ShristyMohanty,

IMS and SUM hospital, India

Abstract

Introduction:

Uterine rupture is the complete disruption of all the layers of the uterus, including the serosa. In resource-rich countries, the most significant risk factor is a previous caesarean section. Uterine rupture is an obstetric emergency with catastrophic maternal and foetal outcome. It is a time sensitive condition needing immediate surgical intervention.

Case report:

Mrs. S, 35 year old resident of Nayagarh, with obstetric score of G5 P3 L3 A1 presented to labour room at 2.30 am on 5/1/2021 at 40 weeks 5 days period of gestation, with the chief complaint of lower abdominal pain since 11.00 am of the previous day (4/1/2021).
Her lower abdominal pain started on 11.00 am on 4/1/2021. It was associated with blood stained mucoid discharge. She went to one CHC and then to a District hospital but despite 12 hours of pain, delivery could not be done.
Finally, at 12.00 am 5/1/2021 she was referred to a higher centre. On her way to our hospital the patient had collapsed and lost her consciousness. She reached our LR at 2.30 am on 5/1/2021.
She had history of previous 3 normal vaginal deliveries. In her present pregnancy, she had gone for one antenatal check up and had done one obstetrical ultrasound at 17 weeks gestation.
On examination, she was severely pale, had cold and clammy extremities, dry lips, dry and coated tongue. Her pulse rate was 160/min and blood pressure was 80/40 mm hg, respiratory rate was 22/min, sp02- 70% on room air.
On obstetric examination- abdomen was distended, uterus was term size, contour maintained, tonically contracted, foetal parts could not be palpated, foetal heart sounds were not audible by stethoscope and could not be located by doppler as well.
On inspection of vulva- vulvaloedema was present, urine was blood stained after catheterisation.
On Per vaginal exam: dry, hot vagina, cervix fully effaced, os fully dilated, head station: 0, caput station: +2.
Laparotomy with Caesarean hysterectomy was done under GA on 5/1/2021. A dead male foetus of 4.65 kgs was delivered at 3.20 am on 5/1/2021 after giving a transverse uterine incision.
There was a rupture of the uterus on the posterior surface extending from the right lateral side. Rupture extended from the round ligament on the right side to the right uterosacral ligament. Around 1 litre of altered blood and clots were present in the pouch of Douglas and the site of rupture. Total abdominal hysterectomy was done. B/L tubes and ovaries were healthy and preserved.

Discussion:

Spontaneous rupture of uterus is difficult to diagnose in an unscarred uterus. We should suspect it in case of unusual and intractable pain abdomen in labouring women. Multiparity, advanced maternal age, grand multipara, low socio-economic status foetalmacrosomia, lac of antenatal care are risk factors.
In this case, there were certain atypical features because it was a posterior rupture. For example, the uterus was tonicallycontracted,foetal parts could not be palpated easily or superficially because the foetus was still inside the uterine cavity. On per vaginal examination, the foetal head had not receded back which usually happens in a ruptured uterus.

Conclusion:

The inconsistent signs and the short time in prompting definitive treatment of uterine rupture make it a challenging event. This case emphasises the importance of knowledge of a wide variety of risk factors, some of which may be specific to low socio-economic strata, and lack of proper antenatal care in a multigravida. It also highlights atypical presentation of a rupture uterus due to a posterior rupture. Because of timely management and tertiary care facilities, the mother’s life could be saved.