Uterine rupture during labour induction with stillborn

Clinical History

A 29-year-old woman with a 28-week gestation stillborn detected at obstetric routine ultrasound, presented to our emergency department. She complained of thoraco-abdominal pain and severe dyspnoea after induction with oxytocin. She had a history of uterine septoplasty 10 months earlier.

Imaging Findings

Thoracic computed tomography (CT) was performed to rule out pulmonary thromboembolism suspicion. It showed peri-hepatic peritoneal fluid (not shown), which lead to a complementary abdomino-pelvic CT. Contrast-enhanced abdomino-pelvic CT showed disruption of the upper segment of the uterus, with the fetus outside the uterine cavity (Fig. 1-3). There was preservation of the gestational sac with amniotic fluid surrounding the fetus and extension of the endometrial cavity to the site of rupture (Fig. 2). Also free peritoneal fluid was present due to haemoperitoneum (Fig. 2).

Discussion

Uterine rupture is a catastrophic complication of pregnancy with a rare incidence of 0.73 per 10, 000 deliveries [1, 2]. It is defined as the disruption of all the layers surrounding the fetus, including the membranes, decidua, myometrium, and serosa [3]. Uterine rupture may occur before, during, or shortly after labour [2, 4].

Predisposing conditions include: previous uterine surgery (caesarean section, myomectomy, septoplasty, prior uterine curettage), excessively long or difficult labour, namely after prolonged induction with oxytocin or similar agents promoting smooth muscle contraction, congenital uterine malformations, persistent retroflexion due to adhesions (“trapped uterus”) and cornual implantation [2-5].

Patients usually present with sudden onset of severe abdominal pain; vaginal bleeding may also occur. Intraperitoneal haemorrhage is often severe, placing the mother at risk for hypovolemic shock. Maternal mortality varies from 2% to 20% and fetal mortality varies from 10% to 25% with good facilities [2].

Only a very short time interval for successful intervention exists once uterine rupture has occurred. If there is a clinical suspicion, uterine rupture is treated by immediate laparotomy, and imaging is not performed [4, 6]. CT is often required for evaluation of more indolent cases [4].

CT images may show disruption of the uterine wall appearing as a low attenuation defect within the otherwise densely enhancing myometrium [7]. If the rupture occurs before the onset of labour, it is usually in the corpus area, either anteriorly or posteriorly, but with advanced labour, the thinned lower uterine segment is the most vulnerable part of the uterus [2, 6]. CT may also show herniation of the gestational sac contents and haemoperitoneum.

A uterine rupture is most often an obstetric emergency (especially if associated with pregnancy). Hysterectomy is often required as part of the management.

Uterine rupture remains one of the most frightening complications in obstetric care. This case highlights the importance of close follow-up of a pregnant patient who has previously had a uterine incision.

Differential Diagnosis List

Final Diagnosis

Uterine rupture

URL:	https://eurorad.org/case/12660
DOI:	10.1594/EURORAD/CASE.12660
ISSN:	1563-4086