Unusual presentation of more common disease/injury

CASE REPORT

Silent uterine rupture in scarred uterus

Ream Langhe, Umme Farwa Shah, Attia Alfathil, Michael Gannon
Obstetrics and Gynaecology, SUMMARY one previous caesarean section at 26 weeks for
Midland Regional Hospital Uterine rupture in pregnancy is a rare and chorioamnionitis following three vaginal deliv-eries.
Mullingar, Mullingar, Ireland catastrophic complication with a high incidence She had regular prenatal care at our clinic. Following
of fetal and maternal morbidity. Very few cases mid-trimester scan, a senior obstetri-cian was involved
Correspondence to have been reported in the literature. in counselling for the mode of delivery, as details of
Dr Ream Langhe;
Case presentation A 28-year-old fifth gravid woman with previous surgery were not known. All benefits and
reamlanghe@ yahoo.co.uk
a history of one caesarean section presented to our risks were explained to the patient including risk of
department at 39 weeks and 6 days gestation with uterine rupture, need for laparotomy, blood
Accepted 16 March 2017
complaints of headache, epigastric pain and nausea. Her transfusion, hysterectomy, Intensive Care Unit
blood pressure was elevated and there was proteinuria. admission, thromboembolic events, trauma to the
Emergency caesarean section was performed in view of bladder, bowel, major blood vessels, maternal
symptoms. Uterine rupture was found during the surgery. A mortality, perinatal morbidity and mortality and
live male infant was delivered in good condition. Postnatal likelihood of successful vaginal birth after caesarean
recovery was unremarkable and the woman discharged on section (VBAC). Information was supplemented with
postoperative day 5. patient information leaflet. As details of previous
Conclusion Rupture of the uterus can surgery were not known, patient was advised of
present in third trimester even before increased risks (as mentioned above) of attempting
labour with minimal or no symptoms. vaginal birth but patient was very keen on having a
vaginal delivery. Decision regarding mode of delivery
was agreed on by the woman and the senior
obstetrician. VBAC was planned. Her antenatal period
BACKGROUND
was uneventful. Four days prior to admission, the
Uterine rupture in pregnancy is a rare and cata-
woman presented to the clinic complaining of
strophic complication with a high incidence of fetal
tightening, which resolved with simple analgesics.
and maternal morbidity. Very few cases have been
reported in the literature. On examination, she was well with a temperature of
36.5°C, pulse rate of 90 beats per minute and
 CASE PRESENTATION blood pressure of 141/91 mm Hg. On abdominal
Uterine rupture is an uncommon but one of the most examination, the uterine size was equivalent to 39
serious obstetric complications, with an increased risk weeks gestation. The fetus was in longitudinal lie and
of maternal and perinatal morbidity, and mortality. 1 unengaged cephalic presentation. There was no
Uterine rupture is reported in 0.5%–1% of patients abdominal tenderness or increase in the uterine tone.
attempting vaginal births after caesarean section. Internal examination was performed, and the cervix
was posterior and closed. CTG was performed for 20 
Uterine rupture occurs when a full-thickness min and was reassuring with a baseline of 140 beats
disruption of the uterine wall that also involves the per minute and variability of 10 beats and had
uterine serosa is present. Classical features of uterine accelerations with no deceleration. The headache
rupture include severe abdominal pain that persists persisted and the blood pressure was rechecked and it
between contractions, scar pain and tenderness, measured 162/100 mmHg. Labetalol 200 mg was
abnormal vaginal bleeding, haema-turia, chest or administered. Urinary protein dipstick revealed 3+
shoulder tip pain, sudden shortness of breath and protein. In view of these symptoms, a decision for
cardiotocograph (CTG) abnormali-ties. However, a emergency lower segment caesarean section was
normal CTG can be obtained in silent uterine rupture. 2 made. CTG was repeated prior to transfer to theatre
Here, we present a case of silent uterine rupture at and it was reassuring with no noticeable contractions.
term in a previously scarred uterus.
On opening the abdomen at emergency caesarean
section via a transverse skin incision, there was no
Case report haemoperitoneum. A complete uterine rupture was
A 28-year-old woman was referred to our depart-ment seen with the amniotic sac protruding into the
by her general practitioner with a provisional abdomen. The rupture was situated in the upper part of
To cite: Langhe R, Shah UF,
diagnosis of preeclampsia in view of frontal head- the lower uterine segment. The uterus was opened
Alfathil A, et al. BMJ Case Rep
Published Online First: [please
ache, nausea, epigastric pain, high blood pressure and through a lower transverse incision and a live male
include Day Month Year]. proteinuria. There was no history of vaginal bleeding baby was born. Birth weight was 2500 g. Neonate’s
doi:10.1136/bcr-2016-218189 or labour pains. The woman was fifth gravida at 39 APGAR at 1 and 5 min were 9 and 10, respectively.
weeks and 6 days gestation, with The lower segment was repaired, and
Langhe R, et al. BMJ Case Rep 2017. doi:10.1136/bcr-2016-218189 1
Unusual presentation of more common disease/injury
the rupture was clearly demarked and repaired. The reminder of the Conclusion
surgery was completed in the usual fashion. Spontaneous silent rupture can occur in women without any
alarming symptom. Hence, high index of suspicion is the key to
OUTCOME AND FOLLOW-UP early diagnosis of uterine rupture in case of previous scar when they
The woman recovery course was uncomplicated. She had a normal present with vague symptoms. Rapid recognition of poten-tial
amount of vaginal bleeding postpartum. Postoperative haemoglobin uterine rupture and immediate laparotomy lower the rate of
was 11 g/dL. Both the woman and newborn were discharged home perinatal death.
in satisfactory condition on postoperative day 5. The woman
attended the clinic 6 weeks postoperative. Both partners were Learning points
counselled for different sterilisation options and they opted for
vasectomy. The woman was discharged from the clinic to their ►► Uterine rupture may sometimes be asymptomatic
general practitioner (GP) care. or present with unusual symptoms.
►► High index of suspicion is very important for cases
DISCUSSION that have atypical scars or preterm caesarean
Uterine rupture can be asymptomatic with rupture being discov-ered section or the nature of scar is unknown.
incidentally on ultrasound or the time of surgery making diagnosis ►► Elective caesarean section at 37 weeks or earlier can
very challenging at the time of presentation. The risk factors for prevent uterine rupture in cases where nature of previous
uterine rupture include previous caesarean sections (single low uterine surgery is not known. The decision should be
transverse, single low vertical, classic vertical, multiple previous made on a case-to-case basis by a senior obstetrician.
caesarean deliveries), previous other uterine surgeries (abdominal ►► Timely diagnosis can save lives.
and/or laparoscopic myomectomy, dilata-tion and curettage) or
induction of labour.3–9 All of these risk factors are associated with an Contributors  RL: conception and design of study, acquisition of data. UFS and RL:
analysis and/or interpretation of data, drafting the manuscript. UFS and MG: revising
increased risk of uterine rupture when attempting for vaginal birth.
the manuscript critically for important intellectual content. RL, UFS,
In 66%–76% of the cases, intrapartum uterine rupture is associated AA, MG: approval of the version of the manuscript to be published.
with abnormalities on the CTG, abdominal pain, haematuria or loss
Competing interests  None declared.
of fetal presenting part on vaginal examination. 10 Very few cases of
silent uterine rupture with delivery of a healthy fetus have been Patient consent  Not obtained.
reported so far.11 12 A review of the literature reveals one case of Provenance and peer review  Not commissioned; externally peer reviewed.
silent uterine rupture in a woman with two prior classical caesarean
sections at the time of elective repeat caesarean section with the REFERENCES
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2 Langhe R, et al. BMJ Case Rep 2017. doi:10.1136/bcr-2016-218189
 Unusual presentation of more common disease/injury

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