I. Case summary The patient, a 28-year-old female, was admitted to the hospital for the second time 20 days after intervention for recurrent irregular vaginal bleeding for more than 2 months mainly after cesarean delivery. The patient underwent a cesarean section (lower transverse uterine incision) at a county hospital in Sichuan on 2009-6-2 because of “39+4 weeks of pregnancy, mixed breech position, premature rupture of membranes”, and delivered a live baby girl weighing 3.4 kg with an Apgar score of 10 out of 10. There was no placental abruption or placental adhesions. The operation went smoothly and the uterus recovered well after the operation. The body temperature was 37.3~37.7℃ on the second day after the operation, and the rest of the body temperature was normal, with a little vaginal bloody malignant fluid. Since her discharge, she has been bleeding irregularly from the vagina, brown in color, complaining of no odor, dripping, small amount, and can use pads. No history of sitting in the bath or sexual intercourse. On 42 days after surgery (2009-7-14), abdominal ultrasound showed that the uterus was 11.2 cm long and 9.4 cm in transverse diameter, 6.7 cm in anterior and posterior diameters, the uterine cavity was separated, the anterior wall of the lower uterus was uneven, the muscle wall at the incision was continuous and not bright, and an echogenic area was seen posteriorly: 2 cm × 1.5 cm. pelvic fluid: 2.5 cm echogenic area was seen in the pelvis. At 21:00 pm, 65 days after the operation (2009-8-6), she suddenly developed heavy vaginal bleeding with blood clots, dark red in volume of about 500 ml. During the gynecological examination, the vaginal bleeding was again about 400ml, and the routine blood test was performed: leukocyte 12.24G/L, neutrophil percentage: 78.8%, hemoglobin 68g/L. Blood β-HCG was 5.46mIU/ml. The patient was given active anti-shock (transfusion of concentrated red blood cells 4u), anti-infection (Roxifene 2.0, VD, qd) and uterine contraction promotion. The vaginal bleeding gradually stopped after the operation, and the anti-infection support symptomatic treatment was continued. Three days after discharge, a small amount of irregular vaginal bleeding, dark red in color, with occasional feeling of lower abdominal cramping, occurred again. On the 85th day after surgery (2009-8-26), the vaginal bleeding increased at noon, and at 18:00 p.m., she suddenly started to bleed heavily again, with blood clots, dark red, about 500 ml, accompanied by chills and low fever. Since the onset of the disease, he had good appetite and normal bowel movements. Past history: He was in good health and had no history of hypertension, diabetes mellitus or heart disease. No history of infectious diseases such as tuberculosis. Menstrual and matrimonial history: past menstruation was regular, the first menstruation was at the age of 14, the cycle was 28 days, and the period was 5-6 days. She was married at the age of 25, had 1 pregnancy and 1 delivery, and had a cesarean section at a county hospital in Sichuan on 2009-6-2 due to “39+4 weeks of pregnancy, mixed breech position, premature rupture of membranes”, and delivered a live baby girl. She was admitted to the hospital for physical examination: body temperature 37.8℃, pulse 105 times/min, respiration 21 times/min, blood pressure 100/60mmHg. Her face was slightly pale, her consciousness was clear and her spirit was fine. The eyelid conjunctiva and mucous membrane of the mouth and lips were slightly pale, and the thorax was symmetrical without deformity. The heart rate was 105 beats/min, rhythmical, and no obvious murmurs were heard. The respiratory sounds of both lungs were clear, and no dry or wet rales were heard. The abdomen was flat and soft, with no pressure pain or rebound pain. The liver and spleen were not palpable under the ribs. A transverse fresh surgical scar was visible at 3 transverse fingers on the pubic bone in the lower abdomen with grade A healing. Specialized conditions: blood stained vulva with clotted blood clots visible from the vaginal opening. Vagina: a large amount of dark red clots could be seen inside. Cervix: smooth, pink surface, rounded orifice, bright red active blood is seen flowing from the ectocervix, negative cervical lifting pain, no abnormal residual tissue is palpated. Uterus, as large as 50+ days of gestation, no significant tenderness, soft, no palpable mass. Adnexa: no pressure pain, no mass was palpated. Auxiliary examinations: routine blood: leukocytes 14.5 G/L, neutrophil percentage: 87.4%, erythrocytes: 2.75 T/L, hemoglobin 76 g/L. CRP: 64 JuL. blood β-HCG was 0.48 mIU/ml. transabdominal ultrasound suggested: uterine body length 8.0 cm transverse diameter 6.8 cm anterior and posterior diameter 4.7 cm, uterine cavity separation, anterior wall of lower uterine segment at The uterine cavity was separated and the anterior wall of the lower uterine segment was uneven, the muscle wall at the incision was continuous and less bright, and an anechoic area was seen posteriorly: 1 cm × 1 cm. Color ultrasound Doppler examination: punctiform blood flow signal was seen at the incision. The remaining auxiliary examinations were not abnormal. The abdominal ultrasound did not show any significant abnormality. Culture of cervical secretion: Enterococcus faecalis was seen, and it was sensitive to vancomycin + ciprofloxacin. Considered “late postpartum hemorrhage, secondary infection after uterine artery embolization, and hemorrhagic anemia (moderate)”, he was monitored for vital signs, given blood transfusion, intensified anti-infection (vancomycin + ciprofloxacin), promoted uterine contraction and supported symptomatic treatment. At the same time, after general discussion and full communication with the patient and her family, total hysterectomy was performed on August 29, 2009 under general anesthesia after preoperative conversation and signature. After one week of postoperative anti-infective and symptomatic supportive treatment, the repeat blood test showed: leukocyte: 6.42G/L, neutrophil percentage: 61.2%, red blood cell: 3.69T/L, hemoglobin: 115g/L, platelet: 270G/L. The repeat CRP: 4JuL. Late puerperal hemorrhage is a common disease in obstetrics and gynecology, one of the serious complications of obstetrics and one of the main causes of maternal death. The main causes of hemorrhage are placenta, fetal membrane and meconium residue, infection of the placental adhesion surface of the uterus or incomplete replantation, infection, and uterine wound dehiscence after cesarean section. Analysis of the causes of late postpartum hemorrhage in this case include: 1. Infection: The patient underwent cesarean section due to premature rupture of membranes and mixed breech position, and the cervical secretion culture of Enterococcus faecalis was found in the second postoperative hospitalization, which may be due to incomplete uterine regeneration caused by infection of Enterococcus faecalis on the placental attachment surface of the uterus, or poor regeneration of the placental attachment surface and poor uterine contraction caused by inflammation of the endometrium caused by Enterococcus faecalis, and incomplete closure of the blood sinus resulting in uterine hemorrhage. 2. Poor wound healing of the uterus after cesarean section, the patient has susceptibility factors of poor incision healing due to premature rupture of fetal membranes before surgery, if the previous cesarean section is of poor quality, such as poor intraoperative hemostasis, especially at both sides of the lower transverse incision of the uterus, the formation of local hematoma or local infection tissue necrosis, resulting in non-healing incision; or abnormal selection of the lower transverse incision of the uterus: too high will cause a large difference in the thickness of the upper and lower edges of the incision, when suturing not easily aligned. Or the incision is too low, the blood supply is poor, and it is close to the vagina, which increases the chance of infection and causes poor healing of the incision; or improper suture technique, poor tissue alignment, poor suture of bleeding vessels, failure to suture retracted vessels on both sides of the incision to form hematoma, too much and too dense suture of tissues, and poor local blood circulation supply, etc., all of which can easily cause poor healing of the incision. Lessons learned: 1. Improve the quality of obstetrics, especially the quality of obstetrical surgery and the quality of critical care. 2. Patients with susceptibility to poor incision healing due to premature rupture of fetal membranes before surgery outside the hospital should be hospitalized as early as possible when first hospitalized, and bacteriological evidence should be obtained: send vaginal cervical secretion culture + drug sensitivity, select antimicrobial agents in a targeted manner, and use them in adequate doses and courses. 3. Patients after cesarean section are generally not Consider placenta-fetal membrane residue, mainly consider infection or cesarean delivery uterine incision dehiscence, only a small amount of bloody malignant fluid, easy should be hospitalized as soon as possible, closely monitored, otherwise delay the disease. 4, and in the emergency uterine artery interventional embolization, not appropriate to add high efficiency broad-spectrum antimicrobial agents mixed with gelatin sponge embolization, affecting the final treatment effect. Third, expert comments late postpartum hemorrhage refers to the massive uterine bleeding that occurs 24 hours after delivery and during the puerperium, called late postpartum hemorrhage (1ate puerperal hemorrhage). The onset of hemorrhage is most common one or two weeks after delivery, but it may occur as late as six weeks after delivery. The vaginal bleeding is small or moderate, continuous or intermittent; it can also be characterized by sudden and heavy bleeding with blood clots. It is often accompanied by chills and low fever, and often results in severe anemia or hemorrhagic shock due to excessive blood loss. In recent years, due to the development of various electronic monitoring technology and social factors, the rate of cesarean delivery has been increasing year by year, leading to the rise of various complications of cesarean delivery, late postpartum hemorrhage is one of the more serious ones, which often occurs 2-3 weeks after delivery, when the mother is already at home and suddenly has a lot of vaginal bleeding, which can endanger the life of the mother if not rescued in time. The etiology and clinical manifestations of late postpartum hemorrhage: ① Placenta-fetal membrane and meconium residue, placenta-fetal membrane residue mostly occurs about 10 days after delivery, the residual placental tissue adhering to the uterine cavity degenerates, necrosis, mechanization, forming placental polyp, when the necrotic tissue falls off, the blood sinus is exposed, or the meconium is not fully stripped, affecting the uterus recovery, secondary to endometritis, causing late postpartum hemorrhage. The clinical manifestations are prolonged duration of bloody malignant fluid, followed by repeated bleeding or hemorrhage. Gynecological examination: incomplete uterine regeneration and loosening of the uterine opening. ②Infection: infection after cesarean section is mainly caused by anaerobic bacteria and aerobic bacteria inherent in the vagina and cervix or intestinal flora displacement, of which anaerobic bacteria are up to 70% ~ 80%. Preoperative patients with multiple anal or vaginal examinations are potential factors for infection, and prenatal infection factors (such as premature rupture of membranes) should also be noted. (3) Incomplete placental adhesion site: due to placental adhesion site infection, the uterus is incompletely repaired, resulting in thrombus dislodgement, blood sinus reopening, causing uterine bleeding. This kind of bleeding mostly occurs 2 weeks after delivery, manifesting as sudden massive vaginal bleeding, examination reveals that the uterus is large and soft, the uterine opening is loose, and the vagina and uterine opening are blocked by blood clots. Anatomical factors: The uterine artery enters the uterus at a right angle at the endocervix, its superior branch is oblique upward and its inferior branch is oblique downward, each dividing into anterior and posterior arcuate arteries to nourish the uterus. The arcuate artery in the isthmus is less and shorter than the vascular branches in the body of the uterus and lacks anastomotic branches, so the transverse incision of the lower uterine segment is easy to cut off the oblique branches of the uterine artery, resulting in insufficient blood supply to the incision, local necrosis and secondary infection; the extended laceration of the transverse incision of the lower uterine segment: the position of the incision of the lower segment is too low, or the fetal head is deep into the pelvis, resulting in delivery difficulties, or it is difficult to take the head when the fetal head is high and floating, plus the thinness of the lower uterine segment at this time, which is easy to cause The lower uterine segment is too high, which will cause the thickness of the upper and lower edge of the incision to be different, and the sutures will not be easily aligned. Or the incision is too low, the blood supply is poor and it is close to the vagina, which increases the chance of infection and causes poor healing of the incision. Improper suture technique, poor tissue alignment, poor suturing of bleeding vessels, failure to suture retracted vessels at both corners of the incision to form hematoma, excessive and dense suture tissue, poor local blood circulation supply, or susceptibility factors such as premature rupture of membranes, prolonged labor, multiple vaginal examinations and intraoperative bleeding or anemia before surgery, resulting in poor incision healing. All of them can be caused by the dissolution and detachment of the intestinal cord, reopening of the blood sinus, massive vaginal bleeding, and even shock. ⑤ Others such as: submucosal myoma or trophoblastic tumor of uterus, etc. The main prevention and control measures include: ① Strictly control the indications for cesarean delivery. ②Rational and adequate use of antibiotics:Bacteriological evidence and drug sensitivity results should be obtained within the first time. ③Improve the quality of obstetrics (cesarean section and obstetric critical care techniques). ④ Correct prenatal and postnatal anemia status and increase resistance. ⑤ Check the placenta and fetal membranes carefully after delivery to exclude residual. If placenta residue cannot be excluded, the uterine cavity should be explored and antibiotics should be applied postoperatively for prevention. The principles of treatment are: ① conservative treatment: for small or moderate amount of vaginal bleeding, broad-spectrum bacteriocin, uterine contraction and supportive therapy should be given; ② scraping: for suspected placenta, fetal membrane or meconium residue, the uterus can be scraped under B ultrasound surveillance under the conditions of open venous access, blood preparation and preparation for surgery, the operation should be gentle to prevent uterine perforation. The scrapings should be sent for pathology. Postoperative anti-infection and pro-uterine contraction therapy should be continued. ③ Interventional or hysterectomy surgery: If the uterine incision is suspected to be split by cesarean section, only a small amount of vaginal bleeding should be hospitalized and given broad-spectrum antibiotics and supportive treatment, and close monitoring. If there is a lot of vaginal bleeding, caesarean section is feasible. If the necrosis around the incision is small, debridement and suturing, internal iliac artery or uterine artery ligation or internal iliac artery embolization are feasible. If peri-incisional tissue necrosis is extensive, subtotal hysterectomy or total hysterectomy at low level is indicated as appropriate. Infection or incisional dehiscence after cesarean section is the most common cause of late postpartum hemorrhage after cesarean section. In this case, the patient had susceptibility to infection of the uterine incision due to premature rupture of fetal membranes before surgery or incisional dehiscence after cesarean section, so when there was only a small amount of bloody malignant fluid, easy should be hospitalized as early as possible, closely monitored, bacteriological evidence obtained, and antibiotics used in a reasonable and adequate amount. Keep in mind the strict indications for cesarean delivery to improve the quality of obstetrics and prevent the serious complication of late postpartum hemorrhage.