I. Case summary The patient, a 28-year-old woman, was admitted to the hospital for the second time 20 days after intervention for recurrent irregular vaginal bleeding for more than 2 months after cesarean section. The patient was admitted to the hospital for the second time 20 days after the intervention. The patient underwent a cesarean section (lower uterine incision) in a county hospital in Sichuan province on June 2, 2009 because of “39+4 weeks’ gestation, mixed breech position, premature rupture of membranes”, and a live baby girl was delivered, weighing 3.4 kg, with an Apgar score of 10 points out of 10. The amniotic fluid during the operation was in the second degree, and the placenta-placenta membranes were delivered intact without placenta previa or adhesions. There was no placental abruption or placental adhesions. The operation went smoothly, the uterus recovered well after the operation, the temperature was 37.3~37.7℃ on the second day after the operation, the rest of the body temperature was normal, and there was a little bloody vaginal discharge, and she was discharged from the hospital 5 days after the operation. After being discharged from the hospital, she had been bleeding irregularly, brownish, with no odor, dripping, small amount, and could use pads. There was no history of sitz bath or sexual intercourse. 42 days after surgery (2009-7-14), abdominal ultrasound: uterine body length 11.2cm transverse diameter 9.4cm anterior and posterior diameters of 6.7cm, separation of the uterine cavity, the lower part of the uterus at the anterior wall of the unevenness of the incision at the myometrial wall is continuous, less than the light and smooth, and its posterior to see the anechoic area: 2cm × 1.5cm. pelvic effusion: pelvic cavity can be seen in the anechoic area of 2.5cm. At 21:00 pm on the 65th day after the operation (2009-8-6), there was a sudden onset of heavy vaginal bleeding, accompanied by blood clots, dark red in color, amounting to about 500 ml, and she was admitted to the hospital as a case of “late postpartum hemorrhage and hemorrhagic anemia” in the emergency room. In the course of the gynecological examination, there was again vaginal bleeding of about 400 ml, and the routine blood test showed that the leukocytes were 12.24 G/L, the neutrophil percentage was 78.8%, and the hemoglobin was 68 g/L. The blood β-HCG was 5.46 mIU/ml, and the patient was actively anti-shocked (transfusion of 4 u of concentrated erythrocytes), anti-infected (rocephin 2.0, VD, qd), and promoted the uterine contraction at the same time. The uterine artery embolization was performed at 23:00 on the same day, after which the vaginal bleeding gradually stopped, and the symptomatic treatment was continued with anti-infective support for one week of hospitalization, and the blood routine was checked: leukocytes were 8.09G/L, neutrophils were 70%, and hemoglobin was 97g/L. The patient was cured and discharged from the hospital. Three days after discharge from the hospital, a small amount of irregular vaginal bleeding occurred again, dark red, and occasionally felt lower abdominal distension. On the 85th day after the operation (2009-8-26), the amount of vaginal bleeding started to increase at noon, and at 18:00 in the evening, there was again a large amount of vaginal bleeding, accompanied by blood clots, dark red in color, amounting to about 500 ml, accompanied by chills and low-grade fever, so she was admitted to the hospital as an emergency case of “late postpartum hemorrhage after uterine artery embolization and hemorrhagic anemia”. Since the onset of the disease, she had good appetite and normal bowel movements. Past history: she was physically fit and had no history of hypertension, diabetes mellitus, heart disease, etc. She had no history of tuberculosis or other infectious diseases. No history of tuberculosis or other infectious diseases. History of menstruation and marriage: regular menstruation, first menstruation at 14 years old, cycle of 28 days, menstrual period of 5-6 days. The last menstrual period was on August 28, 2008. 25 years old, married, pregnancy 1, delivery 1, 2009-6-2 due to “39 + 4 weeks of pregnancy, mixed breech position, premature rupture of membranes” in a county hospital in Sichuan, a cesarean section, the delivery of a live baby girl, love and the child is healthy. She was admitted to the hospital with a temperature of 37.8℃, pulse 105 beats/min, respiration 21 beats/min, blood pressure 100/60mmHg. She was slightly pale, clear and in good spirits, and was admitted to the ward on a flatbed with a cooperative physical examination. Eyelids, conjunctiva, and mucous membranes of the mouth and lips were slightly pale, and the thorax was symmetrical without deformity. Heart rate was 105 beats per minute, rhythmic, no obvious murmurs were heard. Breath sounds of both lungs were clear, and no dry or wet rhonchi were heard. Abdomen was flat and soft, with no tenderness or rebound pain. Liver and spleen were not touched under the ribs. A transverse fresh surgical scar was visible in the lower abdomen at 3 transverse fingers above the pubic bone, grade A healing. Specialized conditions: the vulva is blood stained and coagulated blood clots can be seen draining from the vaginal opening. Vagina: a large number of dark red coagulated blood clots can be visualized inside. Cervix: smooth, pink surface, rounded opening, bright red active blood seen flowing from the ectocervix, negative cervical lifting pain, no abnormal residual tissue palpable. Uterus: size of 50+ days of pregnancy, no obvious pressure, soft, no palpable mass. Adnexa: no tenderness, no palpable mass. Auxiliary examination: blood routine: 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: uterine corpus length 8.0 cm transverse diameter 6.8 cm anterior and posterior diameters 4.7 cm, separation of uterine cavities, the anterior wall of lower uterine segment was uneven, the incision was notched. The uterine cavity was separated, and the lower part of the uterus at the anterior wall of the uterus was uneven, and the myometrial wall at the incision was continuous and poorly illuminated, and anechoic area was seen at the posterior part of the uterus: 1cm×1cm. Color ultrasound Doppler examination: punctate blood flow signal was seen at the incision. There were no abnormalities in the remaining auxiliary examinations. Diagnostic and therapeutic experience: after admission to the hospital, complete all the examinations, abdominal ultrasound did not see obvious abnormalities. Cervical secretion culture: Enterococcus faecalis, sensitive to vancomycin + ciprofloxacin. Considering “late postpartum hemorrhage, secondary infection after uterine artery embolization, hemorrhagic anemia (moderate)”, the patient was given monitoring vital signs, blood transfusion, strengthening anti-infection (vancomycin + ciprofloxacin), promoting uterine contraction and supportive and symptomatic treatment. At the same time, after the departmental discussion and full communication with the patient and her family, total hysterectomy was performed on August 29, 2009 under general anesthesia with the signature of preoperative conversation. The operation went smoothly, and after one week of postoperative anti-infective and symptomatic supportive treatment, the routine blood test showed that: leukocytes: 6.42G/L, neutrophil percentage: 61.2%, erythrocytes: 3.69T/L, hemoglobin: 115g/L, platelets: 270G/L. CRP: 4JuL. The patient was discharged from the hospital after being cured. Late postpartum hemorrhage (late puerperal hemorrhage) is a relatively common disease in obstetrics and gynecology, one of the serious complications in obstetrics, and one of the main causes of maternal mortality. It occurs mainly due to residual placenta, fetal membranes and meconium, infection or incomplete restoration of the placental attachment surface of the uterus, infection, and uterine wound dehiscence after cesarean section. Analysis of the causes of late postpartum hemorrhage in this case were: 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 cervical secretion of the second hospitalization after the operation, which may be the incomplete uterine regrowth caused by uterine placenta adherens surface infection of Enterococcus faecalis, or endometrial inflammation caused by Enterococcus faecalis resulting in the poor regrowth of the placenta adherens surface and the uterine contraction, and the incomplete closure of blood sinus resulting in uterine hemorrhage. 2, Poor healing of uterine wounds after cesarean section, patients with preoperative preoperative premature rupture of membranes leading to incision healing susceptibility factors, if the previous cesarean section surgery is of poor quality, such as poor intraoperative haemostasis, especially at the ends of the lower uterine transverse incision, the formation of local haematomas or local necrosis of infected tissues, resulting in the incision does not heal; or the choice of the lower uterine transverse incision abnormality: too high will cause the upper and lower margins of the incision myocardial layer thickness difference is large, the suture is not easy to align. It is not easy to align the incision. Or the incision is too low, the blood supply is poor, and it is close to the vagina, which increases the chance of infection, all of which cause poor healing of the incision; or improper suture technique, poor tissue alignment, bleeding blood vessels are not tightly sutured, the angle of the two sides of the incision is not sutured to the retracted blood vessels to form a hematoma, the suture of the tissues is too much and too dense, and the local blood circulation is poorly supplied, etc, which are all prone to cause poor healing of the incision. Lessons learned: 1, improve the quality of obstetrics, especially the quality of obstetric surgery and the quality of management of critical illnesses. 2, the patient’s preoperative susceptibility to premature rupture of membranes leading to poor incision healing before surgery, the first hospitalization, should be hospitalized as early as possible, and at the same time, to obtain bacteriological evidence: sent to the vagina and cervix secretions for culture + drug sensitivity, targeting the selection of antimicrobial agents, the use of adequate dose, full course. 3, the patient’s post-caesarean section, generally do not Consider the placenta-placenta residue, the main consideration of infection or cesarean section uterine incision cracking, only a small amount of bloody malodor, easy should be hospitalized as early as possible, close monitoring, otherwise delayed condition. 4, and in the emergency for uterine artery interventional embolization, did not properly add a high-efficacy broad-spectrum antimicrobial agent and gelatin sponge mixed with the embolism, which affects the final therapeutic effect. Third, the expert comment late postpartum hemorrhage refers to the massive uterine bleeding that occurs in the puerperium 24 hours after delivery, called late postpartum hemorrhage (1ate puerperal hemorrhage). The onset of hemorrhage is most common at 1 or 2 weeks postpartum, but may occur as late as 6 weeks postpartum. Vaginal bleeding is small or moderate, continuous or intermittent; it can also be characterized by rapid and heavy bleeding, accompanied by the discharge of blood clots. It is often accompanied by chills and low-grade 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 section has been increasing year by year, resulting in various complications of cesarean section, late postpartum hemorrhage is one of the more serious, often occurring 2-3 weeks after delivery, the mother is already at home, the sudden heavy vaginal bleeding, if not rescued in a timely manner, it will endanger the life of the mother. The etiology and clinical manifestations of late postpartum hemorrhage: ① placenta-placenta membrane and meconium residue, placenta-placenta membrane residue occurs about 10 days after delivery, the residual placental tissue adhering to the uterine cavity undergoes metamorphosis, necrosis, and mechanization, forming placenta polyps, when the necrotic tissue is dislodged, the blood sinuses are exposed or the meconium is incompletely peeled off, which affects the uterine regeneration and causes endometritis, resulting in late postpartum hemorrhage. Clinical manifestations are prolonged duration of bloody malignant discharge, followed by repeated bleeding or hemorrhage. Gynecological examination: incomplete uterine regeneration, flaccid uterine opening. ② Infection: post-cesarean section infection is mainly caused by anaerobic and aerobic bacteria inherent in the vagina and cervix or intestinal flora shift, of which the anaerobic bacteria are as high as 70% ~ 80%. Preoperative patients with multiple anal or vaginal examinations are potential factors for infection, and prenatal infections (e.g. premature rupture of membranes) should also be noted. Placental attachment site insufficiency: due to the infection of the placental attachment site, the uterus is insufficiently restored, resulting in dislodgment of thrombus and reopening of blood sinuses, causing uterine bleeding. This kind of hemorrhage mostly occurs 2 weeks after delivery, manifesting as sudden and massive vaginal bleeding, and examination reveals that the uterus is large and soft, the mouth of the uterus is flaccid, and there are blood clots blocking the vagina and the mouth of the uterus. ④ Poor wound healing of the uterus after cesarean section. Anatomical factors: the uterine artery enters the uterus at a right angle at the endocervical os, and its superior branch runs obliquely upward and its inferior branch runs obliquely downward, each dividing into anterior and posterior arch arteries to nourish the uterus. The arcuate artery in the isthmus of the uterus has fewer and shorter branches than that in the body of the uterus and lacks anastomotic branches. Therefore, it is easy to cut off the obliquely running branches of the uterine artery by transverse incision of the lower uterine segment, which leads to insufficient blood supply to the incision, localized necrosis, and secondary infections; Extended laceration by transverse incision of the lower uterine segment: the position of incision of the lower segment is too low or the head of the fetus penetrates deeply into the pelvis and causes difficulty in delivery or it is difficult to take out the head when the head of the fetus is high and floating. Extension of the incision is easily caused by the thinness of the lower part of the uterus; or the choice of the lower uterine transverse incision is abnormal: too high an incision will cause the thickness of the muscle layer on the upper and lower edges of the incision to differ, and it is not easy to be aligned with the suture. Or the incision is too low, the blood supply is poor, and it is close to the vagina, which increases the chance of infection, all of which cause poor healing of the incision. Or improper suture technique, poor tissue alignment, bleeding blood vessel suture is not tight, the two corners of the incision is not retracted blood vessel suture to form hematoma, suture tissue too much and too dense, poor local blood circulation supply; or preoperative premature rupture of membranes, prolonged labor, multiple vaginal delivery, and intraoperative hemorrhage or anemia and other susceptibility factors, resulting in poor healing of the incision. All of them can be due to the dissolution and detachment of intestinal threads, the reopening of blood sinuses, the emergence of massive vaginal bleeding, or even shock. ⑤ Others, such as uterine submucous fibroid or uterine trophoblastic tumor. The main preventive and curative measures include: ① Strictly grasp the indication of cesarean section. ② Reasonable and sufficient use of antibiotics: obtain bacteriological evidence and drug sensitivity results in the first time. ③Improve the quality of obstetrics (cesarean section and obstetrics critical care techniques). ④ Correct the anemic state before and after delivery to increase resistance. ⑤ Examine the placenta and fetal membranes carefully after delivery to exclude residual. If placental residue cannot be excluded, the uterine cavity should be explored and antibiotics should be applied prophylactically after operation. The principles of treatment are: ① conservative treatment: for small or moderate amount of vaginal bleeding, broad-spectrum antibiotics, uterine contraction agents and supportive therapy should be given; ② scraping: if there is suspicion of retained placenta, fetal membranes or meconium, the uterine cavity can be scraped under the supervision of B-ultrasound under the condition of opening the venous access, preparing blood and preparing for surgery, and the operation should be gentle in order to prevent perforation of the uterus. Scrapings should be sent to pathology. Postoperative treatment should be continued to fight infection and promote uterine contraction. ③ Intervention or hysterectomy: If the uterine incision is suspected to be split by cesarean section, only a small amount of vaginal bleeding should be hospitalized, and broad-spectrum antibiotics and supportive therapy should be given, as well as close monitoring. If there is a lot of vaginal bleeding, caesarean section is feasible. If the necrosis of the tissue around the incision is small, it is feasible to perform debridement and suturing, ligation of the internal iliac artery or uterine artery, or embolization of the internal iliac artery. If the extent of tissue necrosis around the incision is large, low level subtotal hysterectomy or total hysterectomy is chosen as appropriate. Infection or incision fissure after cesarean section is the most common cause of late postpartum hemorrhage after cesarean section. In this case, the patient was susceptible to infection of the uterine incision due to premature rupture of fetal membranes or incision fissure after cesarean section before the operation, so when there was only a small amount of bloody malaise, it was easy to should be hospitalized as early as possible, monitored closely, obtained bacteriological evidence, and antibiotics were used in reasonable and sufficient quantities. Keeping in mind the strict indications for cesarean section, it improves the quality of obstetrics and prevents late postpartum hemorrhage, a serious complication.