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A sudden pop
Images in Obstetrics
www. AJOG.org
A sudden pop Chad A. Grotegut, MD; C. Brennan Fitzpatrick, MD; Leo R. Brancazio, MD
CASE NOTES
A 40-year-old woman, gravida 4 para 3, was admitted to labor and delivery at 35 weeks’ gestation for the evaluation of hypertension. Her history included 1 classical cesarean section performed at 24 weeks for placental abruption. Upon admission, the patient denied abdominal pain or contractions, and fetal testing was reassuring. While in the hospital, the patient reported the sudden onset of abdominal pain, describing the sensation as a “pop.” Uterine contractions occurring every 2 minutes followed. During this time, the fetal heart rate tracing revealed frequent, severe, variable decelerations (Figure 1). The patient was transferred to the operating room for an emergency cesarean section. Upon opening the abdomen, surgeons found 1500 mL of blood. They then noted a defect in the fundal portion of the uterus that measured 5 centimeters in diameter with placenta extruding through that defect (Figure 2).
A fetal heart rate tracing showed repetitive variable decelerations and uterine contractions. Grotegut. A sudden pop. Am J Obstet Gynecol 2008.
Using the defect as the superior aspect of their hysterotomy, the team began a repeat classical cesarean section. A newborn weighing 2845 g and an intact placenta were delivered without difficulty. Apgar scores of 6, 7, and 8 were recorded at 1, 5, and 10 minutes respectively. The cord pH was 7.09 with a base excess of ⫺2. While attempting to repair the hysterotomy, the team found numerous fibroids, some of them large, through the anterior uterine wall. This prevented closure of the uterus. A supracervical hysterectomy was performed without complication. The patient and baby did well following the procedure.
CONCLUSIONS Uterine rupture is a known and feared complication of pregnancy in women who have undergone uterine surgery. Its true incidence during a trial of labor is difficult to determine because in many studies, asymptomatic uterine scar dehiscence identified at the time of repeat cesarean section is grouped
with symptomatic, catastrophic, uterine ruptures.1 One study found that spontaneous, pre-labor, uterine rupture occured in 0.16% of women who had undergone a prior low transverse cesarean section, making it less common than uterine rupture associated with labor.2 Uterine
From the Division of Maternal-Fetal Medicine, Duke University Medical Center, Durham, NC. Cite this article as: Grotegut C, Fitzpatrick CB, Brancazio LR. A sudden pop. Am J Obstet Gynecol 2008;198:340.e1-340.e2. 0002-9378/$34.00 • © 2008 Mosby, Inc. All rights reserved. • doi: 10.1016/j.ajog.2008.01.006
340.e1
American Journal of Obstetrics & Gynecology MARCH 2008
rupture is estimated to occur during labor in 4-9% of women with a history of classical cesarean section, but spontaneous uterine rupture rates are unknown.1 Among 157 women delivering after a prior classical cesarean section, 1 spontaneous uterine rupture occurred before onset of labor (0.6%), and 15 uterine scar dehiscences were noted (9.5%).3 Other reports suggest that one third of uterine ruptures in women with a prior classical cesarean section take
Images in Obstetrics
www.AJOG.org
FIGURE 2
Fundal portion of the uterus, as seen during an emergency cesarean section
place before labor begins.4 Therefore, a high index of suspicion for uterine rupture is necessary when a gravid woman who has had previous uterine surgery presents with severe abdominal pain and worrisome fetal heart rate f patterns. REFERENCES 1. American College of Obstetricians and Gynecologists Committee on Practice Bulletins—Obstetrics. ACOG Practice Bulletin Number 54: Vaginal birth after previous ce-
sarean delivery. Obstet Gynecol 2004;104: 203-212. 2. Lydon-Rochelle M, Holt VL, Easterling TR, Martin DP. Risk of uterine rupture during labor among women with a prior cesarean delivery. N Engl J Med 2001;345:3-8. 3. Chauhan SP, Magann EF, Wiggs CD, Barrilleaux PS, Martin JN Jr. Pregnancy after classic cesarean delivery. Obstet Gynecol 2002;100 (5 Pt 1):946-50. 4. Cunningham FG. Genital tract laceration and puerperal hematomas. In: Gilstrap LC, Cunningham FG, Vandorsten JP, eds. Operative Obstetrics, 2nd ed. New York, NY: McGrawHill; 2002: 236.
Grotegut. A sudden pop. Am J Obstet Gynecol 2008.
MARCH 2008 American Journal of Obstetrics & Gynecology
340.e2
www. AJOG.org
A sudden pop Chad A. Grotegut, MD; C. Brennan Fitzpatrick, MD; Leo R. Brancazio, MD
CASE NOTES
A 40-year-old woman, gravida 4 para 3, was admitted to labor and delivery at 35 weeks’ gestation for the evaluation of hypertension. Her history included 1 classical cesarean section performed at 24 weeks for placental abruption. Upon admission, the patient denied abdominal pain or contractions, and fetal testing was reassuring. While in the hospital, the patient reported the sudden onset of abdominal pain, describing the sensation as a “pop.” Uterine contractions occurring every 2 minutes followed. During this time, the fetal heart rate tracing revealed frequent, severe, variable decelerations (Figure 1). The patient was transferred to the operating room for an emergency cesarean section. Upon opening the abdomen, surgeons found 1500 mL of blood. They then noted a defect in the fundal portion of the uterus that measured 5 centimeters in diameter with placenta extruding through that defect (Figure 2).
A fetal heart rate tracing showed repetitive variable decelerations and uterine contractions. Grotegut. A sudden pop. Am J Obstet Gynecol 2008.
Using the defect as the superior aspect of their hysterotomy, the team began a repeat classical cesarean section. A newborn weighing 2845 g and an intact placenta were delivered without difficulty. Apgar scores of 6, 7, and 8 were recorded at 1, 5, and 10 minutes respectively. The cord pH was 7.09 with a base excess of ⫺2. While attempting to repair the hysterotomy, the team found numerous fibroids, some of them large, through the anterior uterine wall. This prevented closure of the uterus. A supracervical hysterectomy was performed without complication. The patient and baby did well following the procedure.
CONCLUSIONS Uterine rupture is a known and feared complication of pregnancy in women who have undergone uterine surgery. Its true incidence during a trial of labor is difficult to determine because in many studies, asymptomatic uterine scar dehiscence identified at the time of repeat cesarean section is grouped
with symptomatic, catastrophic, uterine ruptures.1 One study found that spontaneous, pre-labor, uterine rupture occured in 0.16% of women who had undergone a prior low transverse cesarean section, making it less common than uterine rupture associated with labor.2 Uterine
From the Division of Maternal-Fetal Medicine, Duke University Medical Center, Durham, NC. Cite this article as: Grotegut C, Fitzpatrick CB, Brancazio LR. A sudden pop. Am J Obstet Gynecol 2008;198:340.e1-340.e2. 0002-9378/$34.00 • © 2008 Mosby, Inc. All rights reserved. • doi: 10.1016/j.ajog.2008.01.006
340.e1
American Journal of Obstetrics & Gynecology MARCH 2008
rupture is estimated to occur during labor in 4-9% of women with a history of classical cesarean section, but spontaneous uterine rupture rates are unknown.1 Among 157 women delivering after a prior classical cesarean section, 1 spontaneous uterine rupture occurred before onset of labor (0.6%), and 15 uterine scar dehiscences were noted (9.5%).3 Other reports suggest that one third of uterine ruptures in women with a prior classical cesarean section take
Images in Obstetrics
www.AJOG.org
FIGURE 2
Fundal portion of the uterus, as seen during an emergency cesarean section
place before labor begins.4 Therefore, a high index of suspicion for uterine rupture is necessary when a gravid woman who has had previous uterine surgery presents with severe abdominal pain and worrisome fetal heart rate f patterns. REFERENCES 1. American College of Obstetricians and Gynecologists Committee on Practice Bulletins—Obstetrics. ACOG Practice Bulletin Number 54: Vaginal birth after previous ce-
sarean delivery. Obstet Gynecol 2004;104: 203-212. 2. Lydon-Rochelle M, Holt VL, Easterling TR, Martin DP. Risk of uterine rupture during labor among women with a prior cesarean delivery. N Engl J Med 2001;345:3-8. 3. Chauhan SP, Magann EF, Wiggs CD, Barrilleaux PS, Martin JN Jr. Pregnancy after classic cesarean delivery. Obstet Gynecol 2002;100 (5 Pt 1):946-50. 4. Cunningham FG. Genital tract laceration and puerperal hematomas. In: Gilstrap LC, Cunningham FG, Vandorsten JP, eds. Operative Obstetrics, 2nd ed. New York, NY: McGrawHill; 2002: 236.
Grotegut. A sudden pop. Am J Obstet Gynecol 2008.
MARCH 2008 American Journal of Obstetrics & Gynecology
340.e2