Subinvolution of the Placental Site, Pneumonia and Pyelonephritis, and Splenic Sequestration Related to Hemoglobinopathy A Lethal Combination
CM Schneider, J Wurzel. Temple University Hospital, Philadelphia, PA
Background: Subinvolution of the placental site, in which there is delayed or subnormal occlusion and sloughing of the superficial spiral arteries at the site of attachment, is a cause of secondary postpartum hemorrhage. This condition occurs at least one day after delivery and can cause life-threatening hemorrhage. We report a case of fatal hemorrhage related to subinvolution of the placental site. Other factors, including multiorgan infection, possible sepsis-related coagulopathy, and sickle hemoglobinopathy likely contributed to the outcome.
Design: A 31-year-old African American female presented with heavy vaginal bleeding and shortness of breath for an unspecified time. She had spontaneously delivered a healthy infant nine days previously. The only complication of the pregnancy was gestational diabetes mellitus. History also included hemoglobin S/beta thalassemia and obesity. The patient presented with brisk vaginal bleeding and a hemoglobin of 2.8 gm/dL. Treatment included administration of multiple blood products and coil embolization of the internal iliac arteries, but she died approximately seven hours after the initial presentation. A complete autopsy was performed.
Results: The uterus weighed 700 grams with extensive blood clot in the endometrial canal. Microscopy showed groups of dilated, widely patent superficial myometrial vessels with little intervening tissue. Immunohistochemistry showed rare keratin positive, presumed trophoblasts in and around vessels; incomplete to absent lining of the vessels by CD31(+) endothelium; rare bcl-2(+) apoptotic cells within the walls. These findings indicated subinvolution of the placental site. Other causes of bleeding such as retained placenta, gestational trophoblastic tumors, and endometritis were excluded. Findings of sepsis included bilateral pneumonia; septic infarctions of the right lung lower lobe; acute left pyelonephritis with numerous small cortical abscesses and an absence of acute cystitis. Supporting the diagnosis of sickle hemoglobinopathy was the presence of sickled erythrocytes in numerous tissues and hepatic extramedullary erythropoiesis. The spleen weighed 1190 grams, consistent with sequestration.
Conclusions: Although not well known to pathologists, subinvolution of the placental site is an important cause of secondary postpartum hemorrhage that can be life-threatening. In this unusual case, sepsis-related coagulopathy and splenic sequestration due to hemoglobinopathy could have contributed to the fatal outcome.
Wednesday, March 11, 2009 1:00 PM
Poster Session VI # 12, Wednesday Afternoon