Urol Radiol 14:200-201 (1992)
Urologic Radiology © Springer-VerlagNewYork Inc. 1992
Uterine and Bladder Rupture During Vaginal Delivery in a Patient with a Prior Cesarian Section: Case Report Azar P. Dagher and Elliot K. Fishman Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
Uterine rupture in patients with prior cesarian sections who subsequently deliver vaginally is a known but uncommon complication [ 1, 2]. The incidence has been reported at 0.5% [3]. Concomitant bladder rupture with uterine rupture is very rare [4]. We present a case of both uterine and bladder rupture in a patient who had a prior cesarian section and presented with a precipitous delivery. The cystogram and computed tomographic (CT) findings are presented, with a discussion of this unusual entity.
Case Report A 34-year-old woman para 3013 at 36 weeks of pregnancy presented to the emergency room in active labor. She was status postcesarian section 5 years ago with two subsequent vaginal deliveries. Over the course of 2 days after precipitous delivery she developed abdominal pain and distention, gross hematuria, and a 20-point drop in her hematocrit. A C T scan demonstrated a large high attenuation collection with air bubbles pushing the uterus to the right side (Fig. 1). These findings were compatible with a uterine bleed with rupture. Intravenous contrast was not given in order to unequivocally identify the high attenuation region as a bleed. The bladder was contracted and compressed by the hematoma. Due to the hematuria, a cystogram was then performed and demonstrated marked intraperitoneal extravasation of contrast (Fig. 2). At surgery a uterine rupture was found at a thinned anterior lower uterine segment tacked up to the posterior aspect of the bladder. Here, a bladder rupture measured 5 × 8 cm. The patient stabilized after repair, and was later discharged without complication.
Address offprint requests to: Elliot K. Fishman, M.D., Department of Radiology and Radiological Science, The Johns Hopkins Hospital, 600 N. Wolfe Street, Baltimore, MD 21205, USA
Discussion Current obstetric practice allows the option of vaginal delivery with intrapartum surveillance despite a prior history of cesarian section [1, 3]. Previous reports note a low complication rate with uterine rupture occurring in 0.5% of cases [3]. In the case of a precipitous onset of labor, as in this case, a cesarian section may not even be an option. Uterine rupture can be explained by thinning of the anterior lower uterine segment in the region of prior uterine incision. Concomitant bladder rupture is very rare [4]. Since the bladder is mobilized anteriorly in these operations, adhesions can develop between the posterior bladder wall and the anterior uterine segment. Rupture in this region can then cause rupture of the bladder itself. The peritoneal reflection between bladder and uterus may be involved in this adhesion to explain intraperitoneal extravasation. In the present case, CT demonstrated the uterine rupture and associated bleeding. Since the bladder was compressed by the hematoma and intravenous contrast was not used, the bladder rupture was seen best on the subsequent cystogram which shows an intraperitoneal rupture. The CT images shown in Fig. 1 show findings compatible with both an intraperitoneal bladder rupture and some extraperitoneal fluid. In extraperitoneal rupture, fluid or blood tracts into the prevesical, perirectal, and presacral spaces, a finding absent in the images [5]. Intraperitoneal rupture produces fluid in the spaces around the uterus and has a more central location [5]. Cystograms have been the study of choice to
A.P. Dagher and E.K. Fishman: Uterine and Bladder Rupture
201
Fig. 1. A, B CT scans through the pelvis show the large high-density hematoma arising from defects in the uterine wall (arrows in A). Air bubbles can be tracked from the uterus to the hematoma. No intravenous contrast was used.
detect bladder rupture or laceration. Kane et al. [6] have shown intravenous contrast-enhanced CT to be at least as sensitive as cystography. Lis and Cohen [7] make the provision that retrograde bladder contrast for CT is necessary for adequate distention. In conclusion, uterine rupture should be suspected in the patient with prior uterine surgery and current vaginal delivery who develops a drop in hematocrit. Due to the potential of adhesions between the bladder and uterus, care should be taken to exclude concurrent bladder injury which may be masked by a large pelvic bleed. Intravenous contrast-enhanced CT could demonstrate this possibility and eliminate the need for a cystogram. References 1. Veridiano NP, Thorner NS, Ducey J: Vaginal delivery after cesarian section. Int J Gynecol Obstet 29:307-311, 1989 2. Hansell RS, McMurray KB, Huey GR: Vaginal birth after two or more cesarian sections: A five year experience. Birth 17: 146-150, 1990 3. Pritchard J, MacDonald PC, Gant NF: Williams Obstetrics, 17111 ed. Appleton-Century-Crafts, 1985, p 870 4. Mullings AM: Rupture of uterus and bladder in vaginal delivery following previous caesarian section. West Indian Med J36:51-53, 1987 5. Lee JK, Sagel SS, Stanley RJ: Computed Body Tomography, 2nd ed. New York: Rover Press, 1989, p 461
Fig. 2. Cystogram done after the infusion of water-soluble contrast via the Foley catheter. The intraperitoneal spill allows contrast to outline bowel loops.
6. Kane NM, Francis IR, Ellis HE: The value of CT in the detection of bladder and posterior urethral injuries. A JR 153: 1243-1246, 1989 7. Lis LE, Cohen AJ: CT cystography in the evaluation ofbladder trauma. J Comput Assist Tomogr 14:386-389, 1990
Urologic Radiology © Springer-VerlagNewYork Inc. 1992
Uterine and Bladder Rupture During Vaginal Delivery in a Patient with a Prior Cesarian Section: Case Report Azar P. Dagher and Elliot K. Fishman Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
Uterine rupture in patients with prior cesarian sections who subsequently deliver vaginally is a known but uncommon complication [ 1, 2]. The incidence has been reported at 0.5% [3]. Concomitant bladder rupture with uterine rupture is very rare [4]. We present a case of both uterine and bladder rupture in a patient who had a prior cesarian section and presented with a precipitous delivery. The cystogram and computed tomographic (CT) findings are presented, with a discussion of this unusual entity.
Case Report A 34-year-old woman para 3013 at 36 weeks of pregnancy presented to the emergency room in active labor. She was status postcesarian section 5 years ago with two subsequent vaginal deliveries. Over the course of 2 days after precipitous delivery she developed abdominal pain and distention, gross hematuria, and a 20-point drop in her hematocrit. A C T scan demonstrated a large high attenuation collection with air bubbles pushing the uterus to the right side (Fig. 1). These findings were compatible with a uterine bleed with rupture. Intravenous contrast was not given in order to unequivocally identify the high attenuation region as a bleed. The bladder was contracted and compressed by the hematoma. Due to the hematuria, a cystogram was then performed and demonstrated marked intraperitoneal extravasation of contrast (Fig. 2). At surgery a uterine rupture was found at a thinned anterior lower uterine segment tacked up to the posterior aspect of the bladder. Here, a bladder rupture measured 5 × 8 cm. The patient stabilized after repair, and was later discharged without complication.
Address offprint requests to: Elliot K. Fishman, M.D., Department of Radiology and Radiological Science, The Johns Hopkins Hospital, 600 N. Wolfe Street, Baltimore, MD 21205, USA
Discussion Current obstetric practice allows the option of vaginal delivery with intrapartum surveillance despite a prior history of cesarian section [1, 3]. Previous reports note a low complication rate with uterine rupture occurring in 0.5% of cases [3]. In the case of a precipitous onset of labor, as in this case, a cesarian section may not even be an option. Uterine rupture can be explained by thinning of the anterior lower uterine segment in the region of prior uterine incision. Concomitant bladder rupture is very rare [4]. Since the bladder is mobilized anteriorly in these operations, adhesions can develop between the posterior bladder wall and the anterior uterine segment. Rupture in this region can then cause rupture of the bladder itself. The peritoneal reflection between bladder and uterus may be involved in this adhesion to explain intraperitoneal extravasation. In the present case, CT demonstrated the uterine rupture and associated bleeding. Since the bladder was compressed by the hematoma and intravenous contrast was not used, the bladder rupture was seen best on the subsequent cystogram which shows an intraperitoneal rupture. The CT images shown in Fig. 1 show findings compatible with both an intraperitoneal bladder rupture and some extraperitoneal fluid. In extraperitoneal rupture, fluid or blood tracts into the prevesical, perirectal, and presacral spaces, a finding absent in the images [5]. Intraperitoneal rupture produces fluid in the spaces around the uterus and has a more central location [5]. Cystograms have been the study of choice to
A.P. Dagher and E.K. Fishman: Uterine and Bladder Rupture
201
Fig. 1. A, B CT scans through the pelvis show the large high-density hematoma arising from defects in the uterine wall (arrows in A). Air bubbles can be tracked from the uterus to the hematoma. No intravenous contrast was used.
detect bladder rupture or laceration. Kane et al. [6] have shown intravenous contrast-enhanced CT to be at least as sensitive as cystography. Lis and Cohen [7] make the provision that retrograde bladder contrast for CT is necessary for adequate distention. In conclusion, uterine rupture should be suspected in the patient with prior uterine surgery and current vaginal delivery who develops a drop in hematocrit. Due to the potential of adhesions between the bladder and uterus, care should be taken to exclude concurrent bladder injury which may be masked by a large pelvic bleed. Intravenous contrast-enhanced CT could demonstrate this possibility and eliminate the need for a cystogram. References 1. Veridiano NP, Thorner NS, Ducey J: Vaginal delivery after cesarian section. Int J Gynecol Obstet 29:307-311, 1989 2. Hansell RS, McMurray KB, Huey GR: Vaginal birth after two or more cesarian sections: A five year experience. Birth 17: 146-150, 1990 3. Pritchard J, MacDonald PC, Gant NF: Williams Obstetrics, 17111 ed. Appleton-Century-Crafts, 1985, p 870 4. Mullings AM: Rupture of uterus and bladder in vaginal delivery following previous caesarian section. West Indian Med J36:51-53, 1987 5. Lee JK, Sagel SS, Stanley RJ: Computed Body Tomography, 2nd ed. New York: Rover Press, 1989, p 461
Fig. 2. Cystogram done after the infusion of water-soluble contrast via the Foley catheter. The intraperitoneal spill allows contrast to outline bowel loops.
6. Kane NM, Francis IR, Ellis HE: The value of CT in the detection of bladder and posterior urethral injuries. A JR 153: 1243-1246, 1989 7. Lis LE, Cohen AJ: CT cystography in the evaluation ofbladder trauma. J Comput Assist Tomogr 14:386-389, 1990
