Successful Conservative Management with Uterine Preservation in an Adolescent with Couvelaire Uterus and Incomplete HELLP Syndrome: A Case Report

Alice Gaibor Pazmiño¹Alex Oña²Ana Claudia Mendes Barbosa³Esteban Ortiz-Prado^1*Juan S. Izquierdo-Condoy^1*

• ¹University of the Americas, Quito, Ecuador
• ²Departamento de Ginecología y Obstetricia, Hospital Pablo Arturo Suárez, Quito, Ecuador
• ³Centro Universitario de Varzea Grande, Várzea Grande, Mato Grosso, Brazil

Introduction: Couvelaire uterus (uteroplacental apoplexy) is a rare, life-threatening obstetric emergency caused by severe placental abruption. It involves hemorrhagic infiltration of the myometrium and uterine serosa and is typically diagnosed intraoperatively. The condition is closely linked to hypertensive disorders of pregnancy, particularly HELLP syndrome. Although conservative management may preserve fertility, it is often complicated by massive postpartum hemorrhage requiring emergency hysterectomy. Case Presentation: We report the case of a 19-year-old primigravid adolescent at 35.3 weeks of gestation who presented to a secondary-level hospital with sudden-onset abdominal pain and absent fetal movements. She had attended only four prenatal visits and had no prior comorbidities. On admission, she was hypertensive with hyperreflexia and marked proteinuria. Laboratory tests indicated severe preeclampsia with incomplete HELLP syndrome. Fetal demise was confirmed, and an emergency cesarean section was performed. Intraoperative findings revealed an 80% placental abruption, a 1000 mL retroplacental hematoma, and diffuse uterine ecchymosis consistent with Couvelaire uterus. Uterine atony with an estimated blood loss of 2000 mL was successfully controlled using a modified B-Lynch compression suture and bilateral uterine artery ligation. Postoperatively, the patient developed hypovolemic shock and KDIGO stage II acute kidney injury requiring intensive care but achieved full recovery and was discharged on postoperative day 5. Conclusions: This case illustrates the diagnostic challenges of Couvelaire uterus in hypertensive pregnancies, particularly among adolescents with limited prenatal care, where placental abruption may occur silently and HELLP syndrome may present incompletely. The successful control of massive hemorrhage and preservation of the uterus using conservative techniques underscore the feasibility of fertility-sparing management even in resource-limited settings. Strengthening access to prenatal and emergency obstetric care remains essential to prevent adverse outcomes in vulnerable populations.