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Uterine contractility after rupture of the gravid uterus: A case report
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This section is suitable for reporting results of therapeutic trials, descriptions of new procedures or instruments, and case reports which illustrate a principle. Reports should be limited to 700 words and 2 references. Use of an illustration or table requires a proportionate reduction in total words.
Uterine contractility after rupture of the gravid uterus: A case report
included one spontaneous abortion and two term vaginal deliveries. The current pregnancy progressed uneventfully. The patient presented to the hospital labor and delivery suite at 41 weeks' gestation after the spontaneous onset of labor. An external electronic fetal monitor was applied and showed uterine contractions every 3 to 4 minutes and a baseline fetal heart rate of 120 bpm. Two hours after admission, the patient began dark red vaginal bleeding and complained of abdominal pain. Five minutes later, the fetal monitor, which had been recording the fetal heart rate at a baseline of 120 bpm, abruptly lost the heart rate signal (Fig. 1). Doptone examination relocated the fetal heartbeat and the rate was 60 to 90 bpm. With a presumptive diagnosis of abruptio placentae, the patient was prepared for an emergency cesarean section. Meanwhile, the uterus continued to contract every 3 to 4 minutes for 10 minutes, after which the external tocodynamometer was removed for the operation (Fig. 2). At the time of operation 2000 ml of freshly clotted blood were found in the abdominal cavity. The placenta and infant were found free-floating in the upper abdomen. The 3068 gm female infant was delivered through the abdominal incision and had Apgar scores of 1 at 1 minute and 3 at 5 minutes. A large rent, measuring 12 by 6 em, was found in the posterior uterus extending from the fundus down to the cervix and extending out into the right broad ligament. A supracervical hysterec-
Laura J. Zuidema, M.D., John W. Goldkrand, M.D., and Bruce A. Work, Jr., M.D. Departments of Obstetrics and Gynecology, University of Illinois School of Medicine, Chicago, Illinois, and Albany Medical College, Union University, Albany, New York
Uterine rupture is a diagnosis rarely made prospectively. In making the diagnosis, clinicians rely on classic textbook signs such as cessation of uterine contractions, loss of fetal heart tones, abdominal pain, and vaginal bleeding. The following case is reported because of the interesting electronic fetal-maternal monitor tracing obtained during the course of labor. A 28-year-old woman, gravida 4, para 2, presented for prenatal care at 18 weeks' gestation. Previous obstetric history Reprint requests: Laura J. Zuidema, M.D., Department of Obstetrics and Gynecology, University of Illinois at Chicago, 840 South Wood St., Chicaqo, IL 60612.
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• • • •• • • ••• • • • • • • ••••• •• • • ••• • • • • •• •• ••• • •• • •• 70105
70106
-110: 75
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Fig. l. Monitor strip showing loss of fetal heart rate signal.
783
784
Communications in brief
November 15, 1984 Obstet Gynecol
Am J
llll ftlllll l l l f t t i U I I I I I I I I I I I I f i i i i i i i i i U I I I I I I U I I I f i i i U I I I I I U U U I I I U I I I I I • U t U U U t t t t l t t l l t U t l l l l t i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i U I I I I I t l l
Fig. 2. Monitor strip showing persistence of uterine contractions after loss of fetal heart signal.
tomy was performed. The patient was transfused with six units of whole blood and two units of plasma, had an uneventful postoperative course, and was discharged home on her seventh postoperative day. Rupture of the gravid uterus, with and without prior trauma or operation, is well described in the obstetric literature. The reported incidence of uterine rupture has varied greatly, ranging anywhere from 1% to 0.008%. Although maternal mortality rates associated with uterine rupture are 5% in industrialized countries, in less developed countries and in the days before aggressive fluid replacement and surgical intervention, maternal mortality rates ranged as high as 55%. Fetal mortality rates range in general from 30% to 60% and in some cases are as high as 100%. 1 The etiology of uterine rupture is varied. It is well known that previous uterine scars such as from low transverse and classical cesarean sections, myomectomies, and uterine plastic repairs predispose the uterus to rupture, usually at the site of the previous scar. In the unscarred uterus, increased age and parity of the gravid woman correlate with spontaneous rupture during labor. Likewise, oxytocic stimulation, fundal pressure, cephalopelvic disproportion, amniocentesis, and breech version and extraction have all been associated with uterine rupture. Classically, uterine rupture is described in the presence of abdominal pain, cessation of uterine contractions, loss of fetal heart tones, and vaginal bleeding. Only one third of these patients, however, present with these signs. The diagnosis of uterine rupture is often not made until the time of laparotomy. Occasionally, the diagnosis is made prospectively when a postpartum patient has vaginal bleeding unresponsive to uterine massage and oxytocics and this is followed by surgical exploration revealing uterine rupture. Usually when a laboring patient develops abdominal pain, vaginal bleeding, and fetal distress, as in this case, the clinical diagnosis of abruptio placentae is made. In this patient, the loss of the fetal heart rate signal by the monitor requiring relocation of the fetal heart signal with the Doptone points to a movement of the fetal heart signal away from the ultrasound coverage and it is at this point that the fetus is presumed to have been extruded from the uterus. Not only can recession of the fetal presenting parts be suggestive of uterine rupture, but marked recession of the fetal heart "signal
should alert the clinician to the possibility of uterine rupture. The interesting aspect of this case is that after the point of presumed rupture of the uterus, the uterus continued to contract for at least 10 minutes. It is well known that the symptomatology of a ruptured uterus may range from mild to severe. Bleeding and pain may be variable and may be associated with other events such as abruptio placentae. This case is reported so that clinicians will be cautious in relying on cessation of uterine contractions as a sign of uterine rupture. In this case the contractions continued after the presumed rupture. It may be that cessation of uterine contractions is a late event in the evolution of uterine rupture occurring after extrusion of the fetus. If the clinician waits for cessation of uterine contractions to diagnose uterine rupture, undue delay in the treatment of uterine rupture may occur. The use of electronic fetalmaternal monitoring provided two interesting clinical observations in this case, once again remindi:ng us that the diagnosis of uterine rupture is often made with difficulty in prospect. REFERENCES 1. Schrinsky DC, Benson RC. Rupture of the pregnant
uterus: a review. Obstet Gynecol Surv 1978;33:217.
Management of acute and subacute puerperal uterine inversion with terbutaline sulfate Bruce W. Kovacs, M.D., and Greggory R. DeVore, M.D. Department of Obstetrics and Gynecology, University of Southern CalifQrnia ~cho?l of Medicine, and Women's Hospital, Los Angeles County/Unzverszty of Southern California Medical Center, Los Angeles, California
Puerperal uterine inversion is an uncommon obstetric emergency that historically has resulted in significant maternal mortality. In the past, classification Reprint requests: Greggory R. DeVore, M.D., Women's Hospital, Room SK40, 1240 North Mission Road, Los Angeles, CA 90033.
This section is suitable for reporting results of therapeutic trials, descriptions of new procedures or instruments, and case reports which illustrate a principle. Reports should be limited to 700 words and 2 references. Use of an illustration or table requires a proportionate reduction in total words.
Uterine contractility after rupture of the gravid uterus: A case report
included one spontaneous abortion and two term vaginal deliveries. The current pregnancy progressed uneventfully. The patient presented to the hospital labor and delivery suite at 41 weeks' gestation after the spontaneous onset of labor. An external electronic fetal monitor was applied and showed uterine contractions every 3 to 4 minutes and a baseline fetal heart rate of 120 bpm. Two hours after admission, the patient began dark red vaginal bleeding and complained of abdominal pain. Five minutes later, the fetal monitor, which had been recording the fetal heart rate at a baseline of 120 bpm, abruptly lost the heart rate signal (Fig. 1). Doptone examination relocated the fetal heartbeat and the rate was 60 to 90 bpm. With a presumptive diagnosis of abruptio placentae, the patient was prepared for an emergency cesarean section. Meanwhile, the uterus continued to contract every 3 to 4 minutes for 10 minutes, after which the external tocodynamometer was removed for the operation (Fig. 2). At the time of operation 2000 ml of freshly clotted blood were found in the abdominal cavity. The placenta and infant were found free-floating in the upper abdomen. The 3068 gm female infant was delivered through the abdominal incision and had Apgar scores of 1 at 1 minute and 3 at 5 minutes. A large rent, measuring 12 by 6 em, was found in the posterior uterus extending from the fundus down to the cervix and extending out into the right broad ligament. A supracervical hysterec-
Laura J. Zuidema, M.D., John W. Goldkrand, M.D., and Bruce A. Work, Jr., M.D. Departments of Obstetrics and Gynecology, University of Illinois School of Medicine, Chicago, Illinois, and Albany Medical College, Union University, Albany, New York
Uterine rupture is a diagnosis rarely made prospectively. In making the diagnosis, clinicians rely on classic textbook signs such as cessation of uterine contractions, loss of fetal heart tones, abdominal pain, and vaginal bleeding. The following case is reported because of the interesting electronic fetal-maternal monitor tracing obtained during the course of labor. A 28-year-old woman, gravida 4, para 2, presented for prenatal care at 18 weeks' gestation. Previous obstetric history Reprint requests: Laura J. Zuidema, M.D., Department of Obstetrics and Gynecology, University of Illinois at Chicago, 840 South Wood St., Chicaqo, IL 60612.
COIOMniiC.S
__..,...,
IJUS (
(OIOMJtii(S
"_. ... ...
1
• • • •• • • ••• • • • • • • ••••• •• • • ••• • • • • •• •• ••• • •• • •• 70105
70106
-110: 75
•
-
I . _..:.._---li---_:_-+___;-+-__;...+-~-:+llt-51 · y25
Fig. l. Monitor strip showing loss of fetal heart rate signal.
783
784
Communications in brief
November 15, 1984 Obstet Gynecol
Am J
llll ftlllll l l l f t t i U I I I I I I I I I I I I f i i i i i i i i i U I I I I I I U I I I f i i i U I I I I I U U U I I I U I I I I I • U t U U U t t t t l t t l l t U t l l l l t i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i U I I I I I t l l
Fig. 2. Monitor strip showing persistence of uterine contractions after loss of fetal heart signal.
tomy was performed. The patient was transfused with six units of whole blood and two units of plasma, had an uneventful postoperative course, and was discharged home on her seventh postoperative day. Rupture of the gravid uterus, with and without prior trauma or operation, is well described in the obstetric literature. The reported incidence of uterine rupture has varied greatly, ranging anywhere from 1% to 0.008%. Although maternal mortality rates associated with uterine rupture are 5% in industrialized countries, in less developed countries and in the days before aggressive fluid replacement and surgical intervention, maternal mortality rates ranged as high as 55%. Fetal mortality rates range in general from 30% to 60% and in some cases are as high as 100%. 1 The etiology of uterine rupture is varied. It is well known that previous uterine scars such as from low transverse and classical cesarean sections, myomectomies, and uterine plastic repairs predispose the uterus to rupture, usually at the site of the previous scar. In the unscarred uterus, increased age and parity of the gravid woman correlate with spontaneous rupture during labor. Likewise, oxytocic stimulation, fundal pressure, cephalopelvic disproportion, amniocentesis, and breech version and extraction have all been associated with uterine rupture. Classically, uterine rupture is described in the presence of abdominal pain, cessation of uterine contractions, loss of fetal heart tones, and vaginal bleeding. Only one third of these patients, however, present with these signs. The diagnosis of uterine rupture is often not made until the time of laparotomy. Occasionally, the diagnosis is made prospectively when a postpartum patient has vaginal bleeding unresponsive to uterine massage and oxytocics and this is followed by surgical exploration revealing uterine rupture. Usually when a laboring patient develops abdominal pain, vaginal bleeding, and fetal distress, as in this case, the clinical diagnosis of abruptio placentae is made. In this patient, the loss of the fetal heart rate signal by the monitor requiring relocation of the fetal heart signal with the Doptone points to a movement of the fetal heart signal away from the ultrasound coverage and it is at this point that the fetus is presumed to have been extruded from the uterus. Not only can recession of the fetal presenting parts be suggestive of uterine rupture, but marked recession of the fetal heart "signal
should alert the clinician to the possibility of uterine rupture. The interesting aspect of this case is that after the point of presumed rupture of the uterus, the uterus continued to contract for at least 10 minutes. It is well known that the symptomatology of a ruptured uterus may range from mild to severe. Bleeding and pain may be variable and may be associated with other events such as abruptio placentae. This case is reported so that clinicians will be cautious in relying on cessation of uterine contractions as a sign of uterine rupture. In this case the contractions continued after the presumed rupture. It may be that cessation of uterine contractions is a late event in the evolution of uterine rupture occurring after extrusion of the fetus. If the clinician waits for cessation of uterine contractions to diagnose uterine rupture, undue delay in the treatment of uterine rupture may occur. The use of electronic fetalmaternal monitoring provided two interesting clinical observations in this case, once again remindi:ng us that the diagnosis of uterine rupture is often made with difficulty in prospect. REFERENCES 1. Schrinsky DC, Benson RC. Rupture of the pregnant
uterus: a review. Obstet Gynecol Surv 1978;33:217.
Management of acute and subacute puerperal uterine inversion with terbutaline sulfate Bruce W. Kovacs, M.D., and Greggory R. DeVore, M.D. Department of Obstetrics and Gynecology, University of Southern CalifQrnia ~cho?l of Medicine, and Women's Hospital, Los Angeles County/Unzverszty of Southern California Medical Center, Los Angeles, California
Puerperal uterine inversion is an uncommon obstetric emergency that historically has resulted in significant maternal mortality. In the past, classification Reprint requests: Greggory R. DeVore, M.D., Women's Hospital, Room SK40, 1240 North Mission Road, Los Angeles, CA 90033.