Abstract

Spontaneous uterine rupture is a rare entity - the reported incidence being 1 in 8000 to 1 in 50000 deliveries. The appropriate treatment depends upon factors such as parity, extent of the defect and magnitude of bleeding. A 35 year old 4th gravida with previous 3 full term normal deliveries presented to us at 23 weeks gestation with signs and symptoms suggestive of uterine rupture. An obstetric hysterectomy was done with an uneventful post operative period.

Introduction

For several decades multiparity has been viewed with great caution. In his 1934 article, entitled “The dangerous multipara” Bathel Solmons writes “my main object is to remove if possible, once and for all, the idea that a primigravida means a difficult labour but a multipara means an easy one. It is altogether a mistake to suppose that in childbearing, practice makes perfect”.

Rupture of the pregnant uterus, one of the most serious obstetric complications, is associated with high rates of maternal and foetal morbidity and mortality. Spontaneous ruptures are virtually always intrapartum and characteristically involve the lower segment. Literature reports of uterine rupture associate ruptures with risk factors such as uterine abnormalities, grand multiparity, macrosomic foetus, cephalopelvic disproportion and trauma to the uterus from prior instrumentation such as in abortion, version or oxytocine stimulation.1-3,5 The commonest cause of rupture is dehiscence from previous caesarean section scar, especially in the presence of oxytocin stimulation in unrecognised cephalopelvic disproportion. We report a case of spontaneous uterine rupture which occurred at 23 weeks gestation.

Case Report

A 35 year old gravida 4, para 3, living 3 was admitted as an emergency at 23 weeks gestation with sudden sharp abdominal pain. She had no significant past medical history. No antenatal registration. The lady was restless with marked pallor, tachycardia and tachypnoea. The pulse was thready, BP 90 mmHg systolic. Abdomen was doughy with marked tenderness. The examination revealed 20 weeks size well contracted uterus. During per vaginal examination patient had a fresh out of bleeding. An iv line was established and blood obtained for grouping and cross matching. She was resuscitated with iv fluids and plasma expanders as hemaccel. Patient transiently responded to these measures. Ultrasound showed a viable foetus with normal biometry consistent with 23 weeks gestation associated with free peritoneal fluid. While awaiting the blood and other facilities she deteriorated dramatically (pulse 120/min, BP 80 mmHg systolic), becoming increasingly breathless. So the patient was rushed in for an emergency laparotomy with the suspicion of uterine rupture. A frank haemoperitoneum of approximately 1000 ml of fresh blood and clots was present. The foetus was lying outside the uterus within the peritoneal cavity. A horizontal full thickness rupture exactly at the fundus, extending from one corner to another was seen. The placenta was lying in the peritoneal cavity but the placental bed could be identified at the fundus. Considering her parity and extent of rupture the decision to go ahead with an obstetric hysterectomy was taken. The rest of the pelvis looked normal with no evidence of endometriosis or adhesions. She was transfused 4 units of the whole human blood and 4 units of FFPs. Her post operative period was uneventful.

Discussion

Risk factors associated with midtrimester uterine rupture include previous salpingectomy and cornual resection following ectopic pregnancy, trauma, myomectomy, congenital abnormalities and sacculation of the entrapped retroverted uterus. (Dubuisson et al, 1995; Arbab et al, 1996). The patient denied any history of previous gynaecological surgery such as dilatation and curettage, termination of pregnancy or use of an IUCD which could have resulted in undiagnosed uterine perforation.

The reported incidence of spontaneous rupture occuring in the absence of previous surgery ranges from 1 in 8000 to 1 in 50000 deliveries.4 It has been suggested that predisposing factors to such malformations, endometriosis and injudicious oxytocic stimulation.

As it was a full thickness rupture it resulted in marked vaginal bleeding, intrauterine foetal death and clinically hard uterus. On the basis of factors such as parity, extent of the defect and magnitude of bleeding we took the right decision to proceed with an obstetric hysterectomy. We believe that we could save the mother in this case due to early diagnosis, continuous clinical assessment and prompt surgical intervention.

References

1. Daylene L. Ripley, Uterine emergencies. Obst Gynecol Clin 1999; 26 : 419.
2. Langton J, Fishwick K, Kumar B, Nwosu EC. Spontaneous rupture of an unscarred uterus at 32 weeks gestation. Human Reprod 1997; 12 : 2066-7.
3. Miller DA, Paul RH. Rupture of the unscarred uterus. Am J Obstet Gynecol 1996; 174 : 345.
4. Sweeten KM, Graves WK, Athanassion A. Spontaneous rupture of an unscarred uterus. Am J Obstet Gynecol 1995; 170 : 1851-5.
5. Toohey JS, Keegan KA Jr, Morgan MA, Francis J, Task S, de Veciana M. The “dangerous multipara” facts or fiction. Am J Obstet Gynecol 1995; 172 : 683.

*Head of the Department, **Honorary Associate Professor, Department of Obst and Gynaec; +Registrar; ++Houseman; KB Bhabha Municipal General Hospital, Bandra (W), Mumbai.