Article inspired by:
Anna Meyendorff, MD
Follow-up Rounds 12/11/15
THE CASE
CC: Abdominal pain
Vitals: T 97.4, BP 70/44, HR 122, RR 22, O2 100% on RA
HPI:
- 27 yo F 17 weeks gestation by LMP
- Acute onset pain 1 hour
- Diffuse radiating to back, sharp, 10/10 intensity
- Emesis x 2
- No prenatal care
PMH/PSH: G6P3, Osteogenesis Imperfecta; cesarean section x 2
Medications: Denies
Allergies: NKMA
Social: Denies toxic habits
Physical Examination:
Vitals: as above
General: AAOx3, moderate distress, tachypneic, blue sclerae
CVS: Tachycardic, regular rate, S1, S2
Pulm: CTAB
Abd: Soft, diffusely tender, gravid abdomen
Pelvic: Closed OS, no blood in vault
Studies:
CBC: WBC 20.9, Hgb 6.1, Hct 19.1, Plt 243
BMP: Na 139, K 3.4, Cl 109, BUN 13, Cr 0.51 Glucose 366, AG 20
Lactate 5.7
bHCG 2337
Rh+
CT A/P: Uterine rupture with hemoperitoneum
BACKGROUND
- Prevalence
- No prior c-section = 0.01%
- Prior c-section = 0.2-0.8%
- Risk factors
- Prior c-section (major)
- Malpresentation
- Labor dystocia
- Hypertension
- Bicornuate uterus
- Grand multiparity
- Connective tissue disorder
- Placenta percreta
- Prior myomectomy
- Misoprostol use (oxytocin likely safe)
- Typically occurs during labor
In whom should I suspect rupture?
- Those with above risk factors plus
- Acute onset/worsening and severe abdominal pain
- Vaginal bleeding (may be minimal)
- Palpable uterine defect on exam
- Hemodynamic instability
What will I see on transabdominal US?
- Disruption of myometrium
- Free peritoneal fluid (FAST+)
- Anhydramnios/empty uterus
- Herniated amniotic sac
- Fetal anatomy outside of uterus
- Absence of FHR
And if US is non-diagnostic?
- CT A/P if reasonably stable
- MRI in the rock-solid stable patient
What else should we consider in the hypotense, gravid patient with abdominal pain?
- Septic shock
- Appendicitis
- Pyelonephritis
- Cholecystitis/Cholangitis
- Pneumonia
- GYN pathology
- Septic abortion
- Rupture ectopic
- Ruptured AAA
- DKA
What’s the next step once the diagnosis is made?
- Get OBGYN following ASAP
- IVF and blood transfusion as indicated
- Prep patient for emergent c-section or ex-lap
- Consider GU consult if hematuria
- Large ruptures may extend into bladder
- Some uterine rupture repairs require intraop GU consult
REFERENCES
Lang, Christoper. “Uterine dehiscence and rupture after previous cesarean delivery.” Up To Date. http://www.uptodate.com, 15 Oct. 2015. Web. 28 Dec. 2015. http://www.uptodate.com/contents/uterine-dehiscence-and-rupture-after-previous-cesarean-delivery
Meyendorff, Anna. “Uterine Rupture.” 11 Dec. 2015. Follow-up Rounds, Emergency Medicine Conference.
Tintinalli, Judith E., and J. Stephan. Stapczynski. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York: McGraw-Hill, 2011.