To the Editor,

We present a very strange case of idiopathic, gross hematuria after cesarean section where all  potential causes were ruled out but the patient continued to have hematuria, which eventually was controlled with multiple irrigations of the bladder.

A 30-year-old G4P1L0A2 with a diagnosis of placenta previa presented at 28 weeks with her first episode of antepartum hemorrhage. The bleeding was minimal, bright red in color and painless. She had a history of one lower segment cesarean section (LSCS), two surgical evacuations and one hysteroscopic septal resection, which was diagnosed during cesarean section. Her previous cesarean section was an uncomplicated, term elective section for breech presentation. The patient was given conservative management as the bleeding stopped spontaneously. Since she had high risk factors for adherent placenta, Doppler ultrasound was done to rule out the same during the presentation being described herein. It was inconclusive and hence magnetic resonance imaging was done which ruled out adherent placenta. She had preterm labor after two days of admission and underwent an emergency cesarean section. There was complete placenta previa and she had a postpartum hemorrhage which was managed with stepwise devascularization along with intrauterine Foleys bulb placement in the lower uterine segment, inflated with 40 cc saline. She had an intraoperative blood loss of 1.6 liters and received three units of packed red blood cell and three units of fresh frozen plasma. She also had gross hematuria intraoperatively. The bladder integrity was checked by retrograde filling with saline followed by bladder irrigation with 1.5 liters saline. She continued to have hematuria in the postoperative period (Figure 1). There was no past history of similar episode or any renal disease. She did not have any history of easy bruising, gum bleeding or previous blood transfusions. She had a hemoglobin of 11.5 g/dL, platelet count of 2.5 lakh/dL, an international normalized ratio of 1.0 and a partial thromboplastin time of 22 seconds (normal 26 seconds), a bleeding time of one minute and clotting time of three minutes. She also had normal renal and liver function tests.

On the second postoperative day, ultrasound showed clots in the bladder for which  tranexamic acid was administered, together with multiple bladder irrigations. She continued to have hematuria for which a cystoscopy was done and the clots were removed. There were no abnormal vessels nor any lesion or stitch in the bladder mucosa. The ureteric orifices were also normal. The bladder irrigation was continued and the hematuria gradually subsided over the next seven days. The catheter was removed and she was discharged in good health.

A similar case was reported by Mujini et al. (1), where LSCS was done for placenta previa and the patient had a similar presentation and was managed conservatively with bladder irrigation and blood transfusion. In a series of three cases reported by Chauhan et al. (2), gross hematuria in the puerperium can occur even after vaginal delivery. However, the first and foremost cause to be ruled out is bladder injury. Once ruled out, conservative management can be safely administered and should include repeated bladder irrigation.