|Year : 2020 | Volume
| Issue : 3 | Page : 220-223
A case of spontaneous uterine rupture in a nongravid uterus
N M Abdul Waris, S Manu Ayyan, K Vimal Rohan, Suresh G Nair
Department of Emergency Medicine, Government Medical College, Kannur, Kerala, India
|Date of Submission||16-Jan-2020|
|Date of Acceptance||19-Apr-2020|
|Date of Web Publication||26-Sep-2020|
Dr. S Manu Ayyan
Department of Emergency Medicine, Government Medical College, Kannur - 670 503, Kerala
Source of Support: None, Conflict of Interest: None
Uterine rupture is defined as separation of the wall of the uterus. Spontaneous rupture is a rare catastrophic complication in pregnant uterus and rarest in nongravid uterus. The diagnosis is not always obvious, and morbidity and maternal and fetal mortality is still high in gravid uterus. We report the case of a 37-year-old nongravid multipara with spontaneous uterine rupture, with a previous history of lower segment cesarean section and myomectomy. There are only a few published literatures, and the present case is an exceptional case that we observe for the first time in our emergency department.
The following core competencies are addressed in this article: Practice-based learning and improvement, Patient care, Medical knowledge.
Keywords: Rupture of the gravid uterus, spontaneous, uterine rupture
|How to cite this article:|
Waris N M, Ayyan S M, Rohan K V, Nair SG. A case of spontaneous uterine rupture in a nongravid uterus. Int J Acad Med 2020;6:220-3
| Introduction|| |
Uterine rupture is defined as the full-thickness separation of the uterine wall and the overlying serosa. It can be complete when all layers, including the peritoneum, are torn. It is incomplete when visceral peritoneum is intact. It may be primary, defined as occurring in a previously intact or unscarred uterus, or may be secondary and associated with a preexisting myometrial incision, injury, or anomaly. Spontaneous rupture is rare among gravid uterus but is rarest among nongravid uterus. The leading causes of rupture uterus among nongravid uterus are ischemia, distal cervical stenosis with hormonal therapy, prior instrumentation, fulminant pelvic infection, previous surgeries, and grand multipara. The strongest incidence was with developing countries than developed countries and was more with scarred uterus than nonscarred uterus. In a secondary analysis of the World Health Organization Multicountry Survey on Maternal and Newborn Health, the incidence of uterine rupture among women with at least one prior cesarean section was 0.5% with high-human development index (HDI) countries to 1.0% in low-HDI countries. Uterine rupture has a vague presentation, which makes its diagnosis difficult.
| Case Report|| |
A 37-year-old female presented to the emergency department with a complaint of a sudden onset of severe abdominal pain for 1 day along with nausea. It was dull-aching pain, which aggravated on movement and respiration. She denied any history of trauma, fever, dysuria, vomiting, and constipation, and had never experienced anything like this current illness before.
She is a gravida 4 para 4 live 4; first and second deliveries were full-term normal vaginal deliveries, third and fourth were lower segment cesarean section (LSCS) deliveries, and the last delivery was 2 years back. The patient had no prior medical history; she had a history of myomectomy 10 years back and had no known family history. Her menstrual history was last menstrual period 21 days ago with regular 30-day cycles. There was no history of vaginal bleeding. She was a nonsmoker and a nonalcoholic and denied any drug use. Review of systems was negative for weight loss, headache, chest pain, shortness of breath, melena, hematemesis, rashes, or joint swelling. On examination, the patient was moderately built and alert. Pallor was revealed on general examination. Vitals showed her temperature to be 98.4°F, blood pressure (BP) was 100/60 mmHg, heart rate (HR) was 106 beats/min (bpm), capillary refill time was <2 s, respiratory rate was 16 breaths/min, and oxygen saturation was 98% on room air. Her abdomen was nondistended with active bowel sounds, but she demonstrated tenderness mainly in the suprapubic and umblical region and diffuse guarding to palpation. There was no rebound tenderness and hepatosplenomegaly. Rest of the system was within normal limits. Bimanual examination was inconclusive.
Complete blood count showed low hemoglobin level. A point-of-care ultrasound of the abdomen was done, which showed free fluid in the hepato-renal pouch and pelvis. Contrast-enhanced computed tomography (CT) of the abdomen [Figure 1]a, [Figure 1]b, [Figure 1]c showed moderate ascites with hemoperitoneum and large hematoma in the pouch of Douglas; an altered contour of uterus with irregularities in the anterior myometrium was noted. The ovaries were not visualized separately, and there was no active extravasation of contrast and urinoma. Rest of the complete metabolic panel, venous blood gas, chest radiograph, and electrocardiogram was unremarkable.
|Figure 1: (a-c) A 37-year-old female patient presented with abdominal pain: contrast-enhanced computed tomography abdomen showing an altered contour of uterus with irregular anterior myometrium, large hematoma in the uterus, and moderate hemoperitoneum|
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Differential diagnosis included perforated bowel, complicated diverticulitis, visceral ischemia and peptic ulcer perforation, ectopic pregnancy, and ovarian cystic rupture. The patient's pain was initially well controlled with hydrocodone/acetaminophen and nonsteroidal anti-inflammatories; however, as more laboratory and imaging studies resulted, the patient continued to have intermittent pain episodes requiring morphine for analgesia. After 2 to 3 h, the pain appeared more severe and the patient became more tachypnea to 22 bpm. Just after the patient returned from CT, she became tachycardic with a HR of 110 beats/min and BP became 90/60 mmHg. She was immediately started with 500 ml of normal saline and later, one pint of blood was transfused. The patient improved and became hemodynamically stable after the resuscitation. She was taken up for exploratory laparotomy and found to have hemoperitoneum with evidence of uterine rupture from an old myomectomy scar intraoperatively. She underwent total abdominal hysterectomy.
The final diagnosis was acute abdomen, hemorrhagic shock, transient responder, hemoperitoneum, and spontaneous uterine rupture.
| Discussion|| |
Spontaneous rupture is rare in nongravid uterus. There are only five published cases pertaining to this topic. The first patient had dilation and evacuation during a pregnancy 2 years prior, the second patient was a 71-year-old woman without any previous unscarred uterus, the third patient had a history of multiple prior abdominal surgeries and deep cauterization, the fourth patient had fulminant pelvic infection prior to the rupture, and the fifth case is about a 40-year-old woman with a history of previous LSCS. Majority of the above cases had a previous history of scarred uterus, which is also obvious in our case with a history of previous myomectomy.
Unscarred uterus is least susceptible to rupture. The most common causes associated with rupture are congenital uterine anomalies, multiparity, previous uterine myomectomy, cesarean deliveries, fetal macrosomia, labor induction, and uterine trauma, which increase the risk of uterine rupture. A study in the Netherlands showed that the incidence of rupture in unscarred and scarred uteri was 0.7 and 5.1/10,000 deliveries, respectively.
The diagnosis of spontaneous rupture is very difficult. The most common presentation of uterine rupture includes severe abdominal pain, shock, and vaginal bleeding. In literature, abdominal pain was present in 60% of cases and vaginal bleeding occurred in 11%–67% of cases. In addition, maternal shock from hypovolemia was associated in 29%–46% of patients. The diagnosis is usually made from history, physical examination, and investigation. Vyas et al. reported the importance of CT in perioperative diagnosis of uterine rupture. Previous literature also showed that 33% cases were correctly diagnosed by CT and magnetic resonance imaging.,, The management aims at stopping the hemorrhage, repairing the anatomic damage, and reducing morbidity with surgical repair or a hysterectomy, depending on several factors such as the size of the uterine defects, patient age, and comorbidities. Early surgical intervention is the key to successful treatment of uterine rupture. The therapeutic management is a total or subtotal hysterectomy. Uterine-sparing procedures can be performed to preserve the reproductive function of patients who have never given birth, with a recurrence risk of uterine rupture assessed between 4% and 19% at a subsequent pregnancy.
| Conclusion|| |
Spontaneous uterine rupture can present with vague symptoms, and it should be one of the differentials in females presenting with acute abdomen.
Declaration of patient consent
The authors certify that they have obtained appropriate patient consent forms. The patient has given their consent for the publication of images and other clinical information to be reported in the journal. The patient understands that their name and initials will not be published, and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
I would like to thank the Department of Obstetrics and Gynaecology, General Surgery, Government Medical College, Kannur, Kerala, India, for their support in publishing this article.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
Ethical conduct of research
The authors declare that this scientific work complies with reporting quality, formatting, and reproducibility guidelines set forth by the EQUATOR Network. The authors also attest that this clinical investigation did not require Institutional Review Board/Ethics Committee Review. For this work, formal consent of the patient was obtained.
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