Any patient in shock is an emergency, but when the patient is pregnant, everybody acts extra fast and is extra cautious, because there are two lives at stake. The case report below is based upon a real event that took place, and showcases the effect and consequence of poverty and poor health access in certain countries.
Dr. Madushika is currently a doctor working in the orthopaedic department and also the emergency treatment unit in Manipal, Nepal. Working in Nepal has exposed her to the reality of a poor health care system and the lack of community midwives combined with poor socioeconomic situations. She has worked in both emergency medicine and critical care, but hopes to specialize in surgery.
On a personal note, Madushika and I actually became friends over social media and bonded very quickly because of our similar nuttiness. She supplies me with a never ending load of medical pictures to share with everyone from her day-to-day run ins with the medically strange and awkward. I’m also very grateful for the madness that she has brought to my life and love catching up with her.
Obstetrics is a stressful speciality, but is very limited in terms of differentials and hence there are only a handful of emergency obstetrics youneed to be familiar with. Uterine rupture is a rare, but serious emergency with poor outcomes for the fetus as death occurs almost instantly.
So what happened?
A 35-year-old pregnant lady presented to the emergency room with a chief complaint of episodes of vomiting and abdominal pain for 3 days.
On further questioning, she stated that the vomit contained food particles, was not billous or blood stained and non-projectile. The vomiting was associated with dizziness, but no episodes of loss of conscious. She also had epigastric pain that was sudden, burning and dull in nature. The pain was not relieved by antacids. She denied any abdominal trauma.
Her pregnancy had not been booked at the local hospital, but on calculation of her LMP (06thOctober 2018), she was 34 + 2 weeks. She is G3P1 (+1) – where she had 1st trimester miscarriage. She claimed there was no PV bleeding/discharge and she had felt foetal movements 2 hours prior to arrival at the hospital. She also had no headaches, blurring of vision or dysuria. Despite not registering her pregnancy she took her prenatal iron and folic acid supplements.
On examination she was ill looking with conjunctival pallor and bilateral pitting oedema up to lower third of leg. There was no cyanosis, clubbing, lymphadenopathy or dehydration present. Cardiovascular and respiratory assessment was normal. Her pulse was 108 bpm, but volume was poor and her blood pressure was 80/40 mmHg on the right arm in supine position. Respiratory rate was 18/min and saturation was 98%.
On inspection of her abdomen, there was striae gravidarum, but no scar marks. There was generalized tenderness diffusely over the abdomen and symphisio-fundal height estimated the uterus to be of 36 weeks size. Lie of the baby could not be assessed as the patient was in severe pain. No uterine contractions were felt and FHS could not heard by pinard or Doppler.
So what did we do?
As the patient required emergency resuscitation, 2 pints of bolus normal saline were given fast, along with IV ondansetron (an antiemetic) and IV ranitidine in preparation for emergency surgery. All baseline investigations were sent – Full blood count, renal functions, liver functions, PT/INR, Group and cross match (4 pints of blood), and urine ull report. Emergency ultrasound was done in the emergency roon and showed a single fetus with cephalic presentation, but no fetal movement was seen or heart sounds heard. No retroplacental clots were seen, but there was inadequate liquor volume and a moderate amount of free fluid in the peritoneal cavity.
The patient was transferred to the operating theatre for emergency c-section. Intraoperatively, upon separating the rectus muscle, the fetus in the amniotic sac was seen floating freely in the peritoneum along with placenta. The dead fetus (IUFD, fresh fetus) was removed form the abdomen and uterus was visualized.
Intra-operative finding of the uterus – fundal rupture seen
Haemoperitoneum of approximately 800ml was removed along with clots and the uterine rupture site was identified as fundal. The fundal rupture measured about 4cm x 4cm. The incision was converted to an open laparotomy and the uterus was removed by subtotal hysterectomy; the abdomen was washed with antibiotics in NS and then flushed with NS multiple times. Uterus was sent for histopathological examination and a drain was kept in situ. 2 pints of whole blood were transfused intra-operatively along with IV fluid and the patient was stabilized. She made a full recovery and was discharged approximately 2 weeks post admission.
Discussion
Uterine rupture is defined as the disruption in the continuity of the all the uterine layers (endometrium, myometrium and serosa) any time after 28 weeks of pregnancy. Rupture can occur spontaneously, due to scar rupture or traumatic/iatrogenic.
Spontaneous rupture (as in this case) occurs mostly during labour due to extensive contraction forces during obstruction – may also occur due to oxytocin overdose, congenital uterine malformations, multiple gestation, fetal malpresentation and fetal macrosomia. Scar rupture is also a common reason and a classical scar is more likely to rupture than a pfannenstial (lower segment) scar.
Direct trauma to the abdomen may also cause uterine rupture, but iatrogenic causes such as too much oxytocin/prostaglandins, the use of forceps and even an external cephalic version may also cause the uterus to rupture.
Impending rupture can be detected if the woman complains of severe abdominal pain and there is increased contractions on the CTG. Women with impending scar rupture will have pain over the previous scar. Other signs/symptoms include fetal distress, vaginal bleeding (may not be present due to concealed bleeding), loss of fetal station and signs of shock.
As soon as the diagnosis is made, emergency resuscitation must be done to stabilize the patient and then proceed to emergency c-section +/- laparotomy. If there is imminent rupture and contractions are ongoing, IV tocolytic agents must be administered to stop the contractions. During the laparotomy if there is persistent bleeding, hysterectomy may be required. Remember, the mother’s life must be saved before the baby’s.
I hope that this has helped you, and more importantly will help you identify patients with the possibility of uterine rupture. Always remember that you should crossmatch at least 4-6 pints of blood as obstetric emergencies tend to have a lot of bleeding. If there are any questions please do let me know!
