Spontaneous rupture of unscarred uterus in early pregnancy : – a rare entity
2
Acta Obstet Gynecol Scand 2000; 79: 431–432 Copyright C Acta Obstet Gynecol Scand 2000 Printed in Denmark ¡ All rights reserved Acta Obstetricia et Gynecologica Scandinavica ISSN 0001-6349 CASE REPORT Spontaneous rupture of unscarred uterus in early pregnancy – a rare entity ABHA SINGH AND SANDHI JAIN From the Department of Obstetric and Gynaecology, Lady Hardinge Medical College & Associated Hospitals, New Delhi, India Acta Obstet Gynecol Scand 2000; 79: 431–432. C Acta Obstet Gynecol Scand 2000 Key words: early pregnancy; spontaneous rupture; unscarred uterus Submitted 29 June, 1999 Accepted 9 November, 1999 The majority of cases of uterine rupture reported in medical literature have occurred during labor or late pregnancy. Early spontaneous rupture of uterus, where no predisposing factors are found, is exceptionally rare. Some authors (1) have classified uterine rupture according to etiology; rupture of previous scar (myomectomy, hysterotomy, etc.), traumatic rupture (version, accident) of an unscarred uterus, spontaneous rupture of an unscarred uterus with pathology (anomalies, multiparity) and spontaneous rupture of an unscarred uterus in a primigravid patient without apparent pathology. Spontaneous rupture of an unscarred apparently normal uterus has been reported as early as 16 (2) and 19 (3) weeks gestation. The present paper reports on a rupture occurring in the first trimester. The main value of the presentation lies in the opportunity to alert the clinician that uterine rupture should be a differential diagnosis at all stages of pregnancy, as it can be fatal. Case report Patient P.K., 30 years, G 5 P 3 A 1 L 1 presented as an emergency case with 2 months amenorrhea and sudden, severe, generalized pain in the abdomen of a few hours’ duration. She had three to four episodes of vomiting and a fainting attack while being brought to the hospital. In her first two pregnacies she had preterm home deliveries at seven months’ gestation. Both the neonates expired within a week after delivery. A year later she had a spontaneous abortion of five months’ duration with no intervention. In her fourth pregnancy a circlage was performed for incompetent cervix at four months’ gestation. The MacDonald stitch was removed at term and she delivered a full term healthy male baby. Abbreviations: PR: pulse rate; RR: respiratory rate; IUCD: intrauterine con- traceptive device; Hb: hemoglobin. C Acta Obstet Gynecol Scand 79 (2000) On admission she looked pale, distressed with marked tachy- cardia (P.R. – 120/min.) and tachypnea (R.R. – 28/min.). She was afebrile with blood pressure of 110/70 mm Hg. Abdominal examination revealed distension, guarding and generalized ten- derness. On speculum examination, the vagina was pale and cervix congested. Cervical movements were extremely tender with resistance in both fornices on palpation. Uterine size could not be assessed properly. Urine pregnancy test was positive. On investigation her Hb was 7 gm/dl, white cell count – 9000/mm 3 and platelet count was normal. Culdocentesis was positive. A diagnosis of rup- tured ectopic pregnancy was made. Decision for urgent lapar- otomy was taken. On opening the abdomen there was hemoperitoneum with approximately 1.5 litres of blood. Uterus was of 8–10 weeks size, soft with a bleeding transverse fundal rupture (3 cm¿2 cm) with irregular margins. The fetus was lying in the abdomi- nal cavity in an intact amniotic sac. On further exploration only the right fallopian tube and round ligament could be identified and a left-sided non-communicating rudimentary horn was seen with no tear or rupture. Total abdominal hysterectomy was performed. Three units of blood were transfused intraoperatively. The patient’s post- operative period was uneventful. She was discharged on the ninth post operative day after stitch removal. Further question- ing failed to reveal any risk factor leading to rupture, such as dilatation and curettage, insertion of an IUCD, abdominal surgery, trauma or any domestic violence. Histopathological ex- amination revealed a normal uterus, fetus and placenta. No pathology was found at the ruptured site. Discussion Spontaneous rupture of the uterus in early pregnancy is rare and a potentially catastrophic event (4). It usually occurs in a scarred uterus, for example following myomectomy, deep cor- nual resection, trauma, previous cesarean section (1, 4, 5). Other less common causes are placenta increta, sacculation of retroverted uterus (4). However, none of the above factors were apparent in our case. Probably multiparity leading to thinning and weakening of uterine musculature (3) and uterine anomaly may be implicated. The incidence of spontaneous rupture occurring in the ab- sence of previous surgery ranges from 1 in 8000 to 1 in 15000 deliveries (4). Spontaneous rupture usually involves the lower segment and occurs during labor, as women with upper seg- ment scars are delivered by cesarean section before the onset of labor (5). Early diagnosis and proper management is necessary to de- crease the high matemal and fetal mortality and morbidity as- sociated with rupture of a gravid uterus. Misdiagnosis in early pregnancy can be dangerous, particularly if the initial symp- toms are vague or if health resources are inadequate. With pro- nounced symptoms, as in the present case, the most relevant differential diagnosis is that of an ectopic pregnancy. An emer- gency laparoscopy or laparotomy will lead to correct diagnosis and enable necessary treatment to take place. A successful out- come might thus be dependent on clinical judgement as well as on available resources. Treatment will primarily depend upon the extent of the lesion, parity and magnitude of bleeding. If future pregnancy is desired, especially in women with no surviving children, the rupture can be repaired with close supervision of subsequent
-
Upload
abha-singh -
Category
Documents
-
view
218 -
download
1
Transcript of Spontaneous rupture of unscarred uterus in early pregnancy : – a rare entity
Acta Obstet Gynecol Scand 2000; 79: 431–432 Copyright C Acta Obstet Gynecol Scand 2000
Printed in Denmark ¡ All rights reservedActa Obstetricia et
Gynecologica ScandinavicaISSN 0001-6349
CASE REPORT
Spontaneous rupture ofunscarred uterus in earlypregnancy– a rare entity
ABHA SINGH AND SANDHI JAIN
From the Department of Obstetric and Gynaecology, LadyHardinge Medical College & Associated Hospitals, NewDelhi, India
Acta Obstet Gynecol Scand 2000; 79: 431–432. C Acta Obstet GynecolScand 2000Key words: early pregnancy; spontaneous rupture; unscarred uterusSubmitted 29 June, 1999Accepted 9 November, 1999
The majority of cases of uterine rupture reported in medicalliterature have occurred during labor or late pregnancy. Earlyspontaneous rupture of uterus, where no predisposing factorsare found, is exceptionally rare. Some authors (1) have classifieduterine rupture according to etiology; rupture of previous scar(myomectomy, hysterotomy, etc.), traumatic rupture (version,accident) of an unscarred uterus, spontaneous rupture of anunscarred uterus with pathology (anomalies, multiparity) andspontaneous rupture of an unscarred uterus in a primigravidpatient without apparent pathology.
Spontaneous rupture of an unscarred apparently normaluterus has been reported as early as 16 (2) and 19 (3) weeksgestation. The present paper reports on a rupture occurring inthe first trimester. The main value of the presentation lies in theopportunity to alert the clinician that uterine rupture shouldbe a differential diagnosis at all stages of pregnancy, as it canbe fatal.
Case report
Patient P.K., 30 years, G5P3A1L1 presented as an emergencycase with 2 months amenorrhea and sudden, severe, generalizedpain in the abdomen of a few hours’ duration. She had threeto four episodes of vomiting and a fainting attack while beingbrought to the hospital.
In her first two pregnacies she had preterm home deliveriesat seven months’ gestation. Both the neonates expired within aweek after delivery. A year later she had a spontaneous abortionof five months’ duration with no intervention. In her fourthpregnancy a circlage was performed for incompetent cervix atfour months’ gestation. The MacDonald stitch was removed atterm and she delivered a full term healthy male baby.
Abbreviations:PR: pulse rate; RR: respiratory rate; IUCD: intrauterine con-traceptive device; Hb: hemoglobin.
C Acta Obstet Gynecol Scand 79 (2000)
On admission she looked pale, distressed with marked tachy-cardia (P.R. – 120/min.) and tachypnea (R.R. – 28/min.). Shewas afebrile with blood pressure of 110/70 mm Hg. Abdominalexamination revealed distension, guarding and generalized ten-derness. On speculum examination, the vagina was pale andcervix congested. Cervical movements were extremely tenderwith resistance in both fornices on palpation. Uterine size couldnot be assessed properly.
Urine pregnancy test was positive. On investigation her Hbwas 7 gm/dl, white cell count – 9000/mm3 and platelet countwas normal. Culdocentesis was positive. A diagnosis of rup-tured ectopic pregnancy was made. Decision for urgent lapar-otomy was taken.
On opening the abdomen there was hemoperitoneum withapproximately 1.5 litres of blood. Uterus was of 8–10 weekssize, soft with a bleeding transverse fundal rupture (3 cm¿2cm) with irregular margins. The fetus was lying in the abdomi-nal cavity in an intact amniotic sac. On further exploration onlythe right fallopian tube and round ligament could be identifiedand a left-sided non-communicating rudimentary horn wasseen with no tear or rupture.
Total abdominal hysterectomy was performed. Three unitsof blood were transfused intraoperatively. The patient’s post-operative period was uneventful. She was discharged on theninth post operative day after stitch removal. Further question-ing failed to reveal any risk factor leading to rupture, such asdilatation and curettage, insertion of an IUCD, abdominalsurgery, trauma or any domestic violence. Histopathological ex-amination revealed a normal uterus, fetus and placenta. Nopathology was found at the ruptured site.
Discussion
Spontaneous rupture of the uterus in early pregnancy is rareand a potentially catastrophic event (4). It usually occurs in ascarred uterus, for example following myomectomy, deep cor-nual resection, trauma, previous cesarean section (1, 4, 5).Other less common causes are placenta increta, sacculation ofretroverted uterus (4). However, none of the above factors wereapparent in our case. Probably multiparity leading to thinningand weakening of uterine musculature (3) and uterine anomalymay be implicated.
The incidence of spontaneous rupture occurring in the ab-sence of previous surgery ranges from 1 in 8000 to 1 in 15000deliveries (4). Spontaneous rupture usually involves the lowersegment and occurs during labor, as women with upper seg-ment scars are delivered by cesarean section before the onset oflabor (5).
Early diagnosis and proper management is necessary to de-crease the high matemal and fetal mortality and morbidity as-sociated with rupture of a gravid uterus. Misdiagnosis in earlypregnancy can be dangerous, particularly if the initial symp-toms are vague or if health resources are inadequate. With pro-nounced symptoms, as in the present case, the most relevantdifferential diagnosis is that of an ectopic pregnancy. An emer-gency laparoscopy or laparotomy will lead to correct diagnosisand enable necessary treatment to take place. A successful out-come might thus be dependent on clinical judgement as well ason available resources.
Treatment will primarily depend upon the extent of thelesion, parity and magnitude of bleeding. If future pregnancyis desired, especially in women with no surviving children, therupture can be repaired with close supervision of subsequent
432 Case Report
pregnancy. If, however, an obvious cause is detected at surgery,the patient is multiparous or it is suspected that future concep-tions may be dangerous, either a repair of the rupture withtubal ligation or hysterectomy would be the treatment of choice(2).
References
1. Sweeten KM, Graves WK, Athanassion A. Spontaneousrupture of the unscarred uterus. Am J Obstet Gynecol1995; 172: 1851–6.
2. Blumenthal JN, Goldberger BS. Spontaneous rupture of auterus at 16 weeks gestation. Aust NZ J Obstet Gynaecol1983; 23: 248.
3. Dewane CJ, McCubbin HJ. Spontaneous rupture of an un-
ERRATUM
Erratum
Acta Obstetricia et Gynecologica Scandinavica 2000;79: 216–220, ‘‘Aggressive angiomyxoma in females: isradical resection for only option?’’
C Acta Obstet Gynecol Scand 79 (2000)
scarred uterus at 19 weeks gestation. Am J Obstet Gynecol1981; 141: 222–3.
4. Langton J, Fishwick K, Nwosu EC. Spontaneous ruptureof an unscarred gravid uterus at 32 weeks gestation. HumReprod 1997; 12: 2066–7.
5. Ozeren M, Ulusoy M, Uyanik E. First trimester spon-taneous uterine rupture after traditional myomectomy:Case report. Isr J Med Sci 1997; 33: 752–3.
Address for correspondence:
Sandhi Jain, M.S.c/o Dr Rajeev JainF-134 Kamla NagarAgra (U.P.), India
The name of one of the authors of the article is listedincorrectly as Ik Ming Chan at p. 216 The authorshould be Yik Ming Chan. We apologize for thie error.
