Rupture in a Primigravida

(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.
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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.

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Oct 7, 2017 | Posted by in GYNECOLOGY | Comments Off on Rupture in a Primigravida

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