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Abstract

Uterine rupture is a life-threatening obstetric emergency. Its diagnosis is often missed or delayed, with vital maternal and fetal risk. (1) in a healthy uterus, it is a rare event. We report the case of a 25-year-old female patient, nulligravida, chronic smoker, who presented with acute pelvic pain with blackish bleeding, hypertensive with visual fog, tachycardic, blackish bleeding of endo-uterine origin, with a gravid cervix and enlarged uterus. Pregnancy at 19 weeks’ amenorrhea outside the uterus, requiring emergency laparotomy. On examination, there was abundant hemoperitoneum, followed by evidence of an anterior isthmic uterine rupture. We opted for uterine reconstruction. Biological workup showed HELLP syndrome. This is a rare and dangerous obstetric complication associated with maternal mortality and morbidity rates ranging from 20.8% to 64.6% (2). Multiparity is recognized as a major risk factor for spontaneous rupture of a non-scarring uterus (3). There are other recognized risk factors contributing to spontaneous rupture of a healthy uterus: obstetric maneuvers, mechanical dystocia, use of oxytocics, abnormal fetal presentations (in particular, transverse fetal position), cephalo-pelvic disproportion, excessive uterine expressions, abnormal placentation (placenta percreta mainly), trauma due to uterine curettage and uterine anomalies, and Ehlers-Danlos syndrome. (4, 5) In our patient, none of these risk factors were found. In some cases, rupture of the gravid uterus has no obvious cause. Treatment is based on total or subtotal hysterectomy. Despite the rarity of rupture occurring in a healthy uterus, it always remains a possibility of its occurrence.

Introduction

Uterine rupture is a life-threatening obstetric emergency. Its diagnosis is often missed or delayed, with vital maternal and fetal risks [1]. There are several risk factors associated with uterine rupture, but the most common is a previous cesarean section. Spontaneous uterine rupture in a healthy uterus is a rare event [2]; spontaneous rupture of a healthy uterus has been reported to occur in 1 in 15,000 [3]. Here we report a case of uterine rupture at 19 weeks’ gestation on a healthy uterus.

Patient and observation

Patient aged 25, married for 3 years, nulligravida, chronic smoker, with a history of ectopic pregnancy on the right with conservative treatment. She had no history of trauma, uterine surgery, or intrauterine intervention, and no symptoms suggestive of Ehlers-Danlos syndrome in herself or family members. The patient presented to our university hospital with acute pelvic pain and blackish bleeding. On admission, the patient was hypertensive at 160/90 mm hg, with visual fog, tachycardic at 90 beats/min, and had a temperature of 37.5°C and conjunctivae that were slightly discolored. Obstetrical examination showed blackish bleeding of endo-uterine origin with a gravid cervix and enlarged uterus. Ultrasound revealed a pregnancy of 19 weeks’ amenorrhea outside the uterus (Figure 1). The patient was rushed to the operating theater for an emergency laparotomy. On examination, the first finding was a large hemoperitoneum, and the second was an anterior isthmic uterine rupture (Figure 2-3). Given the patient’s age and her desire to preserve her fertility, we opted for uterine reconstruction. Biological workup: Hb 7 g/dL, pq 50,000, WBC 10,000, PT 70%, PTT 26, Fg 3.4, AST 50, ALT 70, LDH 800, CRP 50, indicating HELLP syndrome. The patient received 2CG and 2 PFG as well as dual therapy (Loxen 20mg and Aldomet 500mg). Post-operative follow-up was good, and the patient left our facility six days later.

Figure 1: Ultrasound Image of Uterine Rupture

Figure 2: Anterior Uterine Rupture

Figure 3: Anterior Uterine Rupture

Figure 4: Uterine rupture of a 19-week-old fetus

Discussion

The incidence rate for pregnancy-related uterine rupture is 1/1146 pregnancies, and for spontaneous rupture of a non-scarring uterus, it is 1/8434 pregnancies (0.012%) in industrialized countries and 1/920 pregnancies (0.11%) in developing countries. [4] It is a rare and dangerous obstetric complication associated with maternal mortality and morbidity rates ranging from 20.8% to 64.6%. [5]. Uterine rupture is a break in the continuity of the uterine wall and its serosa. The uterine lumen then communicates with the peritoneal cavity. There are two types of uterine rupture: traumatic and spontaneous. The etiologies of so-called traumatic uterine rupture are varied and may be related to shock (direct or indirect) or obstetric maneuvers (endouterine maneuvers or uterine expression). Spontaneous uterine rupture, on the other hand, is recognized as a major risk factor for spontaneous rupture of a non-scarring uterus. [8] There are other recognized risk factors contributing to spontaneous rupture of a healthy uterus: obstetric maneuvers, mechanical dystocia, use of oxytocics, abnormal fetal presentations (in particular transverse fetal position), cephalo-pelvic disproportion, excessive uterine expressions, abnormal placentation (placenta percreta mainly), trauma due to uterine curettage and uterine anomalies, and Ehlers-Danlos syndrome. [9-10]. In our patient, none of these risk factors were found. In some cases, rupture of the gravid uterus has no obvious cause. In their series of 40 uterine ruptures, Schrinsky and Benson found 10 cases of rupture without any predisposing factors [11]. The case presented here emphasizes the possibility of uterine rupture in women whose uterus is not scarred and before labor. Uterine rupture is characterized by the non-specificity and heterogeneity of its symptomatology, resulting in delayed diagnosis [12]. hand, occurs outside any traumatic context [6-7]. Early surgical intervention is generally the secret to successful treatment of uterine rupture [8]. Suturing can be performed [8], helping to preserve fertility in patients who have never given birth, with an estimated risk of recurrence of uterine rupture of between 4% and 19% in a subsequent pregnancy [9]. In our patient, we opted for hysterorrhaphy to preserve her fertility.

Conclusion

Rupture of a healthy uterus can be a catastrophic event involving the vital maternal and fetal prognosis [13]. Despite the rarity of rupture in a healthy uterus, the possibility of its occurrence remains. This is something that every practitioner should be aware of, especially in view of its misleading clinical picture. It must be managed as a matter of urgency, with the mobilization of a multidisciplinary team.

Declaration of Competing Interest

The authors declare that they have no conflict of interest.

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