Couvelaire uterus is a rare obstetric complication that arises from severe placental abruption of a normally inserted placenta. It is characterized by extravasation of blood into the myometrium, uterine serosa, and occasionally the peritoneal cavity (1–3). While most commonly reported in association with severe preeclampsia, HELLP syndrome (frequently accompanied by coagulopathy), and intrauterine fetal demise, its exact incidence is difficult to ascertain but is estimated to complicate <1% of abruptions and is not exclusively linked to older multigravidas; cases are well-documented across various age groups and parities, including young primigravids (2, 4–9). Intraoperatively, the uterus typically displays a violaceous discoloration with increased but ineffective tone, and may present with overt or concealed hemorrhage, as described in several case reports (2, 4, 5, 10). This condition reflects massive decidual bleeding and constitutes an obstetric emergency in which intraoperative recognition and timely management are essential to reduce high maternal morbidity (up to 43%) and perinatal mortality (14.1%) (6, 7, 11).

Hypertensive disorders of pregnancy—particularly severe preeclampsia and HELLP syndrome, including its incomplete variants—are key predisposing factors in the development of this condition. These entities share pathophysiological mechanisms such as widespread endothelial dysfunction, activation of the coagulation cascade, and microvascular injury, which collectively contribute to extensive placental detachment and hemorrhagic infiltration of the myometrium (1, 12). Incomplete or subclinical HELLP syndrome often delays diagnosis, exacerbating risks of complications like acute renal failure, disseminated intravascular coagulation, and cerebral hemorrhage. The evidence on this association is limited to isolated case reports, underscoring its low prevalence but significant clinical relevance (2, 4, 13, 14). Conservative strategies such as oxytocin infusion, uterine compression sutures, and uterine packing can enable uterine preservation in selected cases (3, 4, 12). However, severe cases may necessitate hysterectomy, particularly when associated with unresponsive uterine atony or major intra-abdominal bleeding (4).

This report presents an uncommon clinical case of Couvelaire uterus in a 35.1-week primigravid adolescent, associated with severe preeclampsia and incomplete HELLP syndrome. It highlights diagnostic challenges, conservative surgical decision-making, and the importance of early recognition, particularly in settings with limited access to prenatal care.

We report the case of a 19-year-old mestiza adolescent, primigravida, with no relevant past medical history, who presented to the obstetric emergency department at 35.3 weeks of gestation based on her last menstrual period (LMP). She reported lower abdominal cramping pain radiating to the lumbar region, with a duration of approximately four hours, accompanied by absent fetal movements. She denied loss of amniotic fluid, vaginal bleeding, headache, blurred vision, or fever.

She had attended four prenatal visits during the pregnancy, and two previous obstetric ultrasounds had revealed no abnormalities.

At admission, her blood pressure was elevated (136/101 mmHg), with brisk deep tendon reflexes and significant proteinuria (2088 mg/dL), with a protein-to-creatinine ratio of 18.48. Laboratory testing showed elevated lactate dehydrogenase (LDH 635 IU/L), while hepatic enzymes (AST 39.2 IU/L; ALT 15.2 IU/L) and platelet count (153,000/μL) were within normal limits. These findings, along with hypertension and heavy proteinuria, were consistent with severe preeclampsia and incomplete HELLP syndrome (Table 1).

Obstetric evaluation revealed a singleton fetus in cephalic presentation, with uterine height appropriate for gestational age. Fetal monitoring showed no cardiac activity or uterine contractions. An emergency ultrasound confirmed intrauterine fetal demise. On vaginal examination, the cervix was soft, posterior, 1 cm dilated, and 30% effaced.

Given the context of severe preeclampsia, laboratory findings consistent with incomplete HELLP syndrome, and fetal demise, an emergency cesarean section was indicated. Magnesium sulfate was administered for maternal neuroprotection, and preparations were made to terminate the pregnancy.

During spinal anesthesia-assisted cesarean delivery, the uterus appeared gravid with extensive ecchymotic infiltration involving approximately 40% of the anterior wall and 20% of the right broad ligament, consistent with Couvelaire uterus (Figure 1). The amniotic fluid was dark and wine-colored. An estimated 80% placental abruption and a retroplacental hematoma measuring approximately 1,000 mL were identified. A stillborn female fetus weighing 2,160 g was delivered. Histopathological analysis of the placenta confirmed acute suppurative chorioamnionitis, decidual and intraplacental hemorrhage, and ischemic villous changes. Microscopy revealed necrosis, fibrinoid deposition, and extensive intervillous hemorrhage, along with inflammation of the fetal membranes. The villous maturation was consistent with 34–35 weeks of gestation. These pathological findings corroborate the clinical diagnosis of placental abruption and intrauterine fetal demise, further explaining the maternal decompensation observed perioperatively.

The patient developed uterine atony with an estimated blood loss of 2000 mL, which was successfully controlled using a modified B-Lynch compression suture, thereby avoiding hysterectomy (Figures 2, 3). In the immediate postoperative period, the patient developed hypovolemic shock secondary to severe obstetric hemorrhage and was transferred to the intensive care unit (ICU). She exhibited acute kidney injury (KDIGO stage II) characterized by oliguria (<0.5 mL/kg/h) and mild metabolic acidosis. Estimated blood loss (EBL) was 2000 mL, assessed by visual estimation and suction canister volume. Hemostatic management included intraoperative administration of 1 g tranexamic acid (TXA) IV and immediate transfusion of 1 unit of packed red blood cells (PRBC). Subsequently, in the ICU, she received 2 more PRBC units (08:45), 1 unit of fresh frozen plasma (10:15–10:45), 5 platelet concentrates in the afternoon, and 7 cryoprecipitates in the evening. ROTEM/TEG monitoring was not available; therefore, transfusion thresholds followed the institutional massive transfusion protocol based on conventional laboratory parameters (hemoglobin <8 g/dL, platelets <100 × 10³/μL, INR > 1.2, and fibrinogen <200 mg/dL). Coagulopathy was anticipated based on persistent bleeding, declining hematologic parameters, and HELLP-related thrombocytopenia. Oxytocin 20 IU in 1000 mL RL at 40 mL/h was administered, followed by a modified B-Lynch compression suture and bilateral uterine artery ligation to control uterine atony and avoid hysterectomy. Broad-spectrum antibiotics were started with IV meropenem and later de-escalated to ampicillin-sulbactam. Rescue diuresis was achieved with IV furosemide, and glycemic control was maintained with crystalline insulin as per ICU protocol (Table 2).

The clinical course was favorable, with progressive improvement in both clinical status and laboratory parameters. The patient was transferred to the general ward and discharged 5 days later, hemodynamically stable, with scheduled outpatient follow-up in gynecology and psychology.

The patient and her family were counseled regarding uterine preservation, fertility implications, and postpartum contraception, and written informed consent was obtained. During follow-up at 1-month, histopathologic results confirmed the diagnosis, and at 3 months she demonstrated complete clinical recovery with spontaneous return of normal menstruation. She was subsequently referred to primary care services for family planning counseling and long-term reproductive follow-up.

This case demonstrates an atypical presentation of Couvelaire uterus in a primigravid adolescent with incomplete HELLP syndrome and extensive (DPPNI) placental abruption (80%). The intraoperative diagnosis—despite absent vaginal bleeding—highlights the critical need for anticipatory vigilance in hypertensive pregnancies exhibiting fetal compromise, particularly given that 10–20% of abruptions present covertly (1, 13).

Couvelaire uterus—characterized by hemorrhagic infiltration of the myometrium and uterine serosa—is typically diagnosed during surgical exploration and is strongly associated with severe placental abruption (1, 5). In this case, the patient presented with an extensive but clinically atypical manifestation of the condition, occurring in conjunction with incomplete HELLP syndrome (9). This combination is rarely reported, with only isolated case reports available, likely due to their shared but diagnostically elusive pathophysiology: microvascular endothelial damage that manifests as subclinical coagulopathy and silent myometrial extravasation (13, 15). The coexistence of these two entities significantly worsens the maternal-fetal outcomes by generating synergistic pathophysiological disruptions. These include heightened risks of multiorgan dysfunction, consumptive coagulopathy, and acute kidney injury—as seen in this patient, who developed KDIGO stage II AKI and thrombocytopenia (109,000/μL) (1, 2).

Despite an estimated blood loss of 2000 mL, uterine preservation was successfully achieved using a modified B-Lynch compression suture, thereby avoiding emergent peripartum hysterectomy, as previously described by Uwagbai et al. (14). Surgical decision-making in such contexts must be individualized, taking into account hemodynamic stability, the effectiveness of conservative measures, and the patient’s reproductive wishes. In this case, the uterus was already exteriorized and incised during cesarean delivery, facilitating the direct placement of the compression suture. Given the patient’s young age (19 years), stable coagulation profile, and desire for future fertility, the surgical team opted for uterine conservation. International guidelines (FIGO, ACOG) recommend uterine compression sutures in hemodynamically stable patients with controllable hemorrhage and favorable uterine tone response (16, 17). Hysterectomy is generally reserved for cases unresponsive to conservative measures or with rapid clinical deterioration. The patient responded promptly to the modified B-Lynch technique, with restoration of uterine tone and no further bleeding, supporting the decision to avoid hysterectomy in this scenario (18).

Historically, Couvelaire uterus was considered a surgical emergency warranting immediate hysterectomy due to its alarming appearance. However, recent data highlights that uterine preservation is both feasible and safe in hemodynamically stable patients. A retrospective study from Japan reported that none of the 12 patients with Couvelaire uterus required hysterectomy, although 58.3% received blood transfusions and 25% developed DIC, underscoring the value of early conservative intervention in selected cases (19). Comparatively, published data highlight the severe maternal and neonatal outcomes associated with abruptio placentae and Couvelaire uterus (20). One case series noted that about 5.8% of placental abruptions were complicated by coagulopathy and 16.8% by Couvelaire uterus. Patients with Couvelaire changes tend to have much higher blood loss and transfusion requirements than those without. For instance, Sunanda et al. reported that 67% of Couvelaire cases developed postpartum hemorrhage (versus ~29% in non-Couvelaire abruptions) and required an average of about 5–6 units of blood transfusion, significantly more than the ~2 units in controls. DIC occurred in 22% of Couvelaire cases (versus 14% without) and the maternal mortality in the Couvelaire group reached ~5.6% in that series (21). Taken together, these data reinforce that a Couvelaire uterus signals a high-risk situation often necessitating massive transfusion and critical care support.

Inadequate prenatal care evidenced by only four antenatal visits—was a critical factor delaying recognition of evolving pathology. This suboptimal follow-up obscured the progression of prodromal signs such as hypertension and proteinuria, postponing the diagnosis of both HELLP syndrome and occult placental abruption. Although the patient did not fulfill the full Mississippi criteria for classic HELLP syndrome—defined by hemolysis, elevated liver enzymes, and thrombocytopenia—her laboratory findings supported a diagnosis of incomplete HELLP. Hemolysis was evidenced by a marked LDH elevation (635 U/L), a drop in hemoglobin from 11.5 to 7.3 g/dL, and anisocytosis on peripheral blood smear. Liver enzymes were only mildly elevated (AST 39.2 U/L, ALT 15.2 U/L), and platelet count, initially normal (153,000/μL), declined to a nadir of 82,000/μL. This constellation meets criteria for the partial variant of HELLP syndrome, which—despite lacking one or more components of the classic triad—remains clinically significant and requires aggressive management due to its associated maternal risks (22, 23).

Alternative diagnoses were carefully considered. Acute fatty liver of pregnancy (AFLP) was deemed unlikely due to the absence of hypoglycemia, coagulopathy, and hepatic dysfunction. Thrombotic thrombocytopenic purpura (TTP) and atypical hemolytic uremic syndrome (aHUS) were ruled out given the lack of neurologic symptoms, normal creatinine clearance over time, and absence of schistocytes on smear (24–26). The diagnosis of incomplete HELLP was therefore established based on evolving hematologic trends, liver function, and clinical context. As a result, critical windows for early intervention—including enhanced blood pressure monitoring, corticosteroid administration, or timely delivery—were missed, increasing maternal and fetal risk (14, 20). Current guidelines underscore the importance of structured prenatal care: the American College of Obstetricians and Gynecologists (ACOG) recommends at least 12 visits for low-risk pregnancies, with biweekly assessments after 20 weeks to facilitate the early detection of preeclampsia and other complications (27).

Even with timely recognition and aggressive management, Couvelaire uterus remains associated with significant maternal morbidity. Potential complications include hypovolemic shock, disseminated intravascular coagulation (DIC), massive transfusion requirements, and postoperative uterine dysfunction—particularly in patients with hypertensive disorders or delayed presentations (7, 12, 14). Hemorrhagic infiltration of the myometrium impairs contractility, increasing the risk of refractory uterine atony and exacerbating hemorrhage (4).

Hysterectomy becomes a life-saving measure only when uterine atony remains unresponsive to maximal interventions and hemodynamic instability threatens multiorgan failure. Indicators for such intervention include transfusion of more than six units of blood products, serum lactate >4 mmol/L, or vasopressor dependence. Delaying hysterectomy beyond this threshold increases maternal mortality eightfold, while premature intervention may unnecessarily compromise future fertility (9).

In Latin America, many public and low-resource hospitals simply do not have access to ROTEM/TEG and must rely on conventional transfusion protocols. Consistent with this, a recent Argentine survey found that the vast majority of 55 specialized ICUs had no ROTEM/TEG device on site (28). Consequently, massive transfusion protocols (MTPs) in the region rely on fixed-ratio resuscitation (e.g., 1:1:1 PRBC:FFP:Platelets) and standard labs (INR, fibrinogen, Plt count) as outlined in regional guidelines (28). This patient’s transfusion decisions followed such protocols, guided by hemoglobin decline, persistent bleeding, and rising LDH.

From the fetal perspective, abrupt cessation of placental exchange often results in acute hypoxia and intrauterine death—as occurred in this case—despite prompt surgical intervention (2, 4, 20).

This case highlights the importance of early diagnosis, intensive monitoring, and a multidisciplinary approach in managing high-risk pregnancies—particularly among adolescents with limited access to prenatal care. It was prepared and reported in accordance with the CARE guidelines for case reports, ensuring transparency and reproducibility (29). Moreover, it contributes to the existing literature by demonstrating that even under critical clinical conditions, uterine preservation is feasible using conservative surgical strategies, thereby safeguarding maternal safety and future fertility (4, 5, 14).

Couvelaire uterus represents a rare but life-threatening obstetric emergency that typically becomes evident only during surgery. When it occurs in association with incomplete HELLP syndrome, as in this adolescent primigravid patient, the risk of severe maternal and fetal complications markedly increases. This case emphasizes the need for a high index of clinical suspicion for concealed placental abruption in hypertensive pregnancies—even in the absence of vaginal bleeding—and highlights how delayed or limited prenatal care can obscure early warning signs. Prompt multidisciplinary management, guided by standardized transfusion protocols and conservative surgical techniques such as the modified B-Lynch suture, allowed successful hemorrhage control and uterine preservation. Beyond its clinical relevance, this case provides evidence that fertility-preserving interventions are feasible and effective in well-selected patients, even under resource-limited conditions. Strengthening access to prenatal care and emergency obstetric services remains essential to prevent similar outcomes in vulnerable populations.