PERFCRATION CF THE UTERUS CAUSING RUPTURE IN SUBSEQUENT PREGNANCY J,G. Feeney* St. Luke's Materni~ Hos~tal, B r a ~ o ~ . Summary reTthWO cases are described of rupture of uterus [n pregnancy associated with previous perforation of the uterus. It is suggested that this rare occurrence will become more frequent in Ireland in future years. Introduclion Rupture of the uterus is an uncommon but not rare complication of pregnancy. If it occurs it is almost always caused by dehiscence of a Caesarean section scar, disproportion, real presentation or iatrogenic trauma in labour. Two cases are described of rupture of the uterus due to a previous fundal perforation. Case Histories Case / Mrs. S. S was a 32 year old para 1 + 1, In 1969 she had a forceps delivery of a female infant weighing 2.80 kg. Her second pregnancy had ended with a missed abortion at 14 weeks gestation in March 1978. An evacuation el the uterus was necessary and the operator noted on the case records that the uterine tundus might have been perforated with a curette. However as the blood loss was normal no further procedure was undertaken, The patient's third pregnancy was unremarkable until 31 weeks gestation. She was then admitted to the Coombe Hospital, Dublin on 4th September, 1971. She complained of abdominal pain and backache of sudden onset and of four hours
duration. The pain had started in the epigastrium but now the pain was maximal in the lower abdomen. On examination the patient was pale, the pulse was 80 and the blood pressure 80/50 mm Hg. The size of the uterus corresponded to 1he period of gestation. The uterus was tender and irritable but its consistency was normal, The fetal heart was easily detected with a Sonicaid, the rate being 160 per minute. On vaginal examination the cervix was closed and the membranes were intact. A diagnosis was made of concealed abruptio placentae. An intravenous drip was set up and the patient was cross matched against four units of whole blood. Her pulse and blood pressure were recorded hail hourly. The patient's general condltion remained unchanged over the next ten hours. However she now complained of generalised abdominal pain, shoulder tip pain and even pain up the side of her neck. There was abdominal rigidity with guarding. No rebound tenderness was elicited. A white cell count was 15,400 and an erect x-ray of the abdomen showed a dilated loop of air filled bowel under the left side of the diaphragm. Fourteen hours after her admission to hospital a ]aparotomy was performed. In bowel a mid-line upper abdominal incision was performed, A large amount incision was performed. A large amount 01 clot and free blood was found in the peritoneal cavity. There was a defect in
* Present address : Department of Obstetrics and Gynaecology, University of Leeds, 17 Springfield Mount, Leeds LS2 9NG. ~75
176
IRISH JOURNAL OF MEDICAL SCIENCE
the fundus of the uterus measuring approximately 3 cm. Placental tissue was protruding through the defect and was bleeding actively An emergency lower segment Caesarean section was performed through a separate incision. A Hving female infant weighing 182 k g was delivered. The lower segment was closed in layers, The edges of the fundal defect were cleaned by means of removing the fragmented tissue at the edges. The hole was then closed transversely in two layers. The patient was transfused with four units of whole blood and made an uneventful recovery from surgery. Unfortunately the infant succumbed to respiratory distress syndrome and died 48 hours after delivery. A biopsy was taken from the site of uterine rupture and in addition to fhe characteristic pregnancy changes there was a zone of hyaline degeneration suggestive of scar tissue formation. Case II
M r s J. F. was a 28 year old para 2 + 0 . Her first pregnancy in tg67 had resulted in a spontaneous delivery of a male infant weighing 2.36 kg. at 34 weegs gestation. Her second pregnancy was in 1970 and again premature labour occurred at 36 weeks when she gave birth to Iwin girls weighing 1 96 kg. and 1.67 kg. Her three children were all alive and well. After her second delivery she had a secondary post-parturn haemorrhage. This required transfusion with two units of blood and a uterine evacuation was performed under general anaesthelic At the time it was suspected that the uterus had been perforated with a sponge forceps. However as bleeding ceased spontaneously no further action was taken. Mrs. J. F. had an uneventful third pregnancy until 29 weeks gestation. She was then admitted to St. Luke's Hospital, Bradford, with a four hour history of intermittent iower abdominal pain of abrupt onset. On examination the patient was pate, The pulse was 88 and the blood
pressure 120/60 mm Hg. The uterus was 28 weeks in size and was soft but there was marked tenderness especially at the fundus. The fetal heart was not detected either aurally of with a Sonicaid. On vaginal examination the fetus was presenting cephalically with the head in the mid cavity. The cervix was posterior and um dilated. The initial diagnosis was concealed abruptio placentae with intra-uterine death. An intravenous saline drip was set up, a Foley catheter was inserted and blood was sent for cross matching and serum fibrinogen. It was decided to per* form another vaginal examination in two hours with a view to rupturing the membranes Within an hour, however, the blood pressure fell to 80/50 mm Hg, although the pulse remained constant at 88 per minute At this time the membranes were artificially ruptured and some old blood drained with the liquor. A blood transfusion was started and two units of oxytocin was added to the saline drip, Over the fogowing four hours the datlent's condilion deteriorated. Despite transfusion with four units of blood her pulse rose to 140 per minute, her blood pressure remained low and her urinary output was less than 10 ml per hour. It was now apparent on abdominal examinatlon that the fetus was lying transversely and was very easily palpated. On vaginal examination the cervix was closed and seemed less effaced than at the previous examination. A laparotomy was undertaken and this revealed a fundal uterine rupture 10 cm in length extending to the insertion of the Fallopian tubes on each side. The placenta and the fetal trunk, still covered in membranes, were lying free in the peritoneal cavity. A total hysterectomy was performed and the patient required transfusion with a total of ten units Of b l o o d Forttmate~y there were n o further complications and the patient made an uneventful recovery from her ordeal
PERFORATION OF THE UTERUS CAUSING RUPTURE IN SUBSEQUENT PREGNANCY Histology o1 the uterus failed 10 show any evidence of an old scar but the pathologist c o m m e n t e d that is Iocalised fibrosis had been present it cou[d have been destroyed al the time of rupture.
D~scussion The two cases described are very similar (Table I) and the differences are basically those of degree. Rupture of the uterus due to previous perforation is tale. O'Driscoll (1966) reviewed 143 cases of ruptured uterus in D u b l i n over a period of 15 years and none of these cases was due 1o a previous perforation. Feeney and Barry (1956) describe one case of a ruptured f u n d u s in their series of 45 cases o l ruptured uterus in the C o o m b e a n d NationaI Maternity HospitaIs, DubIin. This occurred in a patient w h o had a previous difficult manual removal o1 the placenta. Perforation of the uterus can happen at m a n y gy~aecological procedures but it is most likely to o c c u r at termination of p r e g n a n c y performed by either dila-
177
tion and curettage or v a c u u m aspiration a l t h o u g h these measures were not undertaken in either of the cases described in this paper. In the United Kingd o m the incidence of uterine perforation at legal abortion has been variously estimated between 1.7 per cent (Courtney, 1969; Stallworthy e t a l . , 1971) and 2.7 p e r cent (Seed, 1971 ). Admittedly these figures were prduced soon after the T e r m i n a t i o n of Pregnancy Act of 1967 and m u c h lower i n c i d e n c e rates have been quoted since. N a t h a n s o n (1972) claims a perforation rate ol only 0.08 per cent at his hospital in N e w York. However if we accept the Btitish ligures it means that of the 1.406 Irish residents who u n d e r w e n t termination ot p r e g n a n c y fn England a n d Wales in 1974 (Walsh, 1976), it is likely that 24 to 40 suffered a perforation of the u t e r u s It seems certain therefere that rupture of the uterus due to a fundal scar will become m u c h more c o m m o n in Ireland in the future. When uterine rupture has occurred it is essential to make the diag-
Age
32
28
Para
1 § 1
2 + 0
Perforation suslained at
Missed abortion
Secondary P.P,H.
Gestation at rupture
3~ weeks
29 weeks
Presented with
Sudden onset of abdominaJ pain Marked tenderness No rigidity No inilial shook
Sudden onset of abdominal pain Marked tenderness No [igidJty NO initial shock
Prowsio~a~ diagnosis
Abruptio place~}tae
Abrupl}o placenlae
Sile of rupture
Fundus
Fundus
Size ef rupture
3 cms,
10 cnls
Transfusion Operative [reaLmenL
4 units Repair of defect
10 units Hysterectomy
Fetal outcome
N.N.D.
S B.
178
IRISH JOURNAL OF MED[OAL SCIENCE
nosis as quickly as possible, However it must be remembered that many patients may not volunteer a history of termination of pregnancy. The diagnosis of ruptured uterus must therefore be considered wherever there is atypical abdominal pain and especially when this is associated with marked fundal tenderness but absence of abdominal wall rigidity and the well known "wooden" consistency of the uterus that is characteristic of abruptio placentae. Often the true diagnosis bacames apparent only when there is sufficient haemorrbage to cause generai~sed peritonism and hypovoiaemic s h o c k My thanks to Dr. D. O'Brien of the Ccembe Lylng-ln Nospital, DubJin and Mr. J, Eyton~ones of St Luke's Hospital, Bradford for a]lowing me to report the cases under their care
References
Courtney, L. O. 1969. Methods and dangers of termination of pregnancy. Prec. roy, Soc. Med 62, 834 Feeney, K., Barry, A. 1956. Rupture and perforation of uterus in association with pregnancy, labour and the puerperium, Brit. reed, J. i, 65. Nathanscn, B. N. 1972, Ambulatory abortion: experience with 26,0OO cases. New Engl. J. Med. 286, 4O3, O DriSColl, K. 1966, Rupture of the uterus. Pros roy See Med. 59r 65. Sood, S. V 1971, Some operative and pest opRralive hazardsof legal termination of pregnancy. Brlt med J. iv, 270 Stallworthy, J. A., Moolgoaker, A. S., Walsh, J. J. 1971 Legal abortion: a critical'assessment el its risks Lancet ii, 1245. Walsh D 1976. Pregnancies of Irish residents terminated in England and Wales in 1973. irish reed, J. 69, 16
duration. The pain had started in the epigastrium but now the pain was maximal in the lower abdomen. On examination the patient was pale, the pulse was 80 and the blood pressure 80/50 mm Hg. The size of the uterus corresponded to 1he period of gestation. The uterus was tender and irritable but its consistency was normal, The fetal heart was easily detected with a Sonicaid, the rate being 160 per minute. On vaginal examination the cervix was closed and the membranes were intact. A diagnosis was made of concealed abruptio placentae. An intravenous drip was set up and the patient was cross matched against four units of whole blood. Her pulse and blood pressure were recorded hail hourly. The patient's general condltion remained unchanged over the next ten hours. However she now complained of generalised abdominal pain, shoulder tip pain and even pain up the side of her neck. There was abdominal rigidity with guarding. No rebound tenderness was elicited. A white cell count was 15,400 and an erect x-ray of the abdomen showed a dilated loop of air filled bowel under the left side of the diaphragm. Fourteen hours after her admission to hospital a ]aparotomy was performed. In bowel a mid-line upper abdominal incision was performed, A large amount incision was performed. A large amount 01 clot and free blood was found in the peritoneal cavity. There was a defect in
* Present address : Department of Obstetrics and Gynaecology, University of Leeds, 17 Springfield Mount, Leeds LS2 9NG. ~75
176
IRISH JOURNAL OF MEDICAL SCIENCE
the fundus of the uterus measuring approximately 3 cm. Placental tissue was protruding through the defect and was bleeding actively An emergency lower segment Caesarean section was performed through a separate incision. A Hving female infant weighing 182 k g was delivered. The lower segment was closed in layers, The edges of the fundal defect were cleaned by means of removing the fragmented tissue at the edges. The hole was then closed transversely in two layers. The patient was transfused with four units of whole blood and made an uneventful recovery from surgery. Unfortunately the infant succumbed to respiratory distress syndrome and died 48 hours after delivery. A biopsy was taken from the site of uterine rupture and in addition to fhe characteristic pregnancy changes there was a zone of hyaline degeneration suggestive of scar tissue formation. Case II
M r s J. F. was a 28 year old para 2 + 0 . Her first pregnancy in tg67 had resulted in a spontaneous delivery of a male infant weighing 2.36 kg. at 34 weegs gestation. Her second pregnancy was in 1970 and again premature labour occurred at 36 weeks when she gave birth to Iwin girls weighing 1 96 kg. and 1.67 kg. Her three children were all alive and well. After her second delivery she had a secondary post-parturn haemorrhage. This required transfusion with two units of blood and a uterine evacuation was performed under general anaesthelic At the time it was suspected that the uterus had been perforated with a sponge forceps. However as bleeding ceased spontaneously no further action was taken. Mrs. J. F. had an uneventful third pregnancy until 29 weeks gestation. She was then admitted to St. Luke's Hospital, Bradford, with a four hour history of intermittent iower abdominal pain of abrupt onset. On examination the patient was pate, The pulse was 88 and the blood
pressure 120/60 mm Hg. The uterus was 28 weeks in size and was soft but there was marked tenderness especially at the fundus. The fetal heart was not detected either aurally of with a Sonicaid. On vaginal examination the fetus was presenting cephalically with the head in the mid cavity. The cervix was posterior and um dilated. The initial diagnosis was concealed abruptio placentae with intra-uterine death. An intravenous saline drip was set up, a Foley catheter was inserted and blood was sent for cross matching and serum fibrinogen. It was decided to per* form another vaginal examination in two hours with a view to rupturing the membranes Within an hour, however, the blood pressure fell to 80/50 mm Hg, although the pulse remained constant at 88 per minute At this time the membranes were artificially ruptured and some old blood drained with the liquor. A blood transfusion was started and two units of oxytocin was added to the saline drip, Over the fogowing four hours the datlent's condilion deteriorated. Despite transfusion with four units of blood her pulse rose to 140 per minute, her blood pressure remained low and her urinary output was less than 10 ml per hour. It was now apparent on abdominal examinatlon that the fetus was lying transversely and was very easily palpated. On vaginal examination the cervix was closed and seemed less effaced than at the previous examination. A laparotomy was undertaken and this revealed a fundal uterine rupture 10 cm in length extending to the insertion of the Fallopian tubes on each side. The placenta and the fetal trunk, still covered in membranes, were lying free in the peritoneal cavity. A total hysterectomy was performed and the patient required transfusion with a total of ten units Of b l o o d Forttmate~y there were n o further complications and the patient made an uneventful recovery from her ordeal
PERFORATION OF THE UTERUS CAUSING RUPTURE IN SUBSEQUENT PREGNANCY Histology o1 the uterus failed 10 show any evidence of an old scar but the pathologist c o m m e n t e d that is Iocalised fibrosis had been present it cou[d have been destroyed al the time of rupture.
D~scussion The two cases described are very similar (Table I) and the differences are basically those of degree. Rupture of the uterus due to previous perforation is tale. O'Driscoll (1966) reviewed 143 cases of ruptured uterus in D u b l i n over a period of 15 years and none of these cases was due 1o a previous perforation. Feeney and Barry (1956) describe one case of a ruptured f u n d u s in their series of 45 cases o l ruptured uterus in the C o o m b e a n d NationaI Maternity HospitaIs, DubIin. This occurred in a patient w h o had a previous difficult manual removal o1 the placenta. Perforation of the uterus can happen at m a n y gy~aecological procedures but it is most likely to o c c u r at termination of p r e g n a n c y performed by either dila-
177
tion and curettage or v a c u u m aspiration a l t h o u g h these measures were not undertaken in either of the cases described in this paper. In the United Kingd o m the incidence of uterine perforation at legal abortion has been variously estimated between 1.7 per cent (Courtney, 1969; Stallworthy e t a l . , 1971) and 2.7 p e r cent (Seed, 1971 ). Admittedly these figures were prduced soon after the T e r m i n a t i o n of Pregnancy Act of 1967 and m u c h lower i n c i d e n c e rates have been quoted since. N a t h a n s o n (1972) claims a perforation rate ol only 0.08 per cent at his hospital in N e w York. However if we accept the Btitish ligures it means that of the 1.406 Irish residents who u n d e r w e n t termination ot p r e g n a n c y fn England a n d Wales in 1974 (Walsh, 1976), it is likely that 24 to 40 suffered a perforation of the u t e r u s It seems certain therefere that rupture of the uterus due to a fundal scar will become m u c h more c o m m o n in Ireland in the future. When uterine rupture has occurred it is essential to make the diag-
Age
32
28
Para
1 § 1
2 + 0
Perforation suslained at
Missed abortion
Secondary P.P,H.
Gestation at rupture
3~ weeks
29 weeks
Presented with
Sudden onset of abdominaJ pain Marked tenderness No rigidity No inilial shook
Sudden onset of abdominal pain Marked tenderness No [igidJty NO initial shock
Prowsio~a~ diagnosis
Abruptio place~}tae
Abrupl}o placenlae
Sile of rupture
Fundus
Fundus
Size ef rupture
3 cms,
10 cnls
Transfusion Operative [reaLmenL
4 units Repair of defect
10 units Hysterectomy
Fetal outcome
N.N.D.
S B.
178
IRISH JOURNAL OF MED[OAL SCIENCE
nosis as quickly as possible, However it must be remembered that many patients may not volunteer a history of termination of pregnancy. The diagnosis of ruptured uterus must therefore be considered wherever there is atypical abdominal pain and especially when this is associated with marked fundal tenderness but absence of abdominal wall rigidity and the well known "wooden" consistency of the uterus that is characteristic of abruptio placentae. Often the true diagnosis bacames apparent only when there is sufficient haemorrbage to cause generai~sed peritonism and hypovoiaemic s h o c k My thanks to Dr. D. O'Brien of the Ccembe Lylng-ln Nospital, DubJin and Mr. J, Eyton~ones of St Luke's Hospital, Bradford for a]lowing me to report the cases under their care
References
Courtney, L. O. 1969. Methods and dangers of termination of pregnancy. Prec. roy, Soc. Med 62, 834 Feeney, K., Barry, A. 1956. Rupture and perforation of uterus in association with pregnancy, labour and the puerperium, Brit. reed, J. i, 65. Nathanscn, B. N. 1972, Ambulatory abortion: experience with 26,0OO cases. New Engl. J. Med. 286, 4O3, O DriSColl, K. 1966, Rupture of the uterus. Pros roy See Med. 59r 65. Sood, S. V 1971, Some operative and pest opRralive hazardsof legal termination of pregnancy. Brlt med J. iv, 270 Stallworthy, J. A., Moolgoaker, A. S., Walsh, J. J. 1971 Legal abortion: a critical'assessment el its risks Lancet ii, 1245. Walsh D 1976. Pregnancies of Irish residents terminated in England and Wales in 1973. irish reed, J. 69, 16
