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We present a case of profuse intraoperative bleeding during cesarean section probably caused by a misplaced copper-T perforating the broad ligament.
A 23-year-old healthy woman was scheduled for an emergency cesarean section. She had a copper-T inserted 4 years ago but when she went to the same dispensary for removal of copper-T 2 years ago, she was told that there was no copper-T inside as the intrauterine device (IUD) threads were not visible. Her pressure was 140/80 mmHg and heart rate 100 beats/min, regular. In the operating room, after preoxygenation with 100% oxygen, rapid sequence induction of anesthesia was performed with thiopentone and tracheal intubation was facilitated with suxamethonium. Anesthesia was maintained with nitrous oxide and halothane in oxygen and neuromuscular blocking agent. At delivery, oxytocin 10 units and pethidine 25 mg were given intravenously. During closure of uterine incision, fresh bleeding from the right side of the uterus was noted which on examination did not appear to be from the present uterine incision. Meanwhile, systolic blood pressure decreased to 90 mmHg and heart rate increased to 140 beats/min. Ringer lactate was rapidly infused. On exploration, a large hematoma in the right broad ligament extending up to the retroperitoneal area and a white object protruding out from the posterior aspect of broad ligament were found. This was pulled out and found to be copper-T. Further, a small rent, approximately 2 cm long was seen at the previous uterine scar on the right side. To control the profuse bleeding, the surgeon exposes the right internal iliac artery and ligated it. Once the bleeding was under control, the wound was closed under layers. Meanwhile, 1 unit of fresh whole blood was transfused and the patient's systolic blood pressure improved to 108 mmHg and heart rate 114 beats/min. At the end of surgery, neuromuscular blockade was reversed with neostigmine and atropine and the patient was extubated. The subsequent postoperative course was uneventful.
There is no cause of bleeding from the broad ligament during cesarean section but in our case bleeding occurs due to perforation of broad ligament by misplaced copper-T. The bleeding being profuse and occurring from the unexpected site away from uterine incision led to a delay in its identification and control resulting in hypotension. The management necessitated ligation of the internal iliac artery because the site of bleeding could not be ascertained due to the presence of blood in the operative field. We speculated that the copper-T had perforated the wall of the uterus as evidenced by a small rent on the side and was lying quiescent in the broad ligament. But on manipulation during the cesarean section, it perforated one of the uterine blood vessels which caused bleeding.
IUDs have been reported to perforate neighboring viscera such as rectum,[1,2] sigmoid colon and the bladder.[4,5] But perforation of broad ligament presumably due to the intraoperative handling of the tissues leading to profuse bleeding and circulatory disturbance is unknown.
In conclusion, our report serves to highlight some important facts. One should not believe that copper-T may have been expelled spontaneously even if pregnancy occur in a patient who had copper-T inserted which was not removed until and unless the patient herself presents or has seen it on expulsion.