Urinary and Hemorrhage Ascites in A Patient with P4A1 Post-Subtotal Hysterectomy

Abstract

Objective: To describe a rare case of combined urinary and hemorrhagic ascites following emergency subtotal hysterectomy for uterine rupture and to highlight the diagnostic challenges associated with this condition.
Methods: Case report
Case: A 33-year-old G5P4A1 woman presented to the emergency department with severe abdominal pain and distension four days after a subtotal hysterectomy for uterine rupture following a c-section. ultrasound showed massive ascites, yet the patient’s hemoglobin remained relatively stable, and laboratory tests showed elevated renal markers, a sign of urinary reabsorption through the peritoneum. Ultrasound and urinary catheterization, which resulted in 3000 cc of urine, confirmed a combined etiology of urinary ascites and hemoperitoneum. Exploratory laparotomy found a 4 cm superior bladder defect and active bleeding from the right infundibulopelvic ligament.

Discussion: This case highlights a rare diagnostic challenge where urinary and hemorrhagic ascites coexisted. Literature indicates that a history of multiple cesarean sections increases tissue adhesion risks five-fold, significantly complicating emergency hysterectomies and increasing the risk of multi-organ injury. A key finding in this case is the "mimicking" effect: the massive intraperitoneal fluid collection initially suggested massive hemorrhage, yet the relatively stable hemoglobin levels proved otherwise. This discrepancy is a vital diagnostic clue that clinicians must recognize to differentiate urinary leakage from isolated hemorrhage.

Conclusion: Combined urinary and hemorrhagic ascites after subtotal hysterectomy is a rare but significant complication. Early recognition through clinical, laboratory correlation and imaging are important for improving patient outcomes in complex obstetric cases.

Keywords: bladder rupture, hemoperitoneum, hemorrhage, post-operative ascites subtotal hysterectomy.