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Prerupture of unscarred uterus masked by an epidural analgesia
50
Letters to the Editor
management in pregnancy requires good obstetric care as well as specific treatment of the condition. In the case of chronic myeloid leukemia, chemotherapy could be deferred until delivery, because a delay in starting treatment is unlikely to have a serious effect on the clinical course [4]. In this patient, it was necessary to initiate therapy when the condition relapsed during pregnancy. Cytotoxic drug treatment in the first trimester may lead to increased incidence of fetal wastage and congenital malformations, whereas this risk is much less if therapy is started in the second or third trimester [ 21. The eventual delivery of a normal baby by this patient may relate to the fact that chemotherapy was started late in the third trimester. However, it is possible that cytotoxic drug therapy contributed to the premature delivery. Our patient was successfully managed with cytotoxic drugs. This confirms the view of some
authors [3,4] that chemotherapy should be used in the management of cases of chronic myeloid leukemia with the aim of successful outcome for both mother and infant. B.C. Ozumba G.O. Obi
Department of Obstetrics and Gynaecology University of Nigeria Teaching Hospital Enugu, Nigeria
References I
2
3 4
Ask-Upmark: Leukemia in pregnancy. Acta Med Stand I70: 635, 1961. Lilleyman JS, Hill AS, Anderton KS: Consequences of acute myelogenous leukemia in early pregnancy. Cancer 40: 1300, 1971. Moloney WC: Management of leukemia in pregnancy. Ann NY Acad Sci 114: 857, 1964. Dora P, Slatter L, Armentrout S: Successful pregnancy during chemotherapy for acute leukemia. Cancer 47: 845, 1981.
Prerupture of unscarred uterus masked by an epidural analgesia
To the Editor
January 9th, 1992
The use of epidural analgesia during labor may delay or mask the diagnosis of spontaneous uterine rupture, thereby increasing the risk to the mother and newborn [l]. The most common etiologies of rupture of an unscarred uterus during labor are oxytocin stimulation, cephalopelvic disproportion, grand multiparity and abruptio placenta 121. The type of rupture is usually described as complete or incomplete, depending on whether the laceration communicates directly with the peritoneal cavity. A women aged 34 years, at her second pregnancy, came to the delivery room 2 h after spontaneous rupture of membranes during the 41st week of her gestation. Her previous pregnancy had been terminated by a voluntary abortion. The cervix was 80% effaced, and the head was not engaged. She had good uterine contractions. She received 75 mg of pethidine and 25 mg of proKeywords: Unscarred uterus; Prerupture; Epidural analgesia. Int J Gynecol Obstet 38
methazine (phenergan). Seven hours later the cervix was completely effaced and dilated 4 cm. The head was engaged. The parturient asked for an epidural analgesia. After receiving 1000 ml of Ringer’s lactate solution, blood pressure was 1lo/80 mmHg. In the sitting position, a Tuohy epidural needle (Portex) was inserted at the LE3_4 interspace with the loss of resistance technique using air in the special syringe. A test dose of 2 ml of lidocaine 1% was injected through the needle. Then 9 ml of bupivacaine 0.25% and 1 ml of fentanyl 50 pg were injected through the needle. An epidural catheter was introduced into the epidural space uneventfully. Its epidural length was 3 cm. One milliliter of bupivacaine 0.25% was injected through the epidural catheter. Analgesia was obtained within 8 min with the level of T7_s. There was no hypotension, nausea, or vomiting. An oxytocin drip of 5 units within 500 ml of glucose 5%, at a rate of 30 ml/h, was started, with augmentation of 10 ml/h every 30 min. Two hours and forty minutes after the start of the epidural
Letters to the Editor
analgesia the parturient complained again of pain. She received 6 ml of bupivacaine 0.25% through the epidural catheter with relief of pain within 5 min. Five minutes after the top-up injection the parturient experienced a hypertonic contraction of the uterus for 1 min. The oxytocin drip was immediately stopped, and the patient received oxygen with a mask and was turned to her left side. With these maneuvers the contractions improved. One hour after the last top-up injection, the parturient started to feel pain only at her right upper and middle abdominal quadrants. The cervical dilatation was 7 cm. It was thought that the epidural catheter was too deep, so it was pulled out for a distance of 1 cm. Then 4 ml of bupivaCaine 0.5% were injected while the patient lay on her right side. This top-up provided analgesia for only 20 min. When the patient could not feel her left side, but complained of pain at her right upper and middle abdominal quadrants. Two short episodes of variable decelerations were noted. These improved after lying on the left side. There was no drop in the blood pressure. Another bolus of 4 ml of bupivacaine 0.5% was injected through the epidural catheter with the patient lying on her right side, The blood pressure was 1lo/80 mmHg. A urine catheter was introduced because of difficulty in micturition. An oxytocin drip was started again 15 min after the last top-up injection and continued for 45 min at 30 ml/h. A long deceleration for 5 min with heart rate of 80 beats/min was then noted, and the oxytocin drip was stopped immediately. The patient was turned again on her left side with an oxygen mask of 7 Umin. Thirty minutes after that another deceleration was noted with a heart rate of 80 beats/min. Then she started to bleed per vagina. A soft area at the lower part of the abdomen was palpated, and the urine became bloody. An emergency cesarean section was performed under epidural anesthesia with lidocaine 2% 20 ml with the suspicion of preof -the uterus. The patient was rupture hemodynamically stable. A hematoma was found at the right side of the uterus and the bladder. A newborn was delivered with an Apgar of 9, weighing 3.455 kg. The cord was around the neck and around the shoulder. The parturient was discharged from the hospital 7 days afterwards.
51
Traumatic or spontaneous rupture of the intact uterus may occur at any stage of gestation. The majority of patients have a predisposing factor such as previous uterine scar, therapeutic abortion or other gynecologic procedure, congenital uterine abnormality, previous intrauterine infection, placenta percreta or cornual pregnancy. Plauche et al. [3] described 2 patients out of 23 in .whom the uterine rupture occurred during epidural analgesia. Crawford [4] contended that any pain associated with imminent rupture will get through an otherwise successful epidural, a phenomenon he calls the epidural sieve. In our case, a combination of bupivacaine and fentanyl was used for epidural analgesia. The addition of opioid to local anesthetic allows a reduction in the dosage of local anesthetic and results in less intense motor block [5]. Despite adequate top-up injections, the parturient complained of one-sided painful contractions. This phenomenon can arise from two main causes: the anesthetic fluid does not reach the affected side or there is a prerupture condition which the usual anesthetic solution dosage is not enough to alleviate. In conclusion, a parturient received epidural analgesia using bupivacaine and fentanyl. Despite adequate anesthetic solution injections, she complained of one-sided painful contractions. Other signs of prerupture uterus necessitated delivery by cesarean section. A uterine hematoma was found at the operation. One-sided painful contractions despite adequate epidural anesthetic injections is suggested as another sign of a preruptured uterus. P. Guedj J. Eldor
Misgav
Department of Anesthesia Ladach General Hospital Jerusalem, Israel
References Ames RPM: Rupture I: 361, 1881.
of the uterus.
Am J Obstet Gynecol
Schrinsky DC, Benson RC: Rupture of the pregnant uterus: a review. Obstet Gynecol Surv 33: 217, 1978. Plauche WC, Von Almen W, Muller R: Catastrophic uterine rupture. Obstet Gynecol 64; 792, 1984. Meier PR, Porreco RP: Catastrophic uterine rupture. Obstet Gynecol 66: 296, 1985. Chestnut DH, Laszewski LJ, Pollack KL, Bates JN, Manago NK, Choi WW: Continuous epidural infusion of 0.0625% bupivacaine-0.0002% stage of labor. Anesthesiology
fentanyl during the second 72: 613, 1990. Int J Gynecol Obstet 38
Letters to the Editor
management in pregnancy requires good obstetric care as well as specific treatment of the condition. In the case of chronic myeloid leukemia, chemotherapy could be deferred until delivery, because a delay in starting treatment is unlikely to have a serious effect on the clinical course [4]. In this patient, it was necessary to initiate therapy when the condition relapsed during pregnancy. Cytotoxic drug treatment in the first trimester may lead to increased incidence of fetal wastage and congenital malformations, whereas this risk is much less if therapy is started in the second or third trimester [ 21. The eventual delivery of a normal baby by this patient may relate to the fact that chemotherapy was started late in the third trimester. However, it is possible that cytotoxic drug therapy contributed to the premature delivery. Our patient was successfully managed with cytotoxic drugs. This confirms the view of some
authors [3,4] that chemotherapy should be used in the management of cases of chronic myeloid leukemia with the aim of successful outcome for both mother and infant. B.C. Ozumba G.O. Obi
Department of Obstetrics and Gynaecology University of Nigeria Teaching Hospital Enugu, Nigeria
References I
2
3 4
Ask-Upmark: Leukemia in pregnancy. Acta Med Stand I70: 635, 1961. Lilleyman JS, Hill AS, Anderton KS: Consequences of acute myelogenous leukemia in early pregnancy. Cancer 40: 1300, 1971. Moloney WC: Management of leukemia in pregnancy. Ann NY Acad Sci 114: 857, 1964. Dora P, Slatter L, Armentrout S: Successful pregnancy during chemotherapy for acute leukemia. Cancer 47: 845, 1981.
Prerupture of unscarred uterus masked by an epidural analgesia
To the Editor
January 9th, 1992
The use of epidural analgesia during labor may delay or mask the diagnosis of spontaneous uterine rupture, thereby increasing the risk to the mother and newborn [l]. The most common etiologies of rupture of an unscarred uterus during labor are oxytocin stimulation, cephalopelvic disproportion, grand multiparity and abruptio placenta 121. The type of rupture is usually described as complete or incomplete, depending on whether the laceration communicates directly with the peritoneal cavity. A women aged 34 years, at her second pregnancy, came to the delivery room 2 h after spontaneous rupture of membranes during the 41st week of her gestation. Her previous pregnancy had been terminated by a voluntary abortion. The cervix was 80% effaced, and the head was not engaged. She had good uterine contractions. She received 75 mg of pethidine and 25 mg of proKeywords: Unscarred uterus; Prerupture; Epidural analgesia. Int J Gynecol Obstet 38
methazine (phenergan). Seven hours later the cervix was completely effaced and dilated 4 cm. The head was engaged. The parturient asked for an epidural analgesia. After receiving 1000 ml of Ringer’s lactate solution, blood pressure was 1lo/80 mmHg. In the sitting position, a Tuohy epidural needle (Portex) was inserted at the LE3_4 interspace with the loss of resistance technique using air in the special syringe. A test dose of 2 ml of lidocaine 1% was injected through the needle. Then 9 ml of bupivacaine 0.25% and 1 ml of fentanyl 50 pg were injected through the needle. An epidural catheter was introduced into the epidural space uneventfully. Its epidural length was 3 cm. One milliliter of bupivacaine 0.25% was injected through the epidural catheter. Analgesia was obtained within 8 min with the level of T7_s. There was no hypotension, nausea, or vomiting. An oxytocin drip of 5 units within 500 ml of glucose 5%, at a rate of 30 ml/h, was started, with augmentation of 10 ml/h every 30 min. Two hours and forty minutes after the start of the epidural
Letters to the Editor
analgesia the parturient complained again of pain. She received 6 ml of bupivacaine 0.25% through the epidural catheter with relief of pain within 5 min. Five minutes after the top-up injection the parturient experienced a hypertonic contraction of the uterus for 1 min. The oxytocin drip was immediately stopped, and the patient received oxygen with a mask and was turned to her left side. With these maneuvers the contractions improved. One hour after the last top-up injection, the parturient started to feel pain only at her right upper and middle abdominal quadrants. The cervical dilatation was 7 cm. It was thought that the epidural catheter was too deep, so it was pulled out for a distance of 1 cm. Then 4 ml of bupivaCaine 0.5% were injected while the patient lay on her right side. This top-up provided analgesia for only 20 min. When the patient could not feel her left side, but complained of pain at her right upper and middle abdominal quadrants. Two short episodes of variable decelerations were noted. These improved after lying on the left side. There was no drop in the blood pressure. Another bolus of 4 ml of bupivacaine 0.5% was injected through the epidural catheter with the patient lying on her right side, The blood pressure was 1lo/80 mmHg. A urine catheter was introduced because of difficulty in micturition. An oxytocin drip was started again 15 min after the last top-up injection and continued for 45 min at 30 ml/h. A long deceleration for 5 min with heart rate of 80 beats/min was then noted, and the oxytocin drip was stopped immediately. The patient was turned again on her left side with an oxygen mask of 7 Umin. Thirty minutes after that another deceleration was noted with a heart rate of 80 beats/min. Then she started to bleed per vagina. A soft area at the lower part of the abdomen was palpated, and the urine became bloody. An emergency cesarean section was performed under epidural anesthesia with lidocaine 2% 20 ml with the suspicion of preof -the uterus. The patient was rupture hemodynamically stable. A hematoma was found at the right side of the uterus and the bladder. A newborn was delivered with an Apgar of 9, weighing 3.455 kg. The cord was around the neck and around the shoulder. The parturient was discharged from the hospital 7 days afterwards.
51
Traumatic or spontaneous rupture of the intact uterus may occur at any stage of gestation. The majority of patients have a predisposing factor such as previous uterine scar, therapeutic abortion or other gynecologic procedure, congenital uterine abnormality, previous intrauterine infection, placenta percreta or cornual pregnancy. Plauche et al. [3] described 2 patients out of 23 in .whom the uterine rupture occurred during epidural analgesia. Crawford [4] contended that any pain associated with imminent rupture will get through an otherwise successful epidural, a phenomenon he calls the epidural sieve. In our case, a combination of bupivacaine and fentanyl was used for epidural analgesia. The addition of opioid to local anesthetic allows a reduction in the dosage of local anesthetic and results in less intense motor block [5]. Despite adequate top-up injections, the parturient complained of one-sided painful contractions. This phenomenon can arise from two main causes: the anesthetic fluid does not reach the affected side or there is a prerupture condition which the usual anesthetic solution dosage is not enough to alleviate. In conclusion, a parturient received epidural analgesia using bupivacaine and fentanyl. Despite adequate anesthetic solution injections, she complained of one-sided painful contractions. Other signs of prerupture uterus necessitated delivery by cesarean section. A uterine hematoma was found at the operation. One-sided painful contractions despite adequate epidural anesthetic injections is suggested as another sign of a preruptured uterus. P. Guedj J. Eldor
Misgav
Department of Anesthesia Ladach General Hospital Jerusalem, Israel
References Ames RPM: Rupture I: 361, 1881.
of the uterus.
Am J Obstet Gynecol
Schrinsky DC, Benson RC: Rupture of the pregnant uterus: a review. Obstet Gynecol Surv 33: 217, 1978. Plauche WC, Von Almen W, Muller R: Catastrophic uterine rupture. Obstet Gynecol 64; 792, 1984. Meier PR, Porreco RP: Catastrophic uterine rupture. Obstet Gynecol 66: 296, 1985. Chestnut DH, Laszewski LJ, Pollack KL, Bates JN, Manago NK, Choi WW: Continuous epidural infusion of 0.0625% bupivacaine-0.0002% stage of labor. Anesthesiology
fentanyl during the second 72: 613, 1990. Int J Gynecol Obstet 38