Introduction
Uterine rupture signifies full-thickness separation of uterine wall. It is associated with uterine bleeding, fetal distress, protrusion/expulsion of fetus/placenta into peritoneal cavity, and warrants urgent laparotomy and cesarean section, followed by uterine repair or hysterectomy [
1]. Prompt diagnosis of this entity is of importance to save maternal and fetal life [
2]. Rupture is most often seen during labour in patients with history of cesarean sections or utero-placental anomalies [
3]. We report a case of spontaneous uterine rupture in a young patient, before onset of labour, in an unscarred uterus with no known risk factors.
Case Report
A 28-year-old second gravida presented with 9 months amenorrhoea and abdominal pain. The patient complained of diffuse, ill-defined abdominal pain for the last 2 days and appeared sick. There was no history of any bleeding per vaginam. Her first delivery was an uneventful normal vaginal delivery two years back. She had not undergone any previous surgery or instrumentation. Clinically, she was not in active labour at the time of presentation and was referred to us for ultrasound scanning.
Ultrasonography was performed on Aloka SSD 4000 USG and Color Doppler machine using broad bandwidth convex and linear probes. The study revealed a dead fetus, of 37 weeks maturity, lying superficially in abdomen [Fig.1]. Fluid-filled maternal bowel loops were noted close to fetal parts [Fig.2], with free fluid in interloop region, suggesting presence of fetus in peritoneal cavity. Bulky uterus with collapsed endometrial cavity [Fig.3] was seen in mother’s lower abdomen. Ill-defined area of discontinuity was noted in anterior wall of lower uterine body, through which uterine cavity was communicating with peritoneal cavity. Placenta was noted outside the uterus, close to its anterior wall. Diagnosis of ‘Uterine rupture with expulsion of fetus and placenta into peritoneal cavity with fetal demise’ was made and the patient was referred for management.
Diagnosis of uterine rupture was confirmed clinically with findings of loss of uterine contour, palpable superficial fetal parts and aspiration of blood from peritoneal cavity. On per vaginam examination, internal os was open and no fetal presenting parts were felt. Emergency laparotomy was performed, revealing rupture of uterus involving its anterior wall and lower uterine segment, with dead fetus (weighing 2.5 kg) and placenta in peritoneal cavity, with hemoperitoneum. Hysterectomy was done and peritoneal cavity cleaned. Histopathology report of the operative specimen revealed ruptured gravid uterus with no evidence of any congenital uterine anomaly.
Discussion
Uterine rupture is a rare and fatal event with incidence of 0.07% of all pregnancies [
1]. Maternal mortality rates are 9.7% and 41.6% for developed and developing countries, respectively. Fetal mortality rates vary between 10.3% (if rupture is urgently followed by surgical intervention) to upto 100% [
2].
Most cases of uterine rupture are observed during labour, some during late pregnancy, and few even during second trimester in the presence of morbidly adhering placenta [
4,
5]. Several risk factors are known for rupture: previous cesarean section or myomectomy, amniocentesis, congenital uterine anomalies, grand-multiparity, increasing maternal age, fetal macrosomia, cephalo-pelvic disproportion, uterine overdistension, placenta increta/percreta, adenomyosis, induction of labour, uterine infection, instrumentation and trauma [
2,
3,
6]. Our case was unique in that she was a young, second gravida with previous uneventful normal vaginal delivery and no history of cesarean section or uterine intervention. Rupture occurred during late third trimester before onset of labour. There was no evidence of any congenital uterine anomaly, uterine disease or adherent placenta in the patient, and no precise cause of rupture or risk factors could be identified.
Clinical diagnosis of rupture is difficult and delayed, which increases importance of meticulous ultrasound scanning, as maternal and fetal prognosis depend upon time interval elapsed. Ultrasonography is quick, inexpensive, easily available, non-invasive, safe and useful imaging modality for confirmation of diagnosis. Diagnostic features are localized extra-peritoneal hematoma, hemoperitoneum, empty uterus, intra-uterine blood/gas bubbles, extra-uterine fetal parts, and presence of fetus with/without placenta outside uterus [
3]. The rent in uterine wall may not always be identifiable on scanning. Fetal compromise is often found when fetus is expelled outside and placenta is disrupted. The diagnosis may be easily missed in a hurriedly done routine scan, where the fetus is still alive, and due attention is not given to the uterine wall or changes in the maternal peritoneal cavity. Moreover, the diagnosis is more likely to be overlooked in a case of partial rupture, with only some fetal parts projecting outside the uterine cavity, and the major part of the fetus’s body and placenta being still inside. Hence, it is of utmost importance to give attention to the integrity of uterine wall and to note changes in the adjacent pelvic cavity of mother, especially in a scan done in the last trimester. Computed Tomography (CT)) and Magnetic Resonance Imaging (MRI) have also been used for diagnosis [
7] but they are more expensive, time consuming and not always available in emergency setting in the Indian scenario. Hence, ultrasound is the most suitable and first line of investigation. Our case illustrates the importance of ultrasound scanning in diagnosis of previously unsuspected case of uterine rupture, which saved the patient’s life following prompt surgery.
Conclusion
Meticulous scanning, as well as knowledge of the sonographic signs of rupture of gravid uterus, is of utmost importance during sonography in the third trimester for any patient presenting with abdominal pain, irrespective of presence or absence of the well-documented associated conditions and risk factors described in literature. A timely diagnosis may prove to be crucial in saving the mother and fetus.
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