What is the management approach for hemoperitoneum post Lower Segment Caesarean Section (LSCS)?

Management of Hemoperitoneum Post-LSCS

Hemoperitoneum following lower segment cesarean section requires immediate hemodynamic stabilization, urgent imaging with CT or ultrasound to identify the bleeding source, and surgical re-exploration in most cases, as conservative management is rarely successful for significant intra-abdominal hemorrhage. 1, 2

Immediate Stabilization and Assessment

• Assess hemodynamic stability immediately by checking vital signs, signs of hypovolemia (tachycardia, hypotension, altered mental status), and severity of active bleeding 2
• Establish large-bore IV access (two lines minimum) and initiate aggressive fluid resuscitation with crystalloids initially, followed by blood products as needed 2
• Obtain baseline laboratory studies urgently: complete blood count, coagulation profile (PT, PTT, INR, fibrinogen), type and crossmatch for at least 4-6 units of packed red blood cells 2
• Maintain normothermia (>36°C) as hypothermia severely impairs clotting factor function and worsens coagulopathy 2
• Do not delay intervention while waiting for laboratory results if the patient is hemodynamically unstable—treat based on clinical presentation 2

Diagnostic Imaging

• CT abdomen and pelvis with IV contrast is the gold standard for hemodynamically stable patients to determine the presence of active hemorrhage, localize bleeding, and identify the source 1
• Look for specific CT findings: active contrast extravasation (indicates ongoing arterial bleeding), hematoma location (bladder flap, subfascial, perivaginal space), uterine rupture signs (gas in myometrial defect extending to parametrial tissue with hemoperitoneum), or uterine dehiscence (>5 cm bladder flap hematoma) 1
• Transvaginal or transabdominal ultrasound can be performed at bedside for unstable patients to rapidly confirm hemoperitoneum, though it is less specific for identifying the bleeding source 3
• Small hematomas (<4 cm) may not be clinically significant and can be managed conservatively, but larger collections require intervention 1

Surgical Management

Surgical re-exploration (relaparotomy or laparoscopy) is the definitive treatment for significant hemoperitoneum post-LSCS, as conservative management rarely controls substantial intra-abdominal bleeding 3

Indications for Immediate Surgical Intervention:

• Hemodynamic instability despite aggressive resuscitation 2, 3
• Active ongoing hemorrhage demonstrated on imaging 1
• Large or expanding hematomas (>4-5 cm) 1
• Signs of uterine rupture (gas in myometrial defect, parametrial extension) 1
• Clinical deterioration with falling hemoglobin despite transfusion 3

Surgical Approach:

• Relaparotomy is preferred for unstable patients or when extensive exploration is needed 3
• Laparoscopy may be considered for stable patients with localized bleeding sources and adequate visualization 3
• Perform systematic exploration: examine the uterine incision line, broad ligament vessels, ovarian vessels, bladder flap, and all peritoneal surfaces for bleeding sources 4, 3
• Achieve meticulous hemostasis with suture ligation of bleeding vessels, as diffuse oozing may indicate coagulopathy requiring correction 3
• Place surgical drains to monitor for rebleeding postoperatively 3

Massive Transfusion Protocol

• Transfuse blood products in 1:1:1 ratio (packed red blood cells: fresh frozen plasma: platelets) if massive hemorrhage occurs (>1500 mL blood loss or ongoing bleeding) 2
• Administer tranexamic acid (1 gram IV over 10 minutes, then 1 gram over 8 hours) within 3 hours of delivery to reduce bleeding risk 2
• Correct coagulopathy aggressively: target fibrinogen >200 mg/dL with cryoprecipitate, platelets >50,000/mm³, INR <1.5 1, 2
• Do not wait for laboratory confirmation before initiating massive transfusion protocol in clinically obvious hemorrhagic shock 2

Uterotonic Agents

• Administer uterotonics aggressively even though the primary issue is surgical bleeding, as uterine atony may be a contributing factor 2
• Oxytocin infusion: 10-40 units in 1000 mL crystalloid at 125-200 mL/hour 2
• Methylergonovine 0.2 mg IM (avoid if hypertensive) 2
• Carboprost 250 mcg IM every 15-90 minutes (maximum 8 doses; avoid if asthmatic) 2
• Misoprostol 800-1000 mcg rectally 2

Interventional Radiology

• Uterine artery embolization may be considered for hemodynamically stable patients with persistent bleeding after initial surgical control, particularly if a vascular source (pseudoaneurysm, arteriovenous malformation) is identified 1, 2
• CTA (CT angiography) should be performed before embolization to identify feeding vessels and plan the procedure 1
• Embolization is NOT appropriate for unstable patients or when uterine rupture/major surgical bleeding is suspected—these require immediate surgical repair 1

Specific Etiologies to Consider

Uterine Rupture:

• CT findings: gas in myometrial defect extending to parametrial tissue, hemoperitoneum, disruption of all uterine layers including serosa 1
• Requires immediate laparotomy with uterine repair or hysterectomy depending on extent of injury 1

Broad Ligament Vessel Rupture:

• Rare but life-threatening cause of hemoperitoneum post-LSCS, often from variceal rupture or vessel injury during surgery 4
• Requires surgical exploration with vessel ligation 4

Coagulopathy-Related:

• Consider DIC, HELLP syndrome, or anaphylaxis if diffuse oozing without clear surgical source 1, 5
• HELLP syndrome: check liver enzymes, LDH, peripheral smear for hemolysis 1
• Anaphylaxis to prophylactic antibiotics: rare but can cause DIC and hemoperitoneum 5

Postoperative Management

• Intensive care unit monitoring for at least 24-48 hours with continuous hemodynamic monitoring 2, 6
• Serial hemoglobin/hematocrit checks every 4-6 hours initially to detect rebleeding 2
• Monitor drain output closely for ongoing bleeding 3
• Maintain low threshold for re-exploration if clinical deterioration, falling hemoglobin, or increasing drain output occurs 6
• Initiate pharmacologic thromboprophylaxis with low molecular weight heparin once hemostasis is secured (typically 12-24 hours post-surgery) 2

Critical Pitfalls to Avoid

• Never delay surgical intervention in hemodynamically unstable patients while pursuing imaging or conservative measures 2, 3
• Do not underestimate blood loss: intra-abdominal bleeding can be massive (>3 liters) without obvious external signs 4, 3
• Avoid blind digital examination before imaging excludes vascular abnormalities or placental complications 2, 7
• Do not rely on initial hemoglobin as it may not reflect acute blood loss until hemodilution occurs hours later 3
• Recognize that small hematomas on initial imaging can rapidly expand—maintain high clinical suspicion and repeat imaging if clinical deterioration occurs 1