Rupture of an Unscarred Uterus in a Woman with Recurrent Prior Uterine Instrumentation

Background: Uterine rupture is an obstetric emergency with potential for catastrophic maternal and fetal outcomes. Uterine instrumentation has not been commonly thought to be associated with uterine rupture. Case Presentation: A 31 year old, gravida 21, para 3, 0, 17, 3 underwent induction of labor at 40 6/7 weeks. She had no prior cesarean deliveries, two prior spontaneous abortions, and fifteen prior surgical terminations of pregnancy in the first trimester. Her active phase of labor was complicated by deterioration of the fetal heart tracing. She underwent vacuum assisted vaginal delivery followed by a postpartum hemorrhage. Bimanual examination revealed a lower uterine segment defect with palpable intra-abdominal contents. She underwent exploratory laparotomy and supracervical hysterectomy. Conclusion: A high index of suspicion and early diagnosis are paramount to the management of uterine rupture. Uterine rupture should be considered in patients with a history of uterine instrumentations. Kfier Kuba*, Dara N. Matseoane-Peterssen and Dena Goffman Department of Obstetrics and Gynecology, Columbia University Medical Center, USA Kfier Kuba, et al., Journal of Clinical Obstetrics, Gynecology & Infertility Remedy Publications LLC. 2018 | Volume 2 | Issue 1 | Article 1030 2 penicillin was started for GBS prophylaxis and oxytocin was initiated via low-dose oxytocin protocol. Cervical exam after sixteen hours of oxytocin was 2 cm / 50% / -3 / posterior position / medium consistency. Artificial rupture of membranes was performed at this time revealing clear amniotic fluid. After nineteen hours of oxytocin, the infusion had reached 18 mu/min and was stopped for a single prolonged fetal heart rate deceleration, with prompt recovery to category one. Shortly thereafter, the patients contractions were every 5 minutes, and oxytocin infusion was re-started at 1mu/min and titrated again using low-dose protocol. After twenty-three hours of oxytocin induction, and seven hours after membrane rupture, the patient had a temperature of 100.5 F and her cervical exam was 8 cm / 100% / -1 / anterior position / soft consistency. Acetaminophen was administered, antibiotic coverage was broadened for presumed chorioamnionitis, and oxytocin was continued. One hour later she was found to be 9 cm dilated with recurrent variable decelerations. An intrauterine pressure catheter was placed posteriorly without difficulty demonstrating a normal appearing baseline pressure and contraction pattern, with a frequency of every 2-3 minutes. Amnioinfusion was initiated per institutional protocol and subsequently stopped when variable decelerations resolved. A total of 384 mL of normal saline was infused. One hour after her previous exam, the patient developed recurrent late decelerations progressing to recurrent prolonged decelerations. At this time, oxytocin infusion was at 5 mu/min, her contractions were every 2 minutes and adequate by Montevideo units. She was found to be 10 cm / 100% / +2 station, with the fetus in left occiput anterior position, and underwent uncomplicated vacuum-assisted vaginal delivery for category two fetal heart tracing. Neonatal birth weight was 4,090 g with APGAR scores 6 and 9 at 1 and 5 minutes, respectively. The arterial cord pH was 7.11 with a base excess of -5.8. The infant was admitted to the neonatal intensive care unit for respiratory distress and ultimately discharged on day of life three. Delivery of the infant was followed by a small amount of blood clot. The placenta was delivered three minutes after the infant with active management of the third stage of labor. There was mild uterine atony which improved with 30 units intravenous oxytocin given per institutional protocol, as well as methylergonovine 0.2 mg intramuscular and misoprostol 1000 mcg given rectally. The patient continued to have episodic bright red vaginal bleeding. The placenta was inspected and noted to be intact without retroplacental clot. There were no perineal or vaginal lacerations, and the cervix was inspected and noted to be intact circumferentially. A bedside transabdominal sonogram was performed and the uterine cavity was manually explored. There was no evidence of retained membranes or placental tissue. However, on intrauterine examination, a defect was noted in the left lower uterine segment, through which bowel was palpated. Transabdominal sonogram confirmed a 7.2 cm heterogeneous collection in the left pelvis. Diagnosis of uterine rupture was made. The patient promptly underwent exploratory laparotomy which revealed hemoperitoneum, a six centimeter vertical defect in the left lower uterine segment extending to the superior aspect of the cervix, lacerated left uterine vessels, and a left broad ligament hematoma. Given the lacerated uterine vessels and broad ligament hematoma, the decision was made for hysterectomy as opposed to primary repair. Supracervical hysterectomy was performed without further complication. Total estimated blood loss was approximately 1,500 mL and the patient received 2 units of red blood cells. She was continued on intravenous antibiotics for forty-eight hours post operatively. Her recovery was otherwise uncomplicated, and she was discharged on post-operative day three. She was seen for follow up as an outpatient twice and her post-partum course was medically uncomplicated.