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Two Cases of Uterine Rupture in Low-Risk Patients
Abstract Number: RF7A10-506
Abstract Type: Case Report Case Series
We present two cases of low-risk, young and otherwise healthy parturients that required cesarean-hysterectomies to control hemorrhage secondary to uterine rupture without prior uterine surgery.
A 40-year-old G2P0 woman presented with hypertension (166/96 mmHg) at 36 weeks and 4 days gestation. She had a history of two posterior-corpus fibroids, and a spontaneous abortion, a recent ultrasound found a posterior placenta and a vertex fetus with EFW of 2826 grams. She was diagnosed with preeclampsia with severe features, started on a magnesium infusion and induced with misoprostol. A combined spinal-epidural technique was performed unremarkably for labor analgesia.
A 37-year-old G8P2 woman presented for induction of labor at 39 weeks 6 days. She notably had 5 prior elective abortions and a history of abdominoplasty. Her sonogram estimated the fetal weight at 3946 grams. Her induction consisted of placement of dinoprostone, and subsequently, a cervical Foley balloon catheter. An epidural was placed for labor analgesia.
Both cases proceeded in a remarkably similar fashion. In both cases, labor was augmented with an oxytocin infusion. 12-14 hours after the infusion was started, the both patients had severe abdominal pain, fetal bradycardia and fetal loss of station. In each case, an emergent cesarean delivery was called and the patients were transported to the operating room.
General anesthesia was induced in both cases and the babies were delivered emergently. APGARs were 8/9 and 2/9 respectively. Both patients were found to have uterine rupture with hemorrhage – posterolateral and right lateral respectively. In each case, the uterine damage was so severe that hemostasis was not possible and a cesarean hysterectomy was performed as a life-saving measure. Both patients received large-bore vascular and arterial access. Both cases received significant blood transfusions , ultimately, both had unremarkable post-partum courses and were discharged on postoperative days 4 and 3 respectively.
The risk of uterine rupture without previous uterine manipulation is less than 0.006% of pregnancies. The major risk factors for uterine rupture are existing uterine abnormalities, previous surgical manipulation e.g. cesarean delivery and myomectomy, increased age, multiparity, malpresentation and excessive induction with oxytocin. Signs and symptoms are acute and include increased uterine pain or lack of breakthrough pain relief with epidural analgesia, severe fetal bradycardia, increased uterine contractions, vaginal bleeding and loss of fetal station.
These cases could help clinicians have increased suspicion for uterine rupture in patients without previous uterine manipulation. The cause of rupture in these cases is not clear. One possibility could be a combination of increased uterine contractions from the oxytocin infusion as well as uterine wall abnormalities from existing fibroids.