{"paper_id":"16ebc1d7-f24b-4e08-b1d2-015237b5b85f","body_text":"International Journal for Multidisciplinary Research (IJFMR) \n \nE-ISSN: 2582-2160   ●   Website: www.ijfmr.com       ●   Email: editor@ijfmr.com \n \nIJFMR23022204 Volume 5, Issue 2, March-April 2023 1 \n \nIs Adenomyosis a Rare Cause of Post-Partum \nHaemorrhage? \n \nGanesh Ramachandran \n \nAssociate Professor Obstetrics and Gynae \nMd (Usm) Frcog (London) Cert Menopause Mgmt (Columbia) \nCimhse (Hong Kong) Exec Dip In Adv Leadership And Mgmt (Uk) Fmsa (M’sia) \nSchool of Medicine, Faculty of Health and Medical Sciences, Taylor’s University \n \nAbstract \nPost-partum haemorrhage is the leading cause of maternal mortality  worldwide. The use of management \nguidelines has improved outcomes resulting in reduction in mortality rates.  Adenomyosis is associated \nwith infertility. Anecdotal reports of adverse pregnancy outcomes have been described. 2 cases of \nsecondary post-partum haemorrhage are described in this report  with a short discussion of its causation \nand impact. \n \nKeywords: Adenomyosis; Post-Partum Haemorrhage; Maternal Mortality \n \nCase 1 \nA 35 year old P1  presented at 10 days post vaginal delivery with bleeding. She was afebrile, \nnormotensive but tachycardic. The abdomen was soft and the uterus just palpable. Pelvic examination \nrevealed an open cervical os and a 14-week size uterus. A diagnosis of retained products of conception \nwas entertained and curettage was undertaken under appropriate antibiotic cover. The procedure was \nuneventful; blood loss was about 800ml intra operatively. The post-operative period was uneventful, and \nthe patient was discharged after 2 days. Histopathology at review revealed strips of curetting as \nmyometrium with adenomyotic foci. No other significant findings were noted. \n \nCase 2 \nA 38 year old  multiparous lady presented 2 weeks post normal vaginal delivery with profuse bleeding. \nShe was hypotensive and tachycardic with a soft abdomen and a 16 week size uterus on palpation. The \nuterus was soft to firm in consistency. There was no response to conservative managemen t with \noxytocics and following initial resuscitation she underwent an examination under anaesthesia. Due to \ncontinued bleeding in theater a decision to perform a total abdominal hysterectomy was made. Total \nblood loss was about 2500ml and 3 units of whole blood were transfused intra operatively. Recovery \nwas uneventful and histopathology revealed an adenomyotic uterus. There was no evidence of retained \nproducts of conception. \n \nDiscussion \nAbout 830 women die every day due to pregnancy or a related complicati on (1). Post -partum \nhaemorrhage, hypertensive diseases in pregnancy and sepsis account for more than 50% of these deaths  \n\n \nInternational Journal for Multidisciplinary Research (IJFMR) \n \nE-ISSN: 2582-2160   ●   Website: www.ijfmr.com       ●   Email: editor@ijfmr.com \n \nIJFMR23022204 Volume 5, Issue 2, March-April 2023 2 \n \n(2). Worldwide the chief cause of maternal mortality is post -partum haemorrhage, the primary cause \nbeing uterine atony. It is estimated that a woman dies every 10 minutes due to post -partum haemorrhage \n(3) and the major burden of this catastrophe is shouldered by the underdeveloped and developing world.  \nIn Malaysia, post-partum haemorrhage is still a major cause of matern al mortality accounting for about \n11% of cases (4). Post-partum haemorrhage is however no longer the chief cause of maternal mortality in \nMalaysia. \nThe reduction in maternal mortality attributed to post-partum haemorrhage maybe attributed to the wide \nspread use of protocols and simulation to  manage the 4 major causes of primary post-partum \nhaemorrhage viz atony, retained products, genital tract trauma and coagulopathy.  \nAdenomyosis is a non-neoplastic benign disorder characterized by the invasion of endomet rium into the \nmyometrium. Traditionally it was thought to be common in multiparous women , presenting with heavy \nmenstrual bleeding and dysmenorrhea . A  definitive diagnosis can  be made only by  examination of \nhysterectomy specimens. Limitations in other modalities for diagnosis have hampered diagnosis of this \ncondition without surgery. Recent improvements in imaging techniques such as trans -vaginal ultrasound \nand magnetic resonance imaging have  made diagnosis possible in younger patients  with symptoms of \ndysmenorrhea and heavy menstrual bleeding . It is also becoming increasingly evident that adenomyosis \nmay be associated with concurrent endometriosis and possibly infertility as well (5). \nThe association of adenomyosis with poor pregnancy outcome has been established though numbers are \nsmall. A study of the literature yielded 29 cases (5).  Complications include: \n• Preterm birth. \n• Premature rupture of membranes. \n• Increased risk of caesarean section. \n• Post-partum haemorrhage/uterine atony. \n• Uterine rupture. \nThe exact cause of post-partum haemorrhage in these patients  with adenomyosis  is unclear but it has \nbeen suggested that myometrium function maybe impaired due to endometrial invasio n resulting in \nuterine atony (5). This would normally result in primary post -partum haemorrhage as compared to the 2 \ncases in our series who presented with secondary post-partum haemorrhage. \nIn both the cases described above the patients were in their mid-thirties, this fits into the demographic of \npatients who may present with adenomyosis.  \nAdenomyosis may be associated with infertility. Treatment of infertility may result in multiple \npregnancy and these patients are often subject to induction of labour and caesarean section for delivery. \nAll of the se three latter conditions are independent risk factors for post -partum haemorrhage as well.  \nThis may partially explain the increased risk of post -partum haemorrhage in patients with adenomyosis \nand infertility. Our 2 patients however did not have any such risk factors.  \nPatients in whom the diagnosis of adenomyosis is suspected prior to pregnancy should be treated as  high \nrisk for post -partum haemorrhage a nd the other complications enumerated above  (2). However, this is a \nchallenge as up to 30% of patients with adenomyosis are asymptomatic (5). \nChanges in the demography of patients, advancing maternal age, increasing rates of infertility and its \ntherapeutic options will result in more high-risk pregnancies. While it is clear that there exists an \nassociation between adenomyosis and adverse obstetric outcomes, t he exact mechanisms are unclear. \nUntil clear pathophysiological pathways are worked out the associat ions are anecdotal but should not be \nignored. Awareness of the possibility of complications and the adverse outcomes  associated with \n\n \nInternational Journal for Multidisciplinary Research (IJFMR) \n \nE-ISSN: 2582-2160   ●   Website: www.ijfmr.com       ●   Email: editor@ijfmr.com \n \nIJFMR23022204 Volume 5, Issue 2, March-April 2023 3 \n \nadenomyosis and pregnancy will  help avoid the catastrophic consequences that maybe associated with \npost-partum haemorrhage. \n \n \n \n \n \n \n \n \n \n \n \n \nReferences \n1. Oyston C, Rueda -Clausen CF, Baker PN. Current challenges in pregnancy -related mortality. \nObstetrics, Gynaecology & Reproductive Medicine 2014;24:162-9. \n2. Say L, Chou D, Gemmill A, Tunçalp Ö, Moller AB, Daniels J, Gülmezoglu  AM, Temmerman M, \nAlkema L. Global causes of maternal death: a WHO systematic analysis. The Lancet Global Health  \n2014;2:323-33. \n3. Weeks A. The prevention and treatment of postpartum haemorrhage: what do we know, and where \ndo we go to next?. BJOG: An International Journal of Obstetrics & Gynaecology 2015; 122:202-10. \n4. Department of Statistics, Malaysia. Statistics on Causes of Death. 2018.  \n5. Vlahos NF, Theodoridis TD, Partsinevelos GA. Myomas and Adenomyosis: Impact on Reproductive \nOutcome. BioMed research international 2017;2017:5926470. \nPOST PARTUM HAEMORRHAGE IS A MAJOR CAUSE OF MATERNAL \nMORTALITY. \nPROTOCOLS FOR THE MANAGEMENT OF THE MAJOR CAUSES OF POST \nPARTUM HAEMORRHAGE HAVE RESULTED IN BETTER CLINICAL \nOUTCOMES. \nCHANGES IN PATIENT PROFILES IN OBSTETRICS MAY RESULT IN NEW \nCAUSATIONS FOR POST PARTUM HAEMORRHAGE. \nADENOMYOSIS IS ANECDOTALLY ASSOCIATED WITH POST PARTUM \nHAEMORRHAGE. \nVIGILANCE IN THE FACE OF SUCH PATIENTS MAY PREVENT AN \nADVERSE OUTCOME.","source_license":"CC0","license_restricted":false}