The most common etiology of postpartum hemorrhage is uterine atony, although hematologic disorders may be present. A 36-year-old nulliparous woman underwent puerperal hysterectomy caused by uncontrolled postpartum hemorrhage. One day after discharge, she vomited in the emergency room a 24-cm long Ascaris lumbricoides. Infestation during gestation may cause hematologic disorders that could complicate pregnancy outcome.
Postpartum hemorrhage causes 536,000 deaths worldwide every year. When conservative procedures fail, puerperal hysterectomy is the ultimate option, which is performed in 10% of postpartum hemorrhage cases. The main bleeding causes are uterine atony and vaginal tearing, although placenta accreta and coagulation disorders have also been reported. We report here a case of concurrent puerperal hysterectomy with ascariasis. To our knowledge, this is the first case describing a suspected association between postpartum hemorrhage and infestation with the parasitic worm Ascaris lumbricoides.
Case report
A 36-year-old nulliparous Ecuadorian woman was admitted to the emergency room in her 37th week of gestation in established labor and with mild diarrhea. Her medical and surgical histories were unremarkable and her pregnancy was uneventful.
At admission all hematological parameters were normal (hemoglobin 126 g/L, hematocrit 5 41%, white blood cells count 7.2·10 9 /L, platelets 260·10 9 /L, activated partial thromboplastin time 41 seconds, bleeding time 487 seconds, fibrinogen 2.3 g/L), except for slightly prolonged prothrombin time (international normalized ratio [INR], 1.6) and mild eosinophilia (0.54·10 9 /L, 7.5% of white blood cells).
After the delivery of a healthy newborn by cesarean section because of fetal distress, in which excessive bleeding was noticed, postpartum hemorrhage developed in the absence of severe uterine atony, placental retention, or vaginal tear. Conservative procedures including medical treatment with oxytocin, rectal methylergometrine, and prostaglandins to ensure complete uterine contraction and because uterine bleeding did not stop, vascular ligation of first uterine arteries and second internal iliac arteries were carried out. Blood tests revealed progressive alteration on coagulation parameters after an estimated blood loss of 950 mL. Hence, after administration of packed red blood cells, fibrinogen, prothrombin complex, and activated factor VII, puerperal hysterectomy was performed to stop the hemorrhage.
There were no postoperative complications, diarrhea resolved, and she did not require more transfusions. Hematological coagulation values returned within normality but eosinophilia (0.49·10 9 /L, 6.6% of white blood cells) and prothrombin coagulation time, which was still prolonged, with INR 1.5 at the time of discharge (8 days after admission), so further hematological control was programmed.
One day after discharge from the hospital, the patient returned to the emergency room with intense abdominal pain and nausea. INR at admission was still 1.5. After 4 hours of conservative management, she vomited a 24-cm long Ascaris ( Figure ). The patient was treated in puerperium with mebendazole 100 mg a day during 3 days. There were no secondary effects to the drug, and the coagulation values decreased to normal ones (INR, 1.1), and no other alterations were found in the hematological controls. Pathological evaluation of the uterus revealed neither abnormal placentation nor any laceration. After 1 year of follow-up, the patient remained asymptomatic.
