Multimodal postpartum imaging of a severe case of Couvelaire uterus

OBJECTIVES: Placental abruption occurs when a normally implanted placenta prematurely separates, causing rupture of decidual spiral arteries and retroplacental hemorrhage. Estimates place the incidence of placental abruption somewhere between 0.22% and 1% of all deliveries. Clinical abruption represents a spectrum from mild to the most severe form, in which blood can extravasate into or through the myometrium, the broad ligament, or the peritoneum, causing the uterus and surrounding structures to take on a blue discoloration. This phenomenon is a clinical entity known as Couvelaire uterus, so named because it was first described by French physician Alexandre Couvelaire in the early 20th century as “uteroplacental apoplexy.” Its incidence is difficult to estimate because it has classically been diagnosed only by direct intraoperative visualization. Imaging is not usually indicated in this clinical setting, so radiologic correlation with operative findings has not been previously described. CASE PRESENTATION: In this report, we discuss the case of a multipara who presented with abdominal pain and vaginal discharge several days after a classical cesarean delivery. Her prolonged and complex clinical course led to evaluation via several radiologic modalities. At first, a focal placenta accreta or retained products of conception were suspected, however these diagnoses did not correlate with the patient’s reported intraoperative findings of a clean endometrial cavity or with histopathology that was consistent with massive abruption. CONCLUSIONS: The clinical presentation and features identified on multimodal imaging were ultimately most consistent with the patient’s intraoperative diagnosis of Couvelaire uterus.