Author Information
Deshpande PS*, Maurya N**, Ansari M***, Gupta AS
(* First Year Resident, ** Fourth Year Resident, *** Assistant Professor, **** Professor; Department of Obstetrics & Gynecology, Seth
G.S.Medical College
& KEM Hospital , Mumbai , India
Abstract
Uterine scar dehiscence and
subsequently rupture is one of the most dreaded complications encountered in
obstetrics and is every obstetricians’ nightmare. The varied presentation
of the phenomenon of dehiscence and rupture from being silent to outright
dramatic and life threatening poses a challenge to the obstetrician in terms of
diagnosis and management. We present a case of uterine classical scar rupture,
clinically simulating intestinal obstruction till we opened the Pandora’s box
and got to the right diagnosis.
Introduction
Acute abdomen due to obstetric cases
must be precisely distinguished from acute abdomen due to other causes as the
approach to management and treatment differs widely in the two. The most common
non obstetric cause of acute abdomen in pregnancy is appendicitis.[1] Commonest
causes of acute abdomen in pregnancy are ruptured ectopic in early pregnancy followed by red
degeneration of myoma and ruptured ovarian cysts.[2] Intestinal obstruction
presenting as acute abdomen in pregnancy is most commonly caused due to
adhesions.[2] Only 0.05% patients who underwent surgery for gynecologic or
obstetric causes had small bowel obstruction due to adhesion.[3]
Case Report
A 29 yrs old gravida 3, para 1,
omtrauterine fetal death 1, abortion 1 with non isoimmunized Rh negative
pregnancy with previous history of lower segment cesarean section with 34 weeks
of gestation was referred from a private hospital as a case of preterm labor
with suspected intestinal obstruction. She had no previous case records. The
only information received from the patient was that cesarean section was done
for prolonged preterm labor at 8 months of gestation in Uttar Pradesh 3 years
ago. The patient was evaluated for the same and as she had no complaints of
vomiting, distension of abdomen or obstipation, intestinal obstruction was
excluded clinically. Her abdomen was soft to touch and had no signs of
tenderness, guarding, or rigidity. Pfannestiel scar of previous cesarean
section was seen. Uterine size corresponded to 34 weeks of gestational age.
Minimal uterine activity was observed. There was no scar tenderness. On
vaginal examination cervical os was closed and there was no show or amniotic
fluid leak. The patient was admitted and treated for threatened preterm labor
with tocolytics. She responded and was then discharged after 2 days of
observation. She again presented after 2 weeks at 36 weeks of gestation with
abdominal pain. She had no uterine activity, scar tenderness or vaginal bleed.
An abdominal para-umbilical defect with herniated bowel loop was noted.
Peristalsis in the herniated bowel loop was felt. Bowel loop returned back
after reposition. She was kept under observation. On the second day, her pain
increased in severity and she had 2-3 episodes of vomiting. The defect had
increased and the bowel loop with persistent peristalsis could not be reduced.
Surgeons evaluated the patient, detected the hyperperistaltic irreducible bowel
loop and suspected intestinal obstruction. Decision for emergency laparotomy
and lower segment cesarean section was taken. The surgery was performed jointly
by the obstetrician and the surgeons. Surgery was done under general and
epidural anesthesia. The abdomen was opened by a midline vertical incision.
Dense adhesions were encountered between the rectus muscle and the anterior
surface of the uterus. A bowel loop was found adherent to the anterior surface
of uterus. After releasing the adhesions a full length classical cesarean
section scar rupture was observed.
Figure 1. Adherent, traumatized
ileal loop (yellow arrows) with classical cesarean incision rupture (blue
arrows).
Figure 2: Full length classical
cesarean section scar rupture (yellow arrows highlight the entire uterine rent).
Near term fetus with 9/10 Apgar
scores was delivered through the previous ruptured classical scar. Approximately 5 cm loop of ileum was densely adhered to the ruptured
scar. This ileal loop had a spiral, irregular rent measuring about 3 cm that
was seen when it was separated from the edge of the ruptured scar after
delivering the fetus. The lower edge of the opened scar did not reach the
visceral peritoneum of the lower segment. The previous scar was excised and the
uterus was repaired in two layers with polyglactin No.1. Four inches of
the bowel was resected and side to side anastamosis was done. Proximal
diverting loop ileostomy was done and a stoma bag was attached. Postoperatively
the patient had sepsis that settled with broad spectrum antibiotics. Stoma
closure was advised after 3 months and proper stoma care was explained. Suture
removal was done after 1 week. The patient improved clinically and was
discharged. Couple was counseled about hazards of further pregnancies and the
risk of performing any more surgery on the patient in view of permanent
contraception and hence the patient’s husband was advised to undergo vasectomy
to limit family size.
Discussion
Uterine rupture can be classified as
complete or incomplete. It is complete when all the layers of the uterine wall
are separated and incomplete when the visceral peritoneum is intact but the
myometrial fibers give way.[4] The greatest risk factor for either form is
previous cesarean delivery.[4] Metaanalysis of 25 studies from 1976 to 2012
indicate the overall incidence of pregnancy related uterine rupture is
0.07%.[5] Incidence of uterine rupture in an unscarred uterus varies
demographically from 0.01% to 0.1%.[5] Incidence of uterine rupture in cases of
previous cesarean section is 0.3%. Classifying further, risk of rupture in a
previous case of low transverse uterine scar varies from 0.2 to 0.9% and it
shoots up to 2-9% in a case of previous classical cesarean section.[4] An
astonishing 10 fold
increase in risk! Classical cesarean section in today’s times is
performed rarely and accounts for 0.5% of all births.[5] The probability for
the performance of a classical cesarean delivery is inversely proportional to
the gestational age at the time of delivery. The rate of classical cesarean
sections in a study was 20% at 24 weeks. 5% and 1% at 30 weeks and at term
respectively [6].
Our patient initially presented with
abdominal pain and as uterine activity was present she was provisionally
diagnosed and treated as a case of threatened preterm labor. She had no
documents of the previous cesarean section. Verbally her previous medical
practitioner had told her that cesarean delivery was done for prolonged labor
at preterm gestational age. In the absence of any previous case records,
operation notes, discharge summaries it was impossible for us to assume that a
classical cesarean section had been performed as this is against the practice
of standard care. Furthermore, presence of the Pfannestiel scar also pointed
towards a lower segment uterine incision rather than an upper segment uterine
incision. The access and the exposure of the upper segment to perform a
classical section is not adequate with a Pfannensteil incision in the 8th
month of pregnancy. Hence the probability of a classical section and its
consequence like scar thinning or rupture in the antenatal period was not
contemplated. The patient presented again after 2 weeks with aggravation of the
same symptoms. The presence of the fixed, irreducible, hyperperistaltic bowel
loop through an abdominal right paramedian defect raised the suspicion of
subacute intestinal obstruction due to adhesion. Exploratory laparotomy
clinched the diagnosis. The hyperperistaltic loop that was adherent to the
previous section scar had a spiral tear and its edges were not bleeding. This
adherent loop formed a barrier and prevented the uterus from expelling out the
fetus into the peritoneal cavity after the scar rupture. The placenta that was
implanted posteriorly was not injured and uteroplacental blood supply was not
compromised thus saving the fetus. Retrospectively, the scar thinning and
rupture had probably set in 2 weeks back. Thus it was the surgical management
of intestinal obstruction that led us to the final diagnosis and subsequent
treatment. Performing a classical cesarean operation without proper indication,
not adequately documenting the same and warning the patient of subsequent
consequences should be strongly condemned as this not only increases the
morbidity but also increases maternal and perinatal mortality and suboptimal
care in subsequent pregnancies. All the subsequent pregnancies have to be
monitored with a hawk’s eye, with good paper work and antenatal care to pick up
the minutest abnormalities from as early as 20 weeks to prevent any such catastrophes.
Conclusion
Cases of acute abdomen in pregnancy
must be addressed seriously. Especially cases of previous cesarean section
should be evaluated in detail if they present with complaints of acute abdomen.
All the possible obstetric and nonobstetric causes must be thought of and the
patient investigated accordingly. Surgical causes deserve a special mention in
cases of previous cesarean section especially adhesions. Combine this with the
fact that in many developing countries, patients do not maintain the records of
the previous surgeries, like in our case; one must be ready for any kind of
surprises.
References
- Kameoka S, Ogawa S. Acute Abdomen in Pregnancy. Japan Medical Association Journal. 2001 44(11):496-500.
- Taylor D, Perry RL. Acute Abdomen and Pregnancy. Available from: emedicine.medscape.com/article/195976-overview#a2
- Al-Took S, Platt R, Tulandi T.Adhesion-related small-bowel obstruction after gynecologic operations. Am J Obstet Gynecol. 1999 Feb; 180(2 Pt 1):313-5.
- Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL,et al. Prior Cesarean Delivery. Williams Obstetrics.24th ed. New Delhi: McGraw Hill Education 2014; pp.609-624
- Nahum GG, Pham KQ. Uterine Rupture in Pregnancy. Available from: http://reference.medscape.com/article/275854-overview#a1
- Chauhan SP. Prior classical cesarean delivery-counseling and management. Contemporary OB/GYN, 2012 Available from: http://contemporaryobgyn.modernmedicine.com/contemporary-obgyn/news/modernmedicine/modern-medicine-feature-articles/prior-classical-cesarean-del
Deshpande PS, Maurya
N, Ansari M, Gupta AS. Subacute Intestinal
Obstruction Due To Classical Cesarean Section Scar Rupture. JPGO 2015.
Volume 2 No. 12. Available from: http://www.jpgo.org/2015/12/subacute-intestinal-obstruction-due-to.html