Uterine Rupture
Patient presentation
32-Year-old B.J., a G3P2, presents to the L & D unit at 38 weeks for induction of labor secondary to desire to VBAC (vaginal birth after cesarean). B.J. reports one vaginal birth 5 years ago (6lb 3oz) and one cesarean section 2 years ago (7lb 1 oz.) secondary to fetal distress. She has a visible LCT (low cervical transverse, i.e., horizontal at the bikini line) scar. She reports that her CS (cesarean section) was uncomplicated. This pregnancy has also been uncomplicated, fetal weight is estimated at 3000g, & clinical pelvimetry is measuring normal. The patient was found to be 3-4 cm dilated and at 09:00 am Pitocin IV induction was initiated at 2mu/min. At 1:00pm the Pitocin is infusing at 20mu/min, B.J. is having contractions every 2-3 minutes, crying and breathing heavily in pain, rating contractions 10/10-pain scale. Cervix is found to be only 5cm and B.J. is given an epidural and Foley catheter. At 6:00pm her cervix is 8cm, but due to slow progress, and contractions remaining in an irregular pattern the MD orders the Pitocin to be increased to a max of 30mu/min (high dose Pitocin). This brings BJ’s contractions to every 1-3 minutes. At 8:00 pm BJ is crying and writhing in pain of the lower abdomen. The MD believes the epidural is not effective and orders anesthesia to reevaluate. Anesthesia replaces the epidural but BJ’s pain persists uncontrollably, she is screaming and holding her lower abdomen, her contractions are suddenly irregular on the fetal monitor but her abdomen is rigid to palpation without relief. Blood is noted in the Foley catheter. Fetal heart rate begins to decelerate from 135 bpm to 75 bpm without return to baseline.
Diagnosis
The diagnosis is Uterine Rupture. No specific tests are required, rather clinical assessment is utilized: Hard rigid abdomen, continuous pain that does not wax/wane with contractions, sudden loss of contraction pattern, & decelerating fetal heart rate.
Treatment
B.J. was rushed to the OR for an emergent CS. Upon incision, the fetus and amniotic fluid was found to be free floating in the abdomen and complete uterine rupture had occurred. An 8lb 13oz female was delivered and had APGAR of 3, 5, & 8 but eventually did well following a few hours of nasal cannula oxygen therapy. B.J.’s original uterine incision was found to have extended through the uterus into the bladder.
Outcome
Blood loss was calculated at 2L. The uterine and bladder tear was repaired. B.J. was started on a course of IV antibiotics and maintained her catheter for 5 days. She required 2 units of PRBCs for an initial H&H of 5 & 16. She was discharged home 5 days following surgery.
Case created by Brittany Johnson, 2011.