Author Information
Saxena A*, Bhandari P**, Gupta AS***.
(* Junior resident, ** Senior resident, *** Professor, Department of Obstetrics & Gynecology, Seth G S Medical College and K E M Hospital, Mumbai, India.)
Saxena A*, Bhandari P**, Gupta AS***.
(* Junior resident, ** Senior resident, *** Professor, Department of Obstetrics & Gynecology, Seth G S Medical College and K E M Hospital, Mumbai, India.)
Abstract
Uterine rupture is an uncommon entity in a scarred uterus and is rare in an unscarred one. Here we are presenting a case of uterine rupture in a 28 year old patient with 36 weeks of gestation with past history of an ectopic pregnancy and a spontaneous incomplete abortion for which check curettage was done.
Introduction
Uterine rupture in pregnancy is not very common. It significantly raises maternal and fetal morbidity and mortality.[1] The most important risk factor for a uterine rupture is the scarred uterus.[2] Uterine rupture during labor in women undergoing trial of labor, with a previous cesarean section, ranges from 325 to 468 per 1,00,000 women.[3,4] Less data is available for uterine rupture in women with no previous history of cesarean section.[5]
Case Report
A 28 year old, gravida 3, ectopic pregnancy 1 and spontaneous abortion 1 with 36 weeks of gestation had come to our emergency room with complaint of acute pain in abdomen and distention since 4 hours. She had past history of a check curettage which was done for spontaneous incomplete abortion 4 years ago and a right salpingectomy was done for an ectopic pregnancy 2 years ago. She was in immense pain, her peripheral pulsations were not palpable, carotid pulse rate was 120 bpm and blood pressure was 80/60 mm of Hg. On per abdomen examination, the uterine size and contour could not be made out and fetal heart sounds could not be heard. Abdomen was guarded and tender. On vaginal examination, cervical os was 1.5 cm dilated, 20-30 % effaced, and presenting part was not felt. There was no evidence of bleeding. On investigations, her hemoglobin, which was 12 gm% 4 weeks ago, had dropped down to 7.5 gm%, white blood cell count was 28,000/mm3 and platelet count was 2,00,000/mm3. She was immediately shifted to the operation theater for exploratory laparotomy with the clinical diagnosis of uterine rupture with hemoperitoneum and hemorrhagic shock. Intraoperatively, hemoperitoneum of 1.5 litres was drained and blood clots of approximately 900 gm were evacuated. A 2x2 cm rent in the fundus of the uterus was seen, close to the right cornua.[Figure 1] The placenta could be seen coming out through the rent. Baby was delivered by taking lower uterine transverse curvilinear incision. Unfortunately, it was a still birth of 3 kg. A drip of 20 IU oxytocin was started but the placenta was completely adherent to the anterior wall of the uterine cavity and could not be separated.[Figure 2] So, an emergency subtotal hysterectomy was done. She received 5 units of whole blood, 4 units of fresh frozen plasma and 8 units of platelets. Postoperatively, she was kept in ICCU for one day for monitoring and then shifted to the general ward. She was stable and was discharged on day 6. Histopathology examination report of the specimen was suggestive of placenta percreta. Suture removal was done on postoperative day 14 and wound was healthy.
Uterine rupture is an uncommon entity in a scarred uterus and is rare in an unscarred one. Here we are presenting a case of uterine rupture in a 28 year old patient with 36 weeks of gestation with past history of an ectopic pregnancy and a spontaneous incomplete abortion for which check curettage was done.
Introduction
Uterine rupture in pregnancy is not very common. It significantly raises maternal and fetal morbidity and mortality.[1] The most important risk factor for a uterine rupture is the scarred uterus.[2] Uterine rupture during labor in women undergoing trial of labor, with a previous cesarean section, ranges from 325 to 468 per 1,00,000 women.[3,4] Less data is available for uterine rupture in women with no previous history of cesarean section.[5]
Case Report
A 28 year old, gravida 3, ectopic pregnancy 1 and spontaneous abortion 1 with 36 weeks of gestation had come to our emergency room with complaint of acute pain in abdomen and distention since 4 hours. She had past history of a check curettage which was done for spontaneous incomplete abortion 4 years ago and a right salpingectomy was done for an ectopic pregnancy 2 years ago. She was in immense pain, her peripheral pulsations were not palpable, carotid pulse rate was 120 bpm and blood pressure was 80/60 mm of Hg. On per abdomen examination, the uterine size and contour could not be made out and fetal heart sounds could not be heard. Abdomen was guarded and tender. On vaginal examination, cervical os was 1.5 cm dilated, 20-30 % effaced, and presenting part was not felt. There was no evidence of bleeding. On investigations, her hemoglobin, which was 12 gm% 4 weeks ago, had dropped down to 7.5 gm%, white blood cell count was 28,000/mm3 and platelet count was 2,00,000/mm3. She was immediately shifted to the operation theater for exploratory laparotomy with the clinical diagnosis of uterine rupture with hemoperitoneum and hemorrhagic shock. Intraoperatively, hemoperitoneum of 1.5 litres was drained and blood clots of approximately 900 gm were evacuated. A 2x2 cm rent in the fundus of the uterus was seen, close to the right cornua.[Figure 1] The placenta could be seen coming out through the rent. Baby was delivered by taking lower uterine transverse curvilinear incision. Unfortunately, it was a still birth of 3 kg. A drip of 20 IU oxytocin was started but the placenta was completely adherent to the anterior wall of the uterine cavity and could not be separated.[Figure 2] So, an emergency subtotal hysterectomy was done. She received 5 units of whole blood, 4 units of fresh frozen plasma and 8 units of platelets. Postoperatively, she was kept in ICCU for one day for monitoring and then shifted to the general ward. She was stable and was discharged on day 6. Histopathology examination report of the specimen was suggestive of placenta percreta. Suture removal was done on postoperative day 14 and wound was healthy.
Figure 1. Uterine fundal rupture.
Figure 2. Completely adherent placenta at rupture site.
Discussion
Uterine rupture causes significant morbidity and mortality in the mother and the fetus. There are various causes for such an event in an unscarred uterus such as obstructed labor, morbidly adherent placenta specially placenta percreta, injudicious use of oxytocin or prostaglandins and rarely intrauterine manipulations such as internal podalic version and breech extraction.[6]
In our case, the cause of rupture was placenta percreta which could have been because of overzealous curetting of the uterine cavity during previous check curettage. Vernekar and her coworker have published a case series of 13 cases of uterine ruptures in unscarred uteruses and found only one case in which uterine rupture was due to placenta percreta. Similar ruptures secondary to placenta percreta have been reported by Imseis et al and Esmans et al.[7,8] Esman et al reported a case of 14th week of pregnancy with previous history of manual extraction of the placenta followed by a check curettage, came with complaints of severe abdominal pain. On performing a laparotomy a hemoperitoneum of 2500 ml and a fundal uterine defect of 4 cm with placental tissue penetrating through the uterine serosa was found which required a hysterectomy. In this case, just like ours, no placental morbidities were diagnosed on repeated antenatal ultrasound examinations. With increasing rates of curettages, morbid adhesions of the placenta should be ruled out by the sonologists to prevent such catastrophies in patients with previous history of check curettage.
Heemskerk and her team reviewed 13 cases of uterine rupture, where 8 cases had a past history of dilatation and curettage which had led to perforations and later to uterine rupture in subsequent pregnancies. It is possible that in our case also an undiagnosed perforation led to a scar and a defect. This defect on healing must have had deficient decidua which eventually led to placenta percreta and rupture at the onset of labor.[9]
Our patient also had right salpingectomy done a few years ago, but it is unlikely to be the cause of this rupture as there was a band of normal tissue between the right cornua and the rent. This rupture may have also occurred by the morbidly adherent placenta which reached the serosa and mimicked a rupture. A subtotal hysterectomy had to be performed in our case though in other cases conservative measures have been described.[10] However, considering that these conservative treatments are associated with a four-fold mortality rate as compared to hysterectomy, the latter is usually preferred in such a situation.[11] Also, besides prompt surgical management, effective fluid management and blood replacement is the key to good outcomes.
Conclusion
Uterine rupture in an unscarred uterus is uncommon and very often not an anticipated complication and therefore, it is important to spread awareness regarding its occurrence, risk factors and management amongst health care providers. Maternal and perinatal outcome can be optimized by awareness of risk factors, recognition by clinical symptoms, signs and prompt surgical intervention.
References
Discussion
Uterine rupture causes significant morbidity and mortality in the mother and the fetus. There are various causes for such an event in an unscarred uterus such as obstructed labor, morbidly adherent placenta specially placenta percreta, injudicious use of oxytocin or prostaglandins and rarely intrauterine manipulations such as internal podalic version and breech extraction.[6]
In our case, the cause of rupture was placenta percreta which could have been because of overzealous curetting of the uterine cavity during previous check curettage. Vernekar and her coworker have published a case series of 13 cases of uterine ruptures in unscarred uteruses and found only one case in which uterine rupture was due to placenta percreta. Similar ruptures secondary to placenta percreta have been reported by Imseis et al and Esmans et al.[7,8] Esman et al reported a case of 14th week of pregnancy with previous history of manual extraction of the placenta followed by a check curettage, came with complaints of severe abdominal pain. On performing a laparotomy a hemoperitoneum of 2500 ml and a fundal uterine defect of 4 cm with placental tissue penetrating through the uterine serosa was found which required a hysterectomy. In this case, just like ours, no placental morbidities were diagnosed on repeated antenatal ultrasound examinations. With increasing rates of curettages, morbid adhesions of the placenta should be ruled out by the sonologists to prevent such catastrophies in patients with previous history of check curettage.
Heemskerk and her team reviewed 13 cases of uterine rupture, where 8 cases had a past history of dilatation and curettage which had led to perforations and later to uterine rupture in subsequent pregnancies. It is possible that in our case also an undiagnosed perforation led to a scar and a defect. This defect on healing must have had deficient decidua which eventually led to placenta percreta and rupture at the onset of labor.[9]
Our patient also had right salpingectomy done a few years ago, but it is unlikely to be the cause of this rupture as there was a band of normal tissue between the right cornua and the rent. This rupture may have also occurred by the morbidly adherent placenta which reached the serosa and mimicked a rupture. A subtotal hysterectomy had to be performed in our case though in other cases conservative measures have been described.[10] However, considering that these conservative treatments are associated with a four-fold mortality rate as compared to hysterectomy, the latter is usually preferred in such a situation.[11] Also, besides prompt surgical management, effective fluid management and blood replacement is the key to good outcomes.
Conclusion
Uterine rupture in an unscarred uterus is uncommon and very often not an anticipated complication and therefore, it is important to spread awareness regarding its occurrence, risk factors and management amongst health care providers. Maternal and perinatal outcome can be optimized by awareness of risk factors, recognition by clinical symptoms, signs and prompt surgical intervention.
References
- Guise JM, McDonagh M, Osterweil P, Nygren P, Chan BK, Helfand M. Systematic review of the incidence and consequences of uterine rupture in women with previous caesarean section. British Medical Journal. 2004;329(7456):19–25.
- Cantwell R, Clutton-Brock T, Cooper G, Dawson A, Drife J, Garrod D, et al. Saving mothers’ lives: reviewing maternal deaths to make motherhood safer: 2006–2008. BJOG. 2011;118(S-1):1–203.
- Signore C, Spong CY. Vaginal Birth After Cesarean: New Insights Manuscripts from a National Institutes of Health Consensus Development Conference, March 8-10, 2010. Seminars in Perinatology 2010;34(4):235-236.
- Guise JM, Denman MA, Emeis C, Marshall N, Walker M, Fu R, et al. Vaginal birth after cesarean: new insights on maternal and neonatal outcomes. Obstetrics and Gynecology 2010 Jun;115(6):1267-78.
- Turner MJ. Uterine rupture. Best Practice and Research Clinical Obstetrics and Gynaecology 2002;16(1):69–79.
- Vernekar M, Rajib R. Unscarred Uterine Rupture: A Retrospective Analysis. The Journal of Obstetrics and Gynecology of India. 2016;66(S1):51–54.
- Imseis HM, Murtha AP, Alexander KA, Barnett BD. Spontaneous rupture of a primigravid uterus secondary to placenta percreta. A case report. Journal of Reproductive Medicine. 1998;43(3):233–6.
- Esmans A, Gerris J, Corthout E, Verdonk E, Declercq S. Placenta percreta causing rupture of an unscarred uterus at the end of the first trimester of pregnancy: case report. Human Reproduction. 2004;19(10):2401–3.
- Heemskerk S, Eikelder MLGT, Janssen CAH. Uterine rupture in pregnancy after an intervention complicated by uterine perforation: Case report and systematic review of literature. Sexual & Reproductive Healthcare. 2019;19:9–14.
- Wang LM, Wang PH, Chen CL, Au HK, Yen YK, Liu WM. Uterine preservation in a woman with spontaneous uterine rupture secondary to placenta percreta on the posterior wall: a case report. Journal of Obstetrics and Gynaecology Research. 2009;35(2):379-84.
- Moriya M, Kusaka H, Shimizu K, Toyoda N. Spontaneous rupture of the uterus caused by placenta percreta at 28 weeks of gestation: a case report. Journal of Obstetrics and Gynaecology Research 1998;24(3):211-214.
Citation
Saxena A, Bhandari P, Gupta AS. A Rare Case Of Uterine Rupture In An Unscarred Uterus. JPGO 2019. Vol 6 No. 8. Available from: https://www.jpgo.org/2019/08/a-rare-case-of-uterine-rupture-in.html
Saxena A, Bhandari P, Gupta AS. A Rare Case Of Uterine Rupture In An Unscarred Uterus. JPGO 2019. Vol 6 No. 8. Available from: https://www.jpgo.org/2019/08/a-rare-case-of-uterine-rupture-in.html