Abstract / Summary
Abstract Background Couvelaire uterus (CU) is a rare, life-threatening complication of placental abruption, occurring in about 1% of cases. Preeclampsia is a major risk factor; however, its diagnosis becomes difficult when concealed hemorrhage hides typical hypertension, delaying recognition. Additionally, the critical impact of the time from symptom onset to surgical intervention on uterine preservation is not well understood in the literature. We present a case of CU with masked preeclampsia and evolving disseminated intravascular coagulation (DIC) to propose a new time-based framework for early recognition and surgical decision-making. Case presentation: We report a 19-year-old unbooked primigravida at 35 + 5 weeks presenting with absent fetal movements. On admission, she was normotensive (110/60 mmHg) with a relative rise in heart rate (HR: 88 bpm), severe proteinuria (1000 mg/dL), thrombocytopenia (78×10⁹/L), and a woody uterus. Coagulation revealed PT 17.7s (INR 1.42) and fibrinogen (3.38 g/L), consistent with non-overt DIC (ISTH score 2/8). Ultrasound confirmed intrauterine fetal demise. Over seven hours, labor did not progress, necessitating emergency cesarean section. Intraoperatively, a retroplacental hematoma and CU were identified, and a prophylactic B-Lynch suture was placed (estimated blood loss 1500–2000 mL). Postoperatively, rebound hypertension to 150/100 mmHg responded promptly to magnesium sulfate, confirming masked PE. She recovered uneventfully and was discharged on postoperative day four. Discussion Based on this case, we propose three educational frameworks: (1) a three-phase hemodynamic model (occult compensation, rebound surge, therapeutic stabilization) to unmask PE during hemorrhage; (2) a "window of opportunity" concept, advocating surgical intervention within 6–8 hours of symptom onset to avoid irreversible DIC (ISTH ≥ 5) and preserve the uterus; and (3) a counterfactual analysis of two similar cases, demonstrating that timely intervention is the single most modifiable factor for uterine salvage. Conclusion Normotension in PA with proteinuria is a red flag, not reassurance. Magnesium responsiveness confirms underlying PE. B-Lynch suture is effective for uterine preservation, even in resource-limited settings. Clinicians must prioritize early evacuation, especially in conflict-affected areas.