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A Ticking Time Bomb Living on the Antepartum Floor
Abstract Number: SU-71
Abstract Type: Case Report/Case Series
A 21 year old G3P0 initially presented at 26w5d with a chief complaint of vague abdominal pain. The patient’s history is complicated by 2 previous uterine ruptures. The first rupture occurred at 30w0d due to a motor vehicle accident leading to fetal demise. The operative report from the initial uterine repair after the motor vehicle accident described an “approximately 10 cm long rupture of the uterine fundus extending around the top of the uterus to the posterior fundus.” The rupture was closed in 3 layers at that time.
The second rupture occurred spontaneously at 31w5d. The patient presented at that time in significant distress and abdominal pain and demonstrated hemodynamic instability. This incident led to fetal demise also. The rupture was surgically repaired at this time as well. After each pregnancy, the patient was advised to not become pregnant for at least a year. Each time she became pregnant less than a year later.
PMH was otherwise uncomplicated in this patient with no comorbidities noted.
The patient was admitted for close monitoring due to her presentation and history. The patient’s pain subsided and no indication of uterine rupture was noted via vital signs or ultrasound. Given the patient’s history of rupture and the significant risk this posed to the mother and the fetus, the high risk obstetric service made the decision to admit the patient with the plan of pursuing elective cesarean delivery at 31w0d. This would allow the parturient and the fetus to be closely monitored for any signs/symptoms of uterine rupture more closely than could reasonably be achieved as an outpatient. The timing of the delivery was chosen based on the timing of her most recent rupture. From an anesthesia standpoint, she was evaluated at the beginning of her hospital admission and was monitored by our service in addition to the obstetricians. Our main focus was ensuring good IV access was maintained in case an emergency were to develop and the patient required significant resuscitation. In addition to vascular access, an active type and screen was kept on the patient at all times throughout her hospital stay.
The patient’s hospital stay was uncomplicated and no further episodes of abdominal pain occurred. Once the patient reached 31w0d, she was taken to the operating room for elective cesarean section. Anesthesia was administered via combined spinal epidural. Intrathecal medications included 12 mg of hyperbaric bupivacaine, 10 mcg fentanyl, 150 mcg morphine. An epidural catheter was placed at the L3/L4 interspace. A T4 sensory level was achieved and the patient delivered a single viable male newborn with Apgars of 3, 3, and 9 at one, five, and ten minutes, respectively. An extremely thin portion of the uterine fundus was noted intraoperatively which was consistent with the previous uterine ruptures and subsequent repairs. The remainder of the hospital course was uncomplicated and the patient was discharged home on post-operative day 3.