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Rupture of the uterine segment and bladder following cesarean section
RUPTURE
OF THE UTERINE SEGMENT AND FOLLOWING CESAREAN SECTION SUSANNE
R.
PARSONS, (From
tkc
M.D., Cottage
R
UPTURE
SANTA BARBARA,
BLADDER CALIF.
Hospital)
of the uterus and rupture of the bladder during pregnancy may occur separately be due to external trauma or or together. They may occur ante partum or intra partum; to obstetrical trauma; to weakened uterine wall due to adenomyosis (Stone*) ; to the scar of previous section; or to injury to the bladder at previous section for delivery. A febrile puerperium following cesarean section is recognized as predisposing to a weakened uterine scar. An incidence of 1 in 220 cases was reRupture of the uterus OCCUPS in about 1:2,000 cases. ported by Whitacre and Fanga from the Peking Union Hospital in a series of 11,500 deliveries. Mrs. M. H., aged 37 years, gravida iii, had hat1 two pregnancies terminated by cesarean section, on account of an asymmetrical anthropoid pelvis, the first child having presented by breech. The first delivery was in January, 194ti, the second in August, 1949. The pregnancies were uneventful. Low cervical sections were preformed by the author both times, with longitudinal incisions through the lower segment. Hoth postoperative courses were afebrile and there were no bladder complications noted either time. Mrs. M. H. registered for her third pregnancy May 12, 1950. The last menstrual period was February 18, and her expec.ted confinement Nov. 25, 1950. The only complaint was slight morning nausea Physical examination showed a 37-year-old woman, height 5 feet, 6 inches, weight 120 pounds, blood pressure 136/66, hemoglobin 8-1 per cent, red blood count 4.25 million, and white blood count 9,500. The differential count was normal. Kahn and Kline tests were negative. Her blood was Group A, Rh positive. The basal metabolic rate was plus 3 per cent, and plus 1 per cent. The urine was negative, tuberculin test negative. The pregnancy progressed uneventfully. Her weight gain was 23 pounds, the blood pressure and urine were normal throughout. The child lay in right occiput anterior position, and the head was not engaged when the patient was admitted to the hospital November 14 for elective section and sterilization the following day. About 11’:30 A.M. the patient was awakened from sleep by a sudden sharp pain in the lower abdomen, and felt the urge to void. She went to the bathroom, passed a small amount of bloody urine, and called the nurse. When seen 15 minutes later the patient was still complaining of pain in the lower abdomen, which was acutely tender to palpation. No uterine contractions were made out, the fetal heartbeat was regular in the right lower quadrant, no boardlike rigidity was found, and there was no vaginal bleeding. The pulse and blood pressure were unchanged. A tentative diagnosis of rupture of the uterus .was made and the patient taken to surgery. As is customary, a French catheter was inserted into the bladder preoperatively and left in place during No note was made by the nurse of bloody urine at this time, although only 30 C.C. surgery. \vere obtained. General anesthesia was used. Pulse and blood pressure remained normal. The abdomen was opened by a low midline incision with excision of the previous scar. The abdominal cavity was free of blood and other fluid, and was protected by a large lap roll in the usual manner. The uterine peritoeum was picked up about 2 cm. above the bladder reflection and incised. At once the end of the indwelling catheter and the infant’s shoulder came into view. The incision was carried laterally on both sides and after placing a lap sponge over the bladder and catheter, the child was readily delivered by lifting the head out of the uterus manually. The rent in the uterus was enlarged anteriorly 2 to 3 cm. in order to facilitate delivery. The child weighed 8 pounds, 2% ounces, and cried spontaneously. 672
Volume Number
64 3
RI!PTCRE
OF
LOWER
UTERlNE
SEGMENT
ANI)
BIa,\I)I)~K.
ci7:i
Uterine sinuses were now clamped by ring clamps and the placenta expressed. The bl:nIder was inspected and found to have split transversely for its entire width. The bladder margins were picked up by Allis clamps, and covered by lap until. the uterus was closed. The The uterine tear was longitudinal through the old scar, and extended to the cervix below. uterus was closed by two layers of continuous No. 1 chromic catgut, the second layer inverting the first. The bladder then was closed by No. 00 plain catgut, in two layers. TWO Cm. of au!. fathiazole were placed over the uterine lower segment and a pieye of Oxycel was left at ihe lower end of the denuded area to control slight oozing. The bladder peritoneum was then sutured well above the upper end of the longitudinal uterine incision. Sterilization was done according to the Pomeroy technique, and the abdomen was closed in layers. A 5 C.C. Fo1e.v Glmose, 1,000 c.c. Ii! t,atheter was inserted into the bladder and left in place for 10 days. per cent in saline, was given during the operation, aud the transfnsion begun on return to the The lochia was normal, the roum. The pulse, temperature, and blood pressure remained good. ‘)‘I .I’ urine in the drainage hottle remained bloody for three days, but thereafter was clear. patient was out of bed on the first postoperative day, and was walking freely about the TOWI! on the third day, with the catheter still in place and at,tached to a small specimen hot: .1’ for convenience. On the ninth postoperative day the catheter \~a3 clamped off for an hour :I!. a time, and the following day the catheter was RnllJved, roidiug was adequate, and the urine? clear. The patient was discharged on the thirteenth postollerative day, with no urinary syrrrl~toms, the abdominal imision was ~vel! healetl, and the uterus involuting normally. f’c*,ric2illin was given during the entire time the catheter I\ as left in 1S1:~(~~~an11 for two days thertafter, to prevent, so far as possible, any urinary infe6on. Follow-up examinations on Jan. 2, 1951, and June 19, 1951, showed a complete recover’, Pelvic examination was normal, the uteras with entirely normal bladder capacity and function. being well involuted and in good anteflexion, with clear vaults :tnS clean cervix. The child, :I normal female, ‘IVXS doing nicely. Cystogrxms done in O(?ober, 1051, showed normal bladd:ar cBontours and position. The capacity was found to be normal. A second ease which the author saw in consultation and which illustrates rupture of tile uterus through the lower segment scar of a previous section, but in which the bladder dissected itself free of the scar, and did not rupture, is that of Mrs. C’. I)., a white woman, aged 22 years! pars i, gravida ii. There was :I history oi’ r~n~ov:tl of a right parovarian cyst arid She was (lrlivered in Deeember, 1928, by I(sw right tube together wit,11 the appendix in 1946. segment Wsarran section aftri 38 hours of labor, witIt 11~1 program: at the cull fetal distress developed, due to a short cord wrapped 3 times allout the chil~l’s body. The child vvas it!suscitated and the patient made an uneventful recovery, lmt for a single elevat,ion in temperThere \v:ts ~~epll:~loprlric tlisiproportion :i* ature on the third postoperative day to 102” 1’. well as fetal distress noted on the record. On Nov. 11, 1949, the patient was admitted in lat~or at 5 :30 .\.>I. The pains heg;rn the previous evening at 9:30 P.M., and on admission were severe, lasting 45 to 60 sec~onrls and every 2 to 3 minutes. At 6 :45 A.M.. the author saw the patient in c,onsultatiou. The sbrlom~n almost continuous. s?nllc~ was tense, exquisitely tender, the pains were extremely severe ilTl(l blood clots were being passed. The pulse was 7%. blaotl pressure 140/99, fetal heartbeat. I::6 takeri Io and regular. .I diagnosis of tlneatene~l uterine rupture Was m;ule and the I~atient surgery at onre, as rectal examination showed an unengagell head with oreni~ling at tile symphpsis. The abdomen was opened and no free blood or fluid was f#Jund in the abdominal cati’,v. When the serosa was incised to prepare the bladder flap, a large clot of blood was foul&d over the lolver segment and under the bladder lrhich had ~lissectcd away from thrx 111t’r!rs. which had ruptured longitudinally, and the child’s head was visible in the aperture in tile The rent was enlarged ant,eriorly and a living child delircrl~~l. lower segment of the uterus. The uterus was closed in the usual manner and thtl uninjured bladder sutured over the III:noded lower segment. The patient recovered.
674
PARSONS
Am. .I. Obst. P Gynec. September, 1952
Summary Two cases are here reported, which were strikingly similar except that, in the second, the bladder itself did not rupture but acted as a tampon to the tear in the uterine lower segment, while, in the first case, rupture of the lower segment into the bladder took place. The second patient had been unwisely allowed to remain in hard labor for several hours before the consultant was called, and rupture had taken place when the patient was first seen by the author.
References 1. stone, M. L.: AM. J. OBST. & C~YNEC. 36: 883, 1938. 2. Whitacre, F. E., and Fang, L. Y.: Arch. Burg. 45: 213,1942. 22-C
WEST
MICHELTORENA
STREET
OF THE UTERINE SEGMENT AND FOLLOWING CESAREAN SECTION SUSANNE
R.
PARSONS, (From
tkc
M.D., Cottage
R
UPTURE
SANTA BARBARA,
BLADDER CALIF.
Hospital)
of the uterus and rupture of the bladder during pregnancy may occur separately be due to external trauma or or together. They may occur ante partum or intra partum; to obstetrical trauma; to weakened uterine wall due to adenomyosis (Stone*) ; to the scar of previous section; or to injury to the bladder at previous section for delivery. A febrile puerperium following cesarean section is recognized as predisposing to a weakened uterine scar. An incidence of 1 in 220 cases was reRupture of the uterus OCCUPS in about 1:2,000 cases. ported by Whitacre and Fanga from the Peking Union Hospital in a series of 11,500 deliveries. Mrs. M. H., aged 37 years, gravida iii, had hat1 two pregnancies terminated by cesarean section, on account of an asymmetrical anthropoid pelvis, the first child having presented by breech. The first delivery was in January, 194ti, the second in August, 1949. The pregnancies were uneventful. Low cervical sections were preformed by the author both times, with longitudinal incisions through the lower segment. Hoth postoperative courses were afebrile and there were no bladder complications noted either time. Mrs. M. H. registered for her third pregnancy May 12, 1950. The last menstrual period was February 18, and her expec.ted confinement Nov. 25, 1950. The only complaint was slight morning nausea Physical examination showed a 37-year-old woman, height 5 feet, 6 inches, weight 120 pounds, blood pressure 136/66, hemoglobin 8-1 per cent, red blood count 4.25 million, and white blood count 9,500. The differential count was normal. Kahn and Kline tests were negative. Her blood was Group A, Rh positive. The basal metabolic rate was plus 3 per cent, and plus 1 per cent. The urine was negative, tuberculin test negative. The pregnancy progressed uneventfully. Her weight gain was 23 pounds, the blood pressure and urine were normal throughout. The child lay in right occiput anterior position, and the head was not engaged when the patient was admitted to the hospital November 14 for elective section and sterilization the following day. About 11’:30 A.M. the patient was awakened from sleep by a sudden sharp pain in the lower abdomen, and felt the urge to void. She went to the bathroom, passed a small amount of bloody urine, and called the nurse. When seen 15 minutes later the patient was still complaining of pain in the lower abdomen, which was acutely tender to palpation. No uterine contractions were made out, the fetal heartbeat was regular in the right lower quadrant, no boardlike rigidity was found, and there was no vaginal bleeding. The pulse and blood pressure were unchanged. A tentative diagnosis of rupture of the uterus .was made and the patient taken to surgery. As is customary, a French catheter was inserted into the bladder preoperatively and left in place during No note was made by the nurse of bloody urine at this time, although only 30 C.C. surgery. \vere obtained. General anesthesia was used. Pulse and blood pressure remained normal. The abdomen was opened by a low midline incision with excision of the previous scar. The abdominal cavity was free of blood and other fluid, and was protected by a large lap roll in the usual manner. The uterine peritoeum was picked up about 2 cm. above the bladder reflection and incised. At once the end of the indwelling catheter and the infant’s shoulder came into view. The incision was carried laterally on both sides and after placing a lap sponge over the bladder and catheter, the child was readily delivered by lifting the head out of the uterus manually. The rent in the uterus was enlarged anteriorly 2 to 3 cm. in order to facilitate delivery. The child weighed 8 pounds, 2% ounces, and cried spontaneously. 672
Volume Number
64 3
RI!PTCRE
OF
LOWER
UTERlNE
SEGMENT
ANI)
BIa,\I)I)~K.
ci7:i
Uterine sinuses were now clamped by ring clamps and the placenta expressed. The bl:nIder was inspected and found to have split transversely for its entire width. The bladder margins were picked up by Allis clamps, and covered by lap until. the uterus was closed. The The uterine tear was longitudinal through the old scar, and extended to the cervix below. uterus was closed by two layers of continuous No. 1 chromic catgut, the second layer inverting the first. The bladder then was closed by No. 00 plain catgut, in two layers. TWO Cm. of au!. fathiazole were placed over the uterine lower segment and a pieye of Oxycel was left at ihe lower end of the denuded area to control slight oozing. The bladder peritoneum was then sutured well above the upper end of the longitudinal uterine incision. Sterilization was done according to the Pomeroy technique, and the abdomen was closed in layers. A 5 C.C. Fo1e.v Glmose, 1,000 c.c. Ii! t,atheter was inserted into the bladder and left in place for 10 days. per cent in saline, was given during the operation, aud the transfnsion begun on return to the The lochia was normal, the roum. The pulse, temperature, and blood pressure remained good. ‘)‘I .I’ urine in the drainage hottle remained bloody for three days, but thereafter was clear. patient was out of bed on the first postoperative day, and was walking freely about the TOWI! on the third day, with the catheter still in place and at,tached to a small specimen hot: .1’ for convenience. On the ninth postoperative day the catheter \~a3 clamped off for an hour :I!. a time, and the following day the catheter was RnllJved, roidiug was adequate, and the urine? clear. The patient was discharged on the thirteenth postollerative day, with no urinary syrrrl~toms, the abdominal imision was ~vel! healetl, and the uterus involuting normally. f’c*,ric2illin was given during the entire time the catheter I\ as left in 1S1:~(~~~an11 for two days thertafter, to prevent, so far as possible, any urinary infe6on. Follow-up examinations on Jan. 2, 1951, and June 19, 1951, showed a complete recover’, Pelvic examination was normal, the uteras with entirely normal bladder capacity and function. being well involuted and in good anteflexion, with clear vaults :tnS clean cervix. The child, :I normal female, ‘IVXS doing nicely. Cystogrxms done in O(?ober, 1051, showed normal bladd:ar cBontours and position. The capacity was found to be normal. A second ease which the author saw in consultation and which illustrates rupture of tile uterus through the lower segment scar of a previous section, but in which the bladder dissected itself free of the scar, and did not rupture, is that of Mrs. C’. I)., a white woman, aged 22 years! pars i, gravida ii. There was :I history oi’ r~n~ov:tl of a right parovarian cyst arid She was (lrlivered in Deeember, 1928, by I(sw right tube together wit,11 the appendix in 1946. segment Wsarran section aftri 38 hours of labor, witIt 11~1 program: at the cull fetal distress developed, due to a short cord wrapped 3 times allout the chil~l’s body. The child vvas it!suscitated and the patient made an uneventful recovery, lmt for a single elevat,ion in temperThere \v:ts ~~epll:~loprlric tlisiproportion :i* ature on the third postoperative day to 102” 1’. well as fetal distress noted on the record. On Nov. 11, 1949, the patient was admitted in lat~or at 5 :30 .\.>I. The pains heg;rn the previous evening at 9:30 P.M., and on admission were severe, lasting 45 to 60 sec~onrls and every 2 to 3 minutes. At 6 :45 A.M.. the author saw the patient in c,onsultatiou. The sbrlom~n almost continuous. s?nllc~ was tense, exquisitely tender, the pains were extremely severe ilTl(l blood clots were being passed. The pulse was 7%. blaotl pressure 140/99, fetal heartbeat. I::6 takeri Io and regular. .I diagnosis of tlneatene~l uterine rupture Was m;ule and the I~atient surgery at onre, as rectal examination showed an unengagell head with oreni~ling at tile symphpsis. The abdomen was opened and no free blood or fluid was f#Jund in the abdominal cati’,v. When the serosa was incised to prepare the bladder flap, a large clot of blood was foul&d over the lolver segment and under the bladder lrhich had ~lissectcd away from thrx 111t’r!rs. which had ruptured longitudinally, and the child’s head was visible in the aperture in tile The rent was enlarged ant,eriorly and a living child delircrl~~l. lower segment of the uterus. The uterus was closed in the usual manner and thtl uninjured bladder sutured over the III:noded lower segment. The patient recovered.
674
PARSONS
Am. .I. Obst. P Gynec. September, 1952
Summary Two cases are here reported, which were strikingly similar except that, in the second, the bladder itself did not rupture but acted as a tampon to the tear in the uterine lower segment, while, in the first case, rupture of the lower segment into the bladder took place. The second patient had been unwisely allowed to remain in hard labor for several hours before the consultant was called, and rupture had taken place when the patient was first seen by the author.
References 1. stone, M. L.: AM. J. OBST. & C~YNEC. 36: 883, 1938. 2. Whitacre, F. E., and Fang, L. Y.: Arch. Burg. 45: 213,1942. 22-C
WEST
MICHELTORENA
STREET