Couvelaire Uterus

Image Source: The New England Journal of Medicine

Blood within the walls of the pregnant uterus of a 29-year-old woman without any trauma.

A 29-year-old primigravid female who was 33 weeks pregnant presented to the obstetric department with contractions. The patient had no water leak (rupture of membranes) or vaginal bleeding. The patient had no history of any recent trauma.

On pelvic examination, the uterine fundus was firm and tender.

Retroplacental hemorrhage was appreciated on transabdominal ultrasonography (Panel A). Fetal heart-rate tracing showed a nonreassuring pattern with deep variable decelerations.

A decision was made to perform an emergency cesarean section. During the operation, the uterus was bruised due to the infiltration of blood into the myometrium.

The extravasation of blood from the placental blood vessels into the myometrium (the middle layer of the uterine wall) of the uterus is called uteroplacental apoplexy or Couvelaire uterus (Panel B).

A working diagnosis of complicated concealed placental abruption was made.

Placental abruption is the premature separation of the placenta, which leads to hemorrhage. If the blood remains contained between the detached placenta and the uterus, without any per vaginal bleeding, it is called concealed placental abruption.

The blood may seep into the myometrium of the uterine wall (Couvelaire uterus), and rarely it can infiltrate the peritoneal cavity too. Couvelaire uterus is a rarely reported complication of placental abruption, which is accurately diagnosed on direct visualization and/or biopsy, explaining the underreported cases.

In such cases, i.e., concealed hemorrhage, there are chances of a delayed diagnosis due to delayed presentation, consequently leading to higher fetal morbidity and mortality. With placental abruption, there is a risk of intrauterine fetal death or hypoxic brain injury.

Postnatally, the neonate’s APGAR scores were 8 and 9 at 1- and 5- minutes, respectively. The patient was given carbetocin, oxytocin, misoprostol, and tranexamic acid. Her uterus was atonic after the C-section.

The child was under care due to prematurity but was soon discharged after recovering. The postoperative course of the mother remained uneventful, and she made a complete recovery without any long term complications.

The management of Couvelaire uterus is ideally conservative, and hysterectomy is discouraged.


Pradip Dashraath, M. a.-C. (2020, November 12). Couvelaire Uterus. Retrieved from The New England Journal of Medicine:

Rathi M, Rathi SK, Purohit M, Pathak A. Couvelaire uterus. BMJ Case Rep. 2014;2014:bcr2014204211. Published 2014 Mar 31. DOI:10.1136/bcr-2014-204211

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Dr. Arsia Hanif has been a meritorious Healthcare professional with a proven track record throughout her academic life securing first position in her MCAT examination and then, in 2017, she successfully completed her Bachelors of Medicine and Surgery from Dow University of Health Sciences. She has had the opportunity to apply her theoretical knowledge to the real-life scenarios, as a House Officer (HO) serving at Civil Hospital. Whilst working at the Civil Hospital, she discovered that nothing satisfies her more than helping other humans in need and since then has made a commitment to implement her expertise in the field of medicine to cure the sick and regain the state of health and well-being. Being a Doctor is exactly what you’d think it’s like. She is the colleague at work that everyone wants to know but nobody wants to be. If you want to get something done, you approach her – everyone knows that! She is currently studying with Medical Council of Canada and aspires to be a leading Neurologist someday. Alongside, she has taken up medical writing to exercise her skills of delivering comprehensible version of the otherwise difficult medical literature. Her breaks comprise either of swimming, volunteering services at a Medical Camp or spending time with family.


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