A Fatal Case of Hypovolemic Shock After Cesarean Section
Daisuke Yajima, MD, Hisala Motani, DDS, Mutsumi Hayakawa, MD, Yayoi sato, phD,
and Hirotaro lwase, MD
Abstract: We report a fatal case of hypovolemic shock caused by
uncontrollable hemorrhaging after emergency cesarean section. In
this patient, the incision in the uterus was located only I cm from the
cervical os. We suspect that this close incision was the cause of the
damage to the uterine venous plexus and the bleeding. We discuss
the cause of death and offer advice on performing autopsies in
patients who have died ofbleeding after cesarean section.
Key Words: cesarean section, hemorrhage, autopsy
(Am J Forensic Med Pathol 2007;28: 212-Zt5)
ln recent years, the rate ofcesarcan section as a proportion
lof all deliveries has risen to about l5o/o in Japan. This
increase has occurred because of such factors as progress in
neonatal treatment, the rapid development of assisted repro-
duction techniques, an increase in the number of older pri-
migravida, changes in patients' rights, and increases in iiti-
Emergency cesarean is a lifesaving operation for baby
and mother. As the method of prompt delivery that is best
able to reduce hypoxic stress on the baby during birth, it can
reduce the risk ofthe development ofcerebral palsy. Because
of the urgent nature of this operation, the surgeon has little
time, and bleeding can be profuse. In such a situation, some
surgeons can feel exhemely mentally and physically stressed
and can take the wrong actions through errors in judgment.2
In the case described here, the baby was delivered
safely, but uncontrollable bleeding continued after delivery.
The surgical team had great difficulty in controlting the
bleeding. Although they finished the operation, the patient,s
condition took a sudden turn for the worse, so she was
transferred to another hospital, where she died. We speculate
as to the cause of death.
This is the case of a previously healthy Z9-year-old
woman who died unexpectedly after undergoing an emer-
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gency cesarean section. Her obstetric history included the
normal spontaneous vaginal delivery of a 2845-9 male infant
2 years earlier. Her medical history was unremarkable and
did not include abdominal surgery. The current pregnancy
had been uneventful. She was admitted to a clinic after the
rupture of her membranes at 39 weeks 5 days of pregnancy.
Prompt cesarean section was indicated because, despite
progress of labor, the baby's head was not descending and
was in frank breech presentation.
The timetable is shown in Figure l. Surgery started at
7:35 epr under spinal anesthesia with lidocaine. On admis-
sion, her heart rate was 84 beats per minute, the systolic and
diastolic blood pressure were I I I and 85 mm Hg, respec-
tively, and the body temperature was 36.5"C. The delivery of
the baby was completed at7:41eru. The blood pressure fell to
72/35 mm Hg after delivery. Although the patient had not
complained of sickness, intravenous infusion and ephedrine
as a pressor were administered. Bleeding in the operative
field continued. The surgeons ligated and applied pressure to
the incision, but the bleeding did not stop. Next, the ascend-
ing branch of the left uterine artery was ligated, and then
bleeding in the peritoneal cavify seemingly stopped. Al-
though venous bleeding under retroperitoneum was noted, it
seemed not to expand. At that time, the patient was conscious
and alert. The anesthesia method was changed to general
anesthesia at 9:15 au because ofa decrease in the effect of
spinal anesthesia. The surgeons had great difficulfy in con-
trolling the bleeding. A gauze swab was left in the peritoneal
cavity for hemostasis. The bleeding volume was 3000 mL
during the operation. Red blood cells-MAP (with mannitol-
adenine-phosphate solution) (2000 mL) and fresh frozen
plasma (240 mL) were transfused during and after the oper-
ation. The patient's wound was finally closed at 10:32 ev
after the doctors confirmed no bleeding in the peritoneal
cavity. At 10:45 eu, after the operation, the blood pressure
was 9l/43 mm Hg, and the heart rute was ll7 bpm. The
patient responded to the calling of her name at 10:50 an. At
I l:00 au, about 30 minutes after the end of the operation, the
patient's blood pressure fell and she entered a state of
cardiopulmonary arrest at ll:10 nv, about 40 minutes after
the completion of surgery. Immediately, cardiopulmonary
resuscitation was performed, and the heart was restarted. At
that time, the blood pressure was 80/56 mm Hg, the heart rate
was 168 bpm, and the patient was transferred to another
hospital. At l2i2l eu, arriving at the hospital, the blood
pressue was 101/54 mm Hg, the heart rate was 226bpm, and
she breathed spontaneously, but the pupillary reflex was not
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[Case study timetablel
7:35 Emergency cesarean section begins under spiual anesthesia. (On admission,
7:41 Delivery of baby Q390 g completed.
7:42 The patient does not complain of feeling sick.(8P72l35)
lntravenous infusion and pressor begun against the fall ofblood pressure.
9: l0 Bleeding continues. Surgeons contiuue trying to stop the bleediag. Blood
infusion starts. The patient is conscious and alert. (BP79/36)
9: 15 Anesthetic merhod changes to general anesthesia. Bleeding continues.
Surgeons continue trying to stop the bleeding.
10:32 Surgery is over (gauze left in peritoneal cavity to facilitate hemostasis)
l0:35 Surgeons inform family that bleeding may occur and patient may die.
l0:45 BP91/43, HRllT
10:50 Patient can respond to calling her name.
I I :00 Hypotension develops.
I I : I 0 Cardioputmonary arrest; cardiopulmonary rezuscitation begins. Heart
restarts and ambulance is called. (BP80/56, HRl68)
I I :20 Ambulance arrives.
12:00 Patient leaves for another hospital.
l2:2 I Patient reaches other hospital. She breathes spontaneously, but pupillary
reflex is not noted. (BPl0l/54, HR226)
Her condition has become unstable.
10:45 next day Patient dies.
Fl GURE l . Ti m etabl e of case study.
noted. There, her condition became unstable, so a reoperation
could not be performed. Despite blood transfusions, she died
about 24 hours after the completion of surgery. The staff at
the hospital to which she was taken discussed the cause of
death at the Risk Management Commission. They concluded
that the cause ofdeath was not disease but an extrinsic factor.
They reported the incident to the police, and 3 days after the
patient's death a medicolegal autopsy was performed.
The patient was 153 cm tall and weighed 74 kg. Her
abdomen and both thighs were discolored red or light blue
and the abdomen was distended. Moderate postmortem livid-
ity had appeared on her back. The opening of the peritoneal
cavity revealed 6400 mL of free dark red blood and clots
(Fig. 2). The uterus was approximately 2l cm long and 14 cm
across. There was a hansverse incision in the vesicouterine
pouch. The right side of the overlying peritoneum incision
was sparsely sutured. Three holes, through each of which I
finger could be inserted, were found in the incision. We were
able to enter the subperitoneal space through the holes (Fig.
3). A gauze swab was present on the right side ofthe cervix.
On the surface of the uterus, there was a transverse incision
due to cesarean section, approximately I cm above the
O 2007 Lippincott Williams & Ililkins
FIGURE 2. Free and coagulated blood in the peritoneal cavity.
FIGURE 3. Loosely sutured incision in the peritoneum overly-
ing the uterus.
Incision used in this cas€
Low cesarean section
FIGURE 4. Location of the usual transverse incision made in
the lower segment of the uterus4 and the incision used in
cervical os. Its length was approximately 7 cm (Fig. 4). The
extent of bleeding had expanded greatly into the subperito-
neal space around the surgical site. Although we could not
find the site of damage to the blood vessels, we suspected that
damage to the uterine venous plexus had caused the bleeding
(Figs. 5, 6). The organs were hypoperfused. The autopsy
revealed no significant underlying disease.
We concluded that the patient died of hypovolemic
shock due to bleeding after cesarean section. From the au-
topsy findings and clinical progression, we deduced that the
surgical team was unable to stop the bleeding. Despite the
transfusion of large quantities of blood, hypovolemic shock
occurred and the patient died.
Among the causes of bleeding after cesarean section are
atonic hemorrhaging, retained placenta, puerperal fever, su-
ture failure, and the production of bleeding granulation tis-
FIGURE 5. The incision in the uterus and venous plexus
(after formalin fixation).
FIGURE 6. The incision in the uterus and venous plexus
(view from right side) (after formalin fixation).
sue.3'a In the patient described here, there was little or no
possibility of atonic hemorrhaging, retained placenta, or co-
agulopathy. No placental retention or bleeding within the
uterine cavity was noted in the autopsy and, according to her
clinical chart, her uterus had contracted well. Also, her
history did not include coagulopathy.
On the other hand, there was the possibility of bleeding
due to damage to blood vessels during surgery or the failure
of sutures, because hemorrhaging was noted in the peritoneal
cavity and in the subperitoneal space around the uterus.
@ 2007 Lippincott llilliams & Wilkins
Yaiima et al
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As a general rule, in low cesarean section, a transverse
incision is made into the anterior wall at the center, or a little
above the center, of the lower uterine segment (Fig. a). The
surgeon needs to take care not to extend the incision too far
laterally, because there are uterine venous plexuses in these
areas.' In the case in question, the incision was made very
low, approximately I cm from the cervical os. Furthermore,
the incision was extended further than normal to the right
(Figs. 5, 6). The extension of the incision seems to have been
made by the head or neck of the baby because the surgical
incision was made very low and it could not allow the exit of
the baby's head. We suspect that this extension of the incision
damaged the venous plexus around the lower uterine segment
and caused the bleeding.
With respect to the question of suture failure, we found
that both edges of the uterine wound were tightly sutured.
There was little possibility of suture failure. However, sutur-
ing of the peritoneum was not complete. There is no reliable
standard that surgeons can use to determine whether sutures
are sufficiently tight, although some surgeons think that such
a standard is not always required.6 However, in this patient,
the bleeding could expand into the peritoneal cavity through
the opening in the peritoneum.
When bleeding continues and is uncontrollable after
cesarean section, the surgeon needs to consider performing
arterial ligation or hysterectomy for the purpose of saving the
mother's life and should treat for disseminated intravascular
coagulation (DIC) promptly.a'z-t t In this patient, although the
ascending branch of the left uterine artery was ligated, no
other surgical hemostasis was performed. Because bleeding
had continued, we suspected the occurrence of DIC, although
findings of DIC were not noted in the historical examination
after the autopsy.
Although the surgeons in this case had great difficulry
in controlling the bleeding and performed blood transfusions,
they left a gavze swab inside the mother's body and com-
pleted their surgery. It is therefore possible that they had felt
uneasy about hemostasis.
The surgeons used lidocaine and nitrous oxide as the
anesthetic. The depth of anesthesia had been normal and malig-
nant hyperthermia had not been noted during the operation.
Placentation and the placenta itself were normal. Amni-
otic fluid embolism was not noted in the historical examination.
Judging from the autopsy findings and the clinical
course, in this patient there was little or no reason for her
death except for venous bleeding.
We can deduce that the bleeding was venous and had
expanded into the peritoneal cavity ttuough the openings in the
peritoneum, after which the patient fell into hypovolemic shock.
When the cause of death is suspected to be bleeding
after cesarean section, we recommend that an autopsy be
performed, paying attention to the following points:
. the presence ofany relevant disease or condition that may
facilitate easy bleeding (eg, atonic hemorrhaging, retained
. the presence of damage to the large vessels around the
. the presence of damage to the venous plexuses of the uterus
. the state of ligation of the incision in the uterus
. the state of ligation of the incision in the peritoneum
. the location and size of the surgical incision in the uterus
. whether, what, and when surgical hemostasis was indicated
. the presence of amniotic fluid embolism
. the presence of anesthesia complications
Disputes over medical treatrnent occur often in the field
ofobstetrics and gynecology and account for one third ofall
treatment disputes. Moreover, disputes over procedures fol-
lowed during labor account for the majority of these.T In
obstetrics and gynecology, TOoh of all accidents or mistakes
happen in the perinatal period. In regard to the mother, many
mistakes are related to cesarean section, bleeding, and the use
of uterotonic agents.12 In light of this situation, the number of
autopsies performed in relation to cesarean section is likely to
increase. We recommend that close attention be paid to the
abovementioned points during such autopsies.
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