Gowri Dorairajan1
(1)
Obstetrics and Gynecology, JIPMER, Puducherry, India
5.1 Rupture Following Obstructed Labour
The traditional teaching is that multigravidae rupture their uterus and primigravidae go for secondary inertia or arrest of labour or exhaustion. I would like to narrate a case I had seen 20 years back in the emergency room. A primigravida was brought to the emergency room by her husband and mother. Her husband had lifted her on his shoulders. Their journey to the hospital had taken 2 days changing from bullock carts to buses from a nearby state. When the husband seated the woman on the bench, the woman had the look of death on her face. She could barely move. The face was expressionless. It had surpassed all the possible pain. The eyes were sunken. She was severely pale. She had not eaten anything for 2 days and was in labour for more than a day before undertaking this journey. She had tachycardia. The blood pressure was 90/60 mm of Hg. Abdomen revealed tenderness all over with distension and absent foetal heart sounds. She was febrile. Vaginal examination revealed pus and slough at the vault. Cervix could not be delineated. The head was high up. I have never since encountered a case with such findings on vaginal examination. After resuscitation laparotomy was carried out. Laparotomy revealed a sloughed off lower segment. The head was visible through it. The lower edge of the lower segment was friable and oedematous. The sigmoid colon and bladder appeared unhealthy oedematous and blue. The foetus was extracted out. Hysterectomy was carried out. Prolonged continued bladder drainage failed to prevent vesicovaginal fistula. Eventually, she developed a high rectal fistula. Vaginal examination 2 weeks later revealed only sloughed out tissue everywhere in the pelvis with faeces and urine pouring from the vagina. Such agonizing could be the misery of obstructed labour. How cruel the health system could be which fails to prevent such a misery that even death would look like a gift. Fortunately, we can take pride that the whole health system has improved drastically with the upgrading of primary centres and community health centres to provide emergency obstetric services. In this case, the rupture was probably due to pressure necrosis and sloughing off of the lower segment due to prolonged pressure necrosis and infection as the patient was probably in active labour for nearly 36–48 h. Fortunate are the present-day residents who would never see such situations.
Chigbu and colleagues [4] reported ruptured uterus in a primigravida due to obstructed labour. The woman reported was 40 years old and was in obstructed labour. She had a rupture of the anterior lower segment with a stillbirth. There was no history of any previous uterine procedure.
It is very rare to find a primigravida with obstructed labour going in for rupture as the uterus goes in for secondary inertia. It can happen when oxytocics are used to augment labour in them to overcome the secondary inertia not realizing that there is obstructed labour due to either malposition or cephalopelvic disproportion.
5.2 Rupture of the Posterior Wall
I would like to narrate the following case just to bring out that the birth attendant who persists and tries to deliver with undue fundal pressure failing to recognize obstructed labour can do a lot of harm.
A primigravida was referred from a health centre late in labour.
She had been in labour for nearly 16 h before she presented. At admission, she was exhausted and dehydrated and had tachycardia. The blood pressure was normal. The abdomen revealed features of obstructed labour with a big baby. The foetal heart rate was 110/min. There was secondary inertia. Vaginal examination revealed vertex at 0 station with a large caput reaching till introitus and irreversible moulding. There was thick meconium stained liquor. An emergency caesarean section was performed. The peritoneal fluid was blood stained (200 ml). The lower segment was stretched. The caesarean section was uneventful. An asphyxiated foetus weighing 3.5 kg was born. The uterine incision was sutured. On examining the posterior surface of the uterus near the fundus, we observed 3 cm area of a bruise with slow ooze (Fig. 5.1). The same was sutured.
Fig. 5.1
Photograph showing disruption due to bruising at the fundus of the uterus
The woman later confirmed the use of continued fundal pressure by the birth attendant in an overenthusiastic effort to deliver the patient. I have never imagined such a possible fate after fundal pressure. It was an eye opener. Fundal pressure should be discouraged by all means. Rupture of the posterior wall in the absence of previous surgery like myomectomy, etc. is extremely rare. Rupture invariably occurs in the anterior wall being the thinnest or in lateral wall in a multigravida with neglected labour. Abdalla and colleagues [1] reported a woman with increasing pain and features of free fluid and falling haemoglobin at 28 weeks of pregnancy. The foetus was doing well. Laparotomy revealed a posterior wall rent with 1 l of haemoperitoneum. They could not identify any cause.
Matsubara and co-authors [6] reported an interesting case. A 27-year-old primigravida had presented at term with irregular uterine contractions. A hard mass was felt anteriorly which was diagnosed to be thinned out bulging anterior uterine wall with foetal parts in it. An incomplete rupture was confirmed by caesarean section. Long-standing sacculation of the uterus was proposed to be the reason for thinning and incomplete rupture.
Rupture of the mid posterior wall of the uterus was reported by Takeda et al. [12] in a primigravida at 32 weeks of pregnancy. She had undergone uterine artery embolization for a cervical ectopic pregnancy 4 years earlier. A similar case of rupture was reported [13] in a woman pregnant after uterine artery embolization for fibroid uterus. She was also found to have abnormal placentation in the form of placenta percreta invading through the layers at the site of rupture.
5.3 Iatrogenic Extraperitoneal Disruption of Uterine Artery Due to Instrumental Delivery
I would like to narrate one more case with iatrogenic cause. The second gravida with previous normal delivery was admitted in labour. The pregnancy was otherwise uncomplicated. There were no comorbidities. The labour progressed well, but in the second stage, the descent of the head was a little delayed. It was slightly mal-rotated head at +2 station. The estimated weight was 3.2 kg. There were no features of cephalopelvic disproportion. In an enthusiastic attempt to deliver, the registrar had applied low forceps. It was a difficult delivery. The baby was born alive but had low Apgar score at birth. There was a deep tear in the left lateral vaginal wall. There was a linear tear in the cervix on the left side. The registrar had sutured the same. The patient did not require any blood transfusion. Two days after delivery, she appeared pale. The pulse was a 100 per minute. The blood pressure was normal. Examination of the abdomen revealed a large oblique mass on the left side from above pubic symphysis occupying the left iliac fossa. Vaginal examination and scan confirmed it to be a left broad ligament hematoma.
Since she was stable, the woman was managed conservatively. Broad-spectrum antibiotics were administered, and two bottles of blood were transfused. There was no further drop in the haemoglobin. There was no pyrexia. After 10 days the hematoma size started shrinking becoming firmer, and after 3 months, it got completely absorbed. Though truly this is not a ruptured uterus, I have described the case because it is rupture of the uterine artery on the left side probably due to the direct extension of the cervical tear. It is possible that the apex was not visualized properly at the time of the primary suturing of the tear. The woman was lucky that the hematoma contained itself to the broad ligament and was self-limiting because of the tamponade effect. However, it is a matter of great concern as it added to the morbidity and the need for the transfusions, and it also extended the hospital stay. Unfortunately, we don’t have her follow-up of subsequent pregnancies as it is a matter of worry that she might rupture her uterus during labour in the subsequent pregnancy.
5.4 Rupture Following Induction of Labour
It is indeed rare for a primigravida to rupture her uterus. Most often there is an iatrogenic element including the injudicious use of oxytocics. The following case is just to bring out how communication gaps can prove dangerous.
A primigravida was admitted at 41 weeks of pregnancy. On examination she was normotensive. She was not anaemic. There were no comorbidities. Abdomen revealed single foetus in right occipito-anterior position with adequate liquor, good foetal heart sounds, and an estimated weight of 3 kg. Ultrasonography confirmed the same. The pelvis was normal. The Bishop score was 4. We planned induction of labour. The cervix was ripened with prostaglandin E2 gel. After 12 h the Bishop score was favourable. 25 micrograms of misoprostol were administered vaginally 4th hourly. After two doses she was in established active labour. Membranes were ruptured artificially at 5 cm dilation. The liquor was clear. The vertex had descended to -1 station. After about 3 h she complained of severe sudden pain lower abdomen and shoulder tip pain. The pulse had risen to 120/min, and blood pressure was 90 systolic. The uterine contractions had ceased. The abdomen was diffusely tender, and the foetal heart sounds were no longer heard. There was bleeding from vagina noted. Suspecting rupture she was taken for urgent laparotomy. There was rupture of the lower segment, and the foetus was in the abdominal cavity. There was 1 l of haemoperitoneum. The foetus was extracted and the lower segment was repaired. On critically analysing the case, it was observed that the third dose of misoprostol had been administered by the staff nurse within half hour of the artificial rupture of membranes because the dose was due. It is very important to understand and delay the administration of the due dose of prostaglandins if the contractions are moderate and artificial rupture of membranes (ARM) has been done because ARM would further augment the contractions. It was very tragic and a wake-up call for the whole team. The labour had got further enhanced after rupturing of membranes and not realizing the third dose of misoprostol had been administered by the staff nurse as there were no written instructions not to do so. In service hospital where the doctor-patient ratio is poor and the nurses are carrying out the administration of drugs, the instructions should be spelled out clearly. Any communication gap between the doctors/residents and the other members of the team administering drugs could prove very costly to patient care. After this incidence we developed safety strategies and protocols for administering inducing agents.
Chen et al. recently published a systematic review [2]. The authors concluded that vaginal misoprostol was very effective in achieving delivery within 24 h but was found to have a high risk of hyperstimulation and foetal compromise compared to oral misoprostol or mechanical method of induction.
Thus, one has to be very careful while using prostaglandins for induction of labour even in a primigravida.
Mourad and colleagues [9] reported a 23-year-old woman who ruptured her uterus after premature rupture of membranes at 32 weeks of pregnancy even before she went in for established labour. There was no induction of labour. They could not establish a cause. Mishina and colleagues [7] reported another interesting case. They diagnosed a large defect in the fundus of the uterus of a primigravida at 32 weeks of gestation who complained of severe abdominal pain. The cause for the weakening of the myometrium could not be established.
5.5 Rupture Due to Uterine Malformations
Malformations of the uterus have been found to increase the risk of rupture. The condition can be diagnosed early in symptomatic women with imaging. We came across a primigravida at 10 weeks of pregnancy with abdominal pain. She had continuous moderate pain on the right side. She was otherwise stable. Sonography made us suspect a rudimentary horn pregnancy. Laparotomy revealed unruptured cornual pregnancy of a rudimentary horn. The noncommunicating horn with pregnancy was excised (Fig. 5.2).
Fig. 5.2
(a) Unruptured cornual pregnancy. (b) The rudimentary horn was a noncommunicating type. (c) The same was excised
If missed in early pregnancy, the horn may eventually rupture as happened in the following case. A primigravida presented at 16 weeks of amenorrhoea with features of haemorrhagic shock. There was haemoperitoneum and diffuse tenderness in the abdomen. Laparotomy confirmed a ruptured cornual pregnancy. Cornual resection was done. Interstitial ectopic pregnancy is a close differential diagnosis in a woman presenting around 14–16 weeks with shock and haemoperitoneum. Spontaneous rupture of cornual or interstitial pregnancies would typically occur around 14–16 weeks of pregnancy. The location of the round ligament helps in differentiating between the two entities. The round ligament would be medial to the rupture site in interstitial pregnancies. There are umpteen cases reported in the literature of rupture of cornual pregnancy. Diagnosis before rupture is possible with MRI, and management with minimally invasive surgery has been reported [5, 11].
Mizutamari and colleagues [8] reported yet another interesting case of a defect in the fundus near the cornual region of a primigravida with an unscarred uterus at 32 weeks. The woman was asymptomatic. Imaging diagnosed a defect with bulging amniotic membrane. Emergency caesarean section was performed. There was perforation near right cornual region. Follow-up hysterography diagnosed an arcuate uterus. The focal thinning of myometrium in the cornual region was proposed to be due to Mullerian abnormality.
Chen and colleagues [3] reported an unusual case of a primigravida. The woman was a known case of endometriosis and had presented with excessive intermenstrual bleed. She was found to have a ruptured endometrioma of the posterior cervicovaginal junction that had ruptured and was bleeding. The same was evacuated and repaired. In the subsequent pregnancy during labour, she had a rupture of this posterior cervical wound that extended to the lateral wall of the lower segment. In the case reported by Nikolaou et al. [10], a 33-year-old primigravida was suspected to have ruptured uterus at 28 weeks of pregnancy on the basis of abnormal foetal heart rate pattern and haemoperitoneum. Laparotomy revealed a large fundal rupture. Histopathology of the hysterectomy specimen had confirmed an adenomyosis.
Thus, a primigravida could rupture her uterus when there is a malformation of the uterus with pregnancy in the noncommunicating rudimentary horn. It is extremely rare to develop rupture after obstructed labour. Injudicious use of labour-inducing agents poses a risk of hyperstimulation and could result in rupture. Most of the ruptures in the primigravida are associated with poor perinatal outcome.
References
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