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Undetected Uterine Rupture During Induction of Labor for Intrauterine Fetal Demise Using Epidural Anesthesia: A Case Report
Abstract Number: RF3BC-243
Abstract Type: Case Report Case Series
Uterine rupture is a rare, but serious complication of pregnancy defined as a full-thickness separation of the uterine wall and overlying serosa occurring in 0.035% of all deliveries. We present a case in which effective diagnosis was clouded by fetal demise in a patient with a functioning epidural. While much debate exists regarding the potential for epidural anesthesia to mask uterine rupture, this presentation shows that a high index of suspicion is required for the pathology.
A 29 year-old G6P1132 woman was admitted at 22 weeks and 4 days gestational age for induction of labor for fetal demise. Her medical history was notable for two prior low transverse cesarean sections, insulin-dependent type 2 diabetes mellitus and obesity with a BMI of 36 kg/m2. She initially presented to the obstetric clinic at 16 weeks’ gestation with vaginal bleeding, and fetal echocardiogram confirmed diagnosis of fetal demise.
Induction of labor was initiated with misoprostol and labor pain was treated with patient-controlled analgesia with intravenous fentanyl. On hospital day 2, she began having increasing tachycardia with normal blood pressures. On hospital day 3, an epidural at the level of L3-4 was placed by the anesthesia team. A mixture of ropivacaine 0.1% with fentanyl 2mcg/mL, as per protocol, was infused through the epidural catheter. On hospital day 4, the patient developed new upper abdominal pain despite effective epidural coverage, fundal tenderness with foul-smelling discharge, temperature of 37.5 Celsius, and leukocytosis with increase in white blood count to 11.7 103/µL. The patient was diagnosed with chorioamnionitis and was initiated on antibiotic therapy with ampicillin and gentamicin. She was subsequently scheduled for D&E.
After cervical dilation in the operating room, the surgical team began the evacuation of fetal tissue with forceps. However, during a second pass with their instruments, the team identified small bowel being pulled through the cervix. Subsequently, uterine rupture was quickly diagnosed and the decision was made to convert the procedure to an exploratory laparotomy with the assistance of a general surgery team to assess the bowel injury. General anesthesia was induced and the patient was intubated with an endotracheal tube in rapid sequence fashion. Laparotomy revealed a 100-cm section of small bowel avulsed from the mesentery. She was extubated and recovered uneventfully in the post-anesthesia care unit
Uterine rupture is a rare but catastrophic complication of pregnancy. Its initial presentation can be as subtle as persistent sinus tachycardia, as in this case. Despite controversy surrounding epidural anesthesia and its potential to mask uterine rupture, neuraxial analgesia did not impede in the diagnosis in this case and can be of potential benefit when used with a mixture of low concentrations of local anesthetic and opioid medications.