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SPONTANEOUS RUPTURE OF UTERINE ARTERY

Asha K Phadke*, Nayana A Dastur**
*Senior Lecturer; **Hon. Prof and Unit Chief, Nowrosjee Wadia Maternity Hospital, Acharya Donde Marg, Parel, Mumbai.

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Spontaneous rupture of utero-ovarian vessels during pregnancy is a rare cause of shock that has a high rate of maternal and foetal loss. Though the usual presentation is of maternal shock, rarely at times the catastrophe can present in form of foetal distress.[1] Acute onset of pain, with maternal shock and presence of haemoperitoneum and foetal distress should make an obstetrician wary of the rare entity of utero-ovarian vessel rupture.

In such an event an exploratory laparotomy followed by caesarean with ligation of the uterine vessel or its branch can help in preventing a maternal mortality. The advent of modern resuscitative facilities, anaesthesia techniques have lowered mortality associated with this condition from 49%[3] to 3.6%.[4]

INTRODUCTION

Spontaneous haemoperitoneum during pregnancy resulting from tear or rupture of a uterine or ovarian vessel is a rare yet catastrophic event, which can be a cause of maternal and foetal loss. In 1912 Lawson stated in American Journal of Obstetrics that "it is surprising to find that aneurysms of the ovarian and uterine vessels are amongst the extremely rare abnormalities met with in medical literature".[2] The overall mortality due to this complication is reported to be 49%3 to 3.6%.[4] Williams originally reported this rare complication in 1904.[5]

In 1950 Hodgkinson and Christensen reviewed the subject and documented 75 cases of utero- ovarian vessel rupture associated with pregnancy. In most of the reports the presenting complains were of acute abdominal pain followed by maternal shock but in contrast to this, in the presented case acute onset of abdominal pain was followed by sudden onset of acute foetal distress hence the tentative diagnosis made prior to exploratory laparotomy was of placental abruption.

CASE REPORT

Mrs. AB, 21 year old female married since one year, A primigravida with 35 weeks of gestation presented in early labour at 7.15 pm.

Presenting parameters - Vitals stable

Pulse 70 beats per minute, BP 110/70 no evidence of pallor or oedema.

PA 36 weeks uterus cephalic 2/5 Th palpable

Foetal heart rate 140/min regular

1-2/10/10 activity.

PV cervix 1 cm posterior short 50% effaced

Vertex presentation

Membranes present

Station -2

Pelvis adequate

At 8.20 pm patient complained of sudden onset of severe pain in abdomen

PA 36 weeks uterus cephalic 2/5 Th palpable

Foetal heart rate 80 beats per minute

Normal uterine tonus.

PV cervix 1 cm posterior short 50% effaced

Vertex presentation

Membranes present

Station -2

Pelvis adequate.

CTG done showed deceleration up to 60 beats per minute, Artificial rupture of membranes carried out to rule out placental abruption.

Emergency ultrasonography done ruled out retro placental clot in a posterior placenta with no evidence of praevia. Foetal heart rate was 60-80 beats per minute. There was free fluid in the abdominal cavity. In view of these findings a decision was made to perform an emergency caesarean section.

Intra operative findings1500 ml of blood was present in the peritoneal cavity. A lower uterine segment caesarean section was performed and a live female baby (birth weight 1600 gm) was delivered (Apgar of 5 and 8 at 1 and 5 min). Checking the uterus for tears and extension of the incision revealed no positive finding. On delivering the uterus out of the laparotomy incision on investigating the posterior surface of the uterus an actively bleeding right uterine artery was seen 1 cm above the cervical uterine junction. Haemostasis was achieved by securing a figure of 8 ligature around the bleeding vessel.

Abdominal lavaging done and other causes of haemoperitoneum ruled out.

Intra and post operatively the patient was transfused 4 units of whole blood. Patient was haemodynamically stable through out.

DISCUSSION

Spontaneous haemoperitoneum during the 3rd trimester of pregnancy resulting from tear or rupture of a uterine or ovarian vessel is a rare yet catastrophic event. Hodgkinson and Christensen in 1950 reported an overall mortality rate of 49%.[3] These figures reflect the difficulties faced by the obstetricians prior to the modern resuscitative, anaesthetic and operative technique. Ever since there has been a fall in the maternal mortality rate to 3.6%.[4]

Aetiology of the condition is unknown though at times arteriovenous malformation or uterine artery aneurysm may be present. The congenital malformation, arterial degeneration and inflammatory process are causes of aneurysm, which can be aggravated by haemodynamic stress of pregnancy and labour.

Presenting symptoms seen are of sudden onset of abdominal pain without vaginal bleeding associated with signs of acute abdomen and hypovolaemia. Foetal distress is a rare finding.[1]

An accurate diagnosis is rarely made prior to laparotomy because of a host of other surgical and obstetrical conditions that can present with a similar clinical picture.

Differential diagnosis includes

-Abruptio placentae

-Rupture uterus

-Abdominal pregnancy

-Perforated appendicitis

-Rupture of splenic/hepatic artery aneurysms.

Placental abruption is the most common differential diagnosis for rupture of the utero-ovarian vessels. The diagnosis of which is aided by establishing the presence of haemoperitoneum in case of a vessel rupture.

Active preoperative resuscitation is crucial. Exploratory laparotomy and control of haemorrhage is the only option. Caesarean is often needed in order to locate the site of the haemorrhage. If the source of bleeding is not identified then other causes of haemoperitoneum should be ruled out and managed accordingly.

Obstetricians should be aware of this rare aetiology of shock, which can present either antenatal or in labour.

REFERENCES

1.Steinberg LH, Goodfellow C, Rankin L. Spontaneous rupture of uterine artery in pregnancy. British Journal of Obstetrics and Gynecology Feb. 1993; 100 : 184.

2.Lawson H. Aneursym of the uterine artery. Am J Obst and Gynec 1912; 66 : 732.

3.Hodgkinson CP, Christensen RC. Hemorrhage from ruptured utero - ovarian veins during pregnancy. Am J Obstet and Gynec 1950; 59 : 1112.

4.Ginsberg KA, Valdes C, Schnider G. Spontaneous utero-ovarian vesel rupture during pregnancy : three case reports and a review of the literature. Obstet Gynecol 1987; 69 : 474.

5.Williams JW. Intrapelvic hematoma following labor not associated with lesions of the uterus. Am J Obstet Gynecol 1904; 50 : 442.

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