonography (POCUS) using the Focused Assessment with Sonography in Trauma (FAST) exam . A modified version of this technique has been suggested in the Obstetrics field (FASO)  in order to evaluate patients in the postpartum period. This approach may facilitate an early diagnosis and an appropriate management, helping to establish the etiology of the bleeding. FASO provides an examination of the uterine and abdominal cavities with a safe, imaging technology at the bedside .
We followed the SCARE criteria and CARE guidelines [7,8] to report a case of an obstetric patient with severe hypovolemic shock using an emergency ultrasound to diagnose intra-abdominal hemorrhage post cesarean delivery and tube sterilization, in the context of a tertiary teaching hospital.
A nineteen-year-old woman, underwent a cesarean delivery and tubal sterilization at 39 weeks of gestational age. The scheduled procedure was carried out under spinal anesthesia using hyperbaric bupivacaine 0.5% (12mg) and fentanyl 20 mcg. The surgery was uneventful, with 300 cc of estimated blood loss and normal hemodynamic throughout the case.
In the immediate post-operative period, the patient was found to have persistent low blood pressure with mean arterial pressures between 48-60 mmHg. She was tachycardic with heart rates 115 – 120 beats per minute. On examination, she appeared pale. There was minimal vaginal bleeding, a good uterine tonus, and no specific signs of peritoneal irritation. Fluid resuscitation was started.
After repeated intravenous fluid boluses totaling 2000 ml of volume resuscitation, the anesthesiologist performed a FASO examination with the patient in supine position using a convex-array transducer. First, the right upper quadrant was examined, evaluating for free fluid in Morison’s pouch. Next, the left upper quadrant (splenorenal recess) was examined, followed by the suprapubic evaluation of the lower abdominal wall and the pouch of Douglas. The FASO examination found a large amount of free fluid in the abdominal cavity, mainly located in the hepatorenal recess and the pouch of Douglas.
In this context, the diagnosis of a severe hemorrhagic shock was considered and the massive transfusion protocol was activated. The patient was immediately transferred to the operating room. After a rapid sequence induction for general anesthesia, an exploratory laparotomy was initiated. The surgical team drained 3,000 ml of hemoperitoneum with evidence of active bleeding through a small vessel in the left fimbriectomy stump, which was repaired with clamping and transfixation ligature (Figure 1).
Postpartum hemorrhage is the leading cause of maternal death worldwide [4,9] , most commonly due to uterine atony . The diagnosis is clinical and its management includes identifying the cause, emergency resuscitation and timely surgical intervention .
Tubal sterilization represents an important contraceptive method worldwide. Annually, more than 350,000 tubal sterilization procedures are held after vaginal birth or cesarean delivery in the United States, with a low rate of complications reported [11,12]. Unlike in uterine atony, in which vaginal bleeding occurs massively as an early sign of hemorrhage, the intra-abdominal bleeding from a vessel after tubal ligation can initially go undetected. Therefore, the diagnosis is usually delayed, increasing the risk of severe complications when definitive surgical treatment is not prompt . Additionally, the interventions to manage uterine atony do not have a long lasting effect if the bleeding is intra-abdominal, increasing the risk of coagulopathy due to undetected bleeding . POCUS assessment using the FASO exam might help in the process of emergency evaluation and result in a timely diagnosis and decrease maternal morbidity .
The gold standard imaging study to evaluate intra-abdominal bleeding is computerized tomography (CT). Currently, the use of FAST protocol in the emergency department allows the evaluation of intra-abdominal and pericardial bleeding caused by trauma. POCUS has the advantage of being inexpensive, repeatable, and rapid at the patient’s bedside, with no exposure to radiation . The modification of the technique for obstetrics patients (FASO examines the following anatomical areas: placenta and uterine cavity, bilateral hypochondria and the pouch of Douglas. Furthermore, it is useful to evaluate the diameter of the inferior vena cava in order to aid in the evaluation of volume status  (Figure 2).
Currently, the evaluation of uterine involution is done with a physical examination, but it can be influenced by the body-mass index, rigidity of the abdominal muscles, and the position of the umbilicus in relation to the symphysis pubis . Given that clinical assessment can be variable, complementary methods like FASO are necessary. Proper training and clinical integration are required to use FASO safely given that postpartum patients can have physiologic intra-abdominal free fluid that is not pathological. In studies with CT  free fluid might be present in up to 73% of patients after Caesarian section. Nevertheless, if there is a large amount of free fluid, FAST has demonstrated an excellent sensitivity (69%–98%) and specificity (94%–100%) for detection of free fluid , with reported volume necessary to enable detection around 600mL in the Morison’s pouch. This can be improved using the Trendelenburg position, in which smaller amounts of free fluid (100-400 mL) in the splenorenal and hepatorenal spaces can be identified [16,17].
FASO examination in our patient showed free fluid in all the abdominal windows. This finding, in the clinical context of hemodynamic instability was highly suggestive of intra-abdominal hemorrhage. FASO proved helpful in the clinical decision-making process to proceed with surgical intervention.
In addition to the history and physical examination, POCUS should be considered in evaluating the post-partum patient for post-partum hemorrhage using the FASO exam. Combining clinical evaluation with the FASO exam might improve the decision-making process in patients with suspected post-partum hemorrhage.
Informed consent: The patient gave informed consent for publication.
Conflict of interest: There is not conflict of interest.
Statement of Ethics: Approved by the institutional ethical committee.
1. Say L, Chou D, Gemmill A, Tunçalp Ö, Moller AB, Daniels J, et al. Global causes of maternal death: A WHO systematic analysis. Lancet Glob Heal. 2014;2(6):323–33.
2. Alkema L, Chou D, Hogan D, Zhang S, Moller AB, Gemmill A, et al. Global, regional, and national levels and trends in maternal mortality between 1990 and 2015, with scenario-based projections to 2030: A systematic analysis by the un Maternal Mortality Estimation Inter-Agency Group. Lancet 2016;387(10017):462–74.
3. Oba T, Hasegawa J, Sekizawa A. Postpartum Ultrasound: Postpartum Assessment Using Ultrasonography. J Matern Neonatal Med. 2016;7058:1–4.
4. Mercier FJ, Van de Velde M. Major Obstetric Hemorrhage. Anesthesiol Clin. 2008;26(1):53–66.
5. Richards JR, McGahan JP. Focused Assessment with Sonography in Trauma (FAST) in 2017: What Radiologists Can Learn. Radiology. 2017;283(1):30–48.
6. Hoppenot C, Tankou J, Stair S, Gossett DR. Sonographic evaluation for intra-abdominal hemorrhage after cesarean delivery. J Clin Ultrasound 2016;44(4):240–4.
7. Agha RA, Fowler AJ, Saeta A, Barai I, Rajmohan S, Orgill DP, et al. The SCARE Statement : Consensus-based surgical case report guidelines. 2016;34:180–6.
8. Gagnier JJ, Kienle G, Altman DG, Moher D, Sox H, Riley D, et al. The CARE guidelines : consensus-based clinical case report guideline development. 2014;67:46–51.
9. Anderson FWJ. Maternal mortality: an enduring epidemic. Clin Obstet Gynecol. 2009;52(2):214–23.
10. ACOG, Zelop CM. Postpartum Hemorrhage. Acog Pract Bull. 2006;76(6):1–9.
11. Wallach EE, Chan LM, Sc B, Ch MBB, Westhoff CL, Sc M. Tubal sterilization trends in the United States. Fertil Steril. 2010;94(1):1–6.
12. Population Division. Levels and Trends of Contraceptive Use as Assessed in 2002. New York, NY: Department of Economic and Social Affairs, United Nations; 2006.
13. Tauchi M, Hasegawa J, Oba T, Arakaki T, Takita H, Nakamura M, et al. A case of uterine rupture diagnosed based on routine focused assessment with sonography for obstetrics. J Med Ultrason.2016;43(1):129–31.
14. Diniz CP, Araujo Júnior E, Lima MM de S, Guazelli CAF, Moron AF. Ultrasound and Doppler assessment of uterus during puerperium after normal delivery. J Matern Neonatal Med. 2014;27(18):1905–11.
15. Hiller N, Schor-Bardach R, Gileles-Hillel A, Stroumsa D, Simanovsky N. CT appearance of the pelvis after Cesarean delivery-what is considered normal? Clin Imaging. 2013;37(3):514–9.
16. Von Kuenssberg Jehle D, Stiller G, Wagner D. Sensitivity in Detecting Free Intraperitoneal Fluid with the Pelvic Views of the FAST Exam. Am J Emerg Med. 2003;21(6):476–8.
17. Abrams BJ, Sukumvanich P, Seibel R, Moscati R, Jehle D. Ultrasound for the detection of intraperitoneal fluid: The role of trendelenburg positioning. Am J Emerg Med. 1999;17(2):117–20.