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J Emerg Trauma Shock. 2010 Apr-Jun; 3(2): 191–192.
PMCID: PMC2884455

Hematometra and acute abdomen

Abstract

We report a case of a young woman who presented as acute abdomen due to hematometra resulting from cervical fibroid. This uncommon cause of acute abdominal pain should be considered in women especially with amenorrhea.

Keywords: Hematometra, acute abdomen, ultrasonography

INTRODUCTION

The diagnosis of acute abdomen is one of the most daunting tasks in medicine. Acute abdominal pain is the reason for 5% to 10% of all emergency department visits. Hematometra is a rare cause of acute abdomen.

CASE REPORT

A 28-year-old female presented as an emergency with 1½ months’ amenorrhea and acute pain abdomen. She had had two normal deliveries and one intrauterine death, which had been followed by manual removal of the placenta. The patient also complained of reduced flow during periods since 2 years. On examination, the vitals were stable. Per abdominal examination revealed tenderness in the hypogastrium and left iliac fossa. A cystic mass of about 7×8 cm size was felt in the left iliac fossa; the lower border of the mass could not be felt. Pelvic examination was limited by pain. Per speculum examination showed a cervical fibroid arising from the posterior lip of the cervix. The os could not be visualized. Per vaginal examination revealed extreme tenderness on movement of the cervix. Movements of the mass were transmitted to the cervix. An emergency transabdominal ultrasound revealed an enlarged hour-glass shaped uterus, with sudden narrowing in the region of the lower uterine segment. There was an iso-to hyperechoic collection within the endometrial cavity with an approximate volume of 100 ml [Figures [Figures11 and and2].2]. A transvaginal scan showed the collection in the endometrial cavity clearly [Figures [Figures33 and and4].4]. The urine pregnancy test was negative and routine examination was normal. Hemoglobin was 9 g/l and the white blood cell count 14800/mm3. Attempts at dilation of the cervix with Hegar dilators were unsuccessful. The patient underwent diagnostic laparoscopy, which revealed a enlarged cystic uterus. Under anesthesia, the attempt to dilate the cervical os was repeated but was unsuccessful as before.

Figure 1
Transabdominal ultrasound revealed an enlarged uterus and cervical fibroid with iso-to hyperechoic collection within the endometrial cavity; BL-bladder, UT-uterus, H-hematometra
Figure 2
Hand-drawn diagram of the transabdominal scan showing U-uterus; H-hematometra; C-cervical fibroid; and B-bladder
Figure 3
Transvaginal scan showed the iso-to hyperechoic collection in the endometrial cavity clearly; hematometra (H).
Figure 4
Hand-drawn diagram of the transvaginal scan showing uterus (U), hematometra (H), and cervical fibroid (C)

As the patient had requested for hysterectomy, we decided to proceed with a vaginal hysterectomy. During the procedure, while pushing the bladder, the anterior wall of the thinned-out uterus gave way and thick, old, blood was seen coming out of the rent. Histopathological examination of the specimen showed cervical fibroid. The patient was discharged after an uneventful postoperative period.

DISCUSSION

Acquired obstruction of the lower female genital tract is rare.[1] Hematometra is a retention of blood in the uterine cavity caused by obstruction to menstrual flow at the level of the uterus, cervix, or vagina. In older women, the obstruction is usually acquired and occurs at the level of the cervix.[2] In young women, hematometra may be due to congenital anomalies such as an imperforate hymen or a noncommunicating Müllerian duct.[3] Transabdominal sonography is a noninvasive imaging modality useful for examining occlusions of the genital tract.[4] Transvaginal sonography is important in the evaluation of hematometra because it affords clear visualization of the endometrial cavity.[5]

CONCLUSION

The rare possibility of hematometra should be considered in any women presenting with acute abdominal pain, especially when the pain is associated with secondary amenorrhea.

Footnotes

Source of Support: Nil

Conflict of Interest: None declared.

REFERENCES

1. Sherer DM, Khoury-Collado F, Hellmann M, Abdelmalek E, Kheyman M, Abulafia O. Transvaginal sonography of hematotrachelos and hematometra causing acute urinary retention after previous repair of intrapartum cervical lacerations. J Ultrasound Med. 2006;25:269–71. [PubMed]
2. Fisch AE, Jacobson JB. Ultrasound findings in segmental uterine distension. J Clin Ultrasound. 1976;4:209–11. [PubMed]
3. Fujimoto VY, Klein NA, Miller PB. Late-onset hematometra and hematosalpinx in a woman with a noncommunicating uterine horn. A case report. J Reprod Med. 1998;43:465–7. [PubMed]
4. Sheih CP, Liao YJ, Liang WW, Lu WT. Sonographic presentation of unilateral hematometra: report of two cases. J Ultrasound Med. 1995;14:695–7. [PubMed]
5. Scheerer LJ, Bartolucci L. Transvaginal sonography in the evaluation of hematometra. A report of two cases. J Reprod Med. 1996;41:205–6. [PubMed]

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