2020 FSA Posters

P073: WARNING SIGNS: CASE REPORT OF UTERINE RUPTURE WITH COMPLETE PLACENTAL ABRUPTION
Daniel Heath; Anthony Cometa, MD, Assistant, Professor; University of Florida

Introduction:  Peripartum and postpartum hemorrhage is the second leading cause of morbidity and mortality in pregnant women in the United States.  Uterine rupture and placental abruption are two contributors to hemorrhage; early identification of possible uterine rupture or placental abruption is paramount so that adequate preparation can occur prior to delivery.  We present a case where a patient exhibited classic symptoms of uterine rupture and was also found to have complete placental abruption.

Case: A 29-year-old Gravida 4 Para 3003 at 37 weeks gestation presented by ambulance  due to abdominal pain and contractions occurring every three minutes.  Her past medical history included three prior cesarean deliveries (CD), chronic HTN, HIV, obesity, and sickle cell trait.  On cervical exam the patient’s cervix was closed despite frequent contractions.  Severe fetal bradycardia was noted and stat CD was called due to concern for uterine rupture.  General anesthesia was induced via rapid sequence induction and the baby was delivered shortly there-after.  Uterine rupture was discovered in addition to complete placental abruption with the baby and the entire placenta located outside of the uterus. Blood loss for the case was estimated at 350 mL.  Appropriate resuscitation was provided and the patient was extubated in the operating room at the end of the case.

Discussion:  Our patient exhibited typical physical findings for uterine rupture including severe abdominal pain, closed cervix, vaginal bleeding, and fetal heart rate abnormalities.  Her history of  prior CD increased her risk for uterine rupture.  The overall incidence of uterine rupture is 0.6 per 10,000 in patients without prior CD but increases to 22 per 10,000 in patients with history of prior CD.  She also had risk factors for placental abruption including smoking and hypertension.  In patients presenting with vaginal bleeding and risk factors concerning for additional obstetric pathology, a high index of suspicion should be raised. Being able to properly identify patients with these conditions facilitates adequate preparation to ensure the best possible outcome for both mother and baby.

References:

Thurn, L., Wikman, A., Westgren, M., & Lindqvist, P. (2019). Massive blood transfusion in relation to delivery: incidence, trends and risk factors: a population-based cohort study. BJOG: An International Journal of Obstetrics & Gynaecology, 126(13), 1577–1586. doi: 10.1111/1471-0528.15927

Habes, D., Strecha, M., Kalousek, I., & Kestranek, J. (2019). uterine rupture during pregnancy. Czech Gynocology.