Apoplexia uteri: A rarely described post-mortem finding

摘要

We present a case of apoplexia uteri, a rarely described condition of haemorrhagic necrosis in an atrophic endometrium and myometrium associated with terminal stress. This entity is well recognised in older literature but few recent publications have addressed this condition. It is thought to occur in association with hypoperfusion with passive hyperaemia and reperfusion injury. This case serves to highlight this rarely encountered entity as a possible cause of haemorrhage in an atrophic endometrium in the 'perimortem' period. Incidental findings are occasionally observed in the course of forensic autopsy practice and knowledge of rarely encountered entities, such as that described in this case, is essential to prevent diagnostic uncertainty and misdiagnosis. We describe a case of apoplexia uteri in an atrophic endometrium discovered at post-mortem. Apoplexia uteri is a rarely encountered condition which is most commonly described in the older literature. Few recent publications are available on the subject. Cases to date describe haemorrhagic necrosis of the post-menopausal atrophic endometrium. It is reported as occurring in association with terminal stress. The underlying mechanism is postulated to involve hypoperfusion with passive hyperaemia and reperfusion injury. We report a case of a 33-year-old female who underwent a coroner's autopsy. At autopsy there was evidence of cirrhosis and hepatorenal syndrome and also evidence of cerebral hypoxia. The endometrium and myometrium showed changes of apoplexia uteri. The case was that of a 33-year-old woman who died following an episode of acute cerebral hypoxia. Her clinical history was significant for hepatorenal syndrome and alcohol consumption. At 'post-mortem' there was evidence of cirrhosis and hypoxic brain injury. In addition two foci of endometrial and myometrial haemorrhage were identified (see Fig. 1). These two foci of haemorrhage on the anterior and posterior walls of the uterus were symmetrical in shape. This symmetry is somewhat unusual and suggested an associated traumatic or hormonal injury from an in-trauterine contraceptive device; however such a device was not seen at the time of post-mortem. Histological sections from this area of haemorrhage demonstrated a discrete focus of inner layer myometrial infarction with extensive haemorrhage and extravasation of red blood cells into the affected endometrium and adjacent myometrium (Figs. 2-4). The infarct seen was not associated with an inflammatory response suggesting that it was a terminal event. The adjacent non-haemorrhagic endometrium showed changes consistent with atrophy despite her age. There was no evidence of a primary vasculitic process or a vascular lesion.