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Posterior Uterine Rupture without Previous Cesarean Delivery or Myomectomy
Abstract Number: T-83
Abstract Type: Case Report/Case Series
Uterine rupture is a known risk of pregnancy and can cause multiple serious complications including hemorrhage, shock, maternal or newborn mortality and potentially require hysterectomy for management. Risk factors include increased age, multiparity, malpresentation, excessive induction with oxytocin, low birth weight, uterine abnormalities, previous surgical manipulation, particularly myomectomy and cesarean delivery (CD). Uterine rupture, while rare, occurs in approximately 1:2500-1:5000 deliveries. We present a case of 32yo with pre-eclampsia with severe features who developed posterior uterine rupture without previous CD or myomectomy.
32 y.o. G4P2012 female with IUP at 35w1d wga with a history of endometriosis and Behcet’s syndrome presented with contractions and pre-eclampsia with severe features. She was started on magnesium and given a betamethasone series for preterm induction. Low dose oxytocin was initiated for labor augmentation. Pt requested an epidural for labor analgesia. She had a unilateral block that required a second epidural. After several hours of labor with reassuring fetal tracing, cervical exam was performed and though previously normal, now revealed fetal head in posterior cul-de-sac of the pelvis with a very anterior cervix. Decision was made to proceed to the OR for CD. Lidocaine 2% with epi was administered via the epidural for surgical anesthesia. After standard pfannenstiel and fascial incisions, hemoperitoneum was noted and evacuated. A low transverse uterine incision was made and a vigorous baby was delivered. Upon exteriorization of the uterus, a large posterior uterine defect was discovered and remained attached only via the uterosacral ligaments and uterine vessels. Hysterectomy was performed, as safe reapproximation of the uterus was not possible. Arterial and central lines were placed and the patient remained with epidural anesthesia. She received 4units of RBCs and 2u of FFP. After an uneventful hospital course mother and baby were discharged POD 3.
The classic presentation of uterine rupture involves fetal distress with profound fetal bradycardia in the setting of previous CD. Other risk factors and variable presentations have been documented. We present a case of posterior uterine rupture with reassuring fetal status in a patient whose only previous surgical history included resection of endometriosis. Prior operative note indicated endometriosis primarily on the posterior uterus. Resection was performed without complication. Typically CD and myomectomy history are the most concerning surgical risk factors for uterine rupture. This case should raise suspicion for uterine rupture in patients with previous endometrial procedures as well.
Ofir, K. Uterine rupture: Risk factors and pregnancy outcome. Amer J of Ob & Gyn. 2003.
Dow, M. Third Trimester Uterine Rupture without Previous Cesarean: A Case Series and Review of the Literature. Amer J Perinatol 2009.