Rupture of the uterus at 35 weeks

Margaret has been admitted for lower abdominal pains and urine retention at 35 weeks gestational age. She has a previous cesarean section scar of  2008.

At abdominal inspection, apart from the vertical umbilical-pubic scar, it was possible to notice a round, tender mass of the hypogastrium, more or less where you expect to palpate urine retention.

The mass was looking like full of fluid and it was very painful even at gentle palpation.

I have decided to send the patient to pass urine and to review again.

When she has come back, she has told me that she had passed little urine. The mass at the hypogastrium was still there.

I therefore decided to insert a catheter, and actually very little urine drained, while the size of the mass did not reduce.

At this point I have checked an ultrasound scan. The balloon of the Foley catheter was outside the mass, which was looking round and cystic. It contained clear fluid with the image of a hand inside it. Observing the area with attention, I noticed that the cyst started like a hernia from an opening in the anterior wall of the uterus.

I therefore have made the provisional diagnosis of ruptured uterus with intact amniotic sac.

The fetal heart was normal and the body weight of the child was about 2400 grams with an estimated gestational age of 35 weeks.

Actually it was a bit early for an elective cesarean section (which is better done at 37 weeks gestational age), but we decided not to risk waiting and to operate, in order to prevent major internal bleeding and possible risks either for the mother or for the fetus.

We have given the patient a dose of 8 mg dexamethazone i.v., and we have rushed to theatre.

The diagnosis was correct. The scar on the uterus had given way, and the amniotic sac had herniated through the opening. Fortunately no artery was involved and there was no bleeding.

We have used the rupture as the way out for the fetus. It was not very easy to extract the child because the presentation was actually transverse, and we caused serious uterine lacerations. Fortunately it was possible to repair the uterus without ending up in hysterectomy.

Now both mother and child are ok: the fetus was quite mature at birth and there were no signs of pulmonary immaturity. The APGAR score was excellent from the first moment.

Dr Bro Giuseppe Gaido