A Case of Concealed Unscarred Uterine Rupture

A 28-year-old woman, para 3, was referred to a tertiary care hospital with severe postpartum hemorrhage (PPH) and severe anemia following a ventouse-assisted vaginal delivery at a district hospital. 

The lady had been married for ten years with two previous full-term normal vaginal deliveries––the last one occurring six years ago––all without complications. During her current pregnancy, she had four antenatal visits and no history of uterine scars, pelvic surgeries, or bleeding disorders.

Her referral documents indicated that she had delivered a 3.5 kg baby boy using a ventouse, after which she experienced severe PPH. Initial interventions, including uterine massage, oxytocin (40 IU in 500 ml Ringer's lactate), and intravenous tranexamic acid (1 gm), failed to stop the vaginal bleeding. On examination, a cervical tear was identified and repaired, followed by the application of a tight vaginal pack. One unit of packed red blood cells (PRBC) was transfused.

The patient had been owing due to a lack of blood supply at the district hospital.

The patient reported abdominal pain for three days prior to delivery, with non-progressing labor. The delivery was conducted employing ventouse assistance; however, she was not informed about the ventouse delivery and its potential complications. After delivery, excessive vaginal bleeding occurred, and she was told she had an internal injury/cut – prompting her referral.

On admission, the patient was severely pale and in shock, with a pulse rate of 135 beats/min and blood pressure of 70/48 mm Hg. She was conscious but drowsy, with a distended abdomen and a retracted uterus. 

Bleeding resumed immediately on vaginal pack removal. Immediate resuscitative measures included oxygen, intravenous crystalloids, inotropic drugs, and tranexamic acid and oxytocin drip administration. The lady was also started on broad-spectrum antibiotics, and strict input-output charting was initiated. Blood was drawn for investigation and cross-matching, and an emergency laparotomy was planned.

Under anesthesia, the uterus was deviated to the left iliac fossa at the umbilicus level. Vaginal examination indicated cervical laceration and right-sided broad ligament fullness. Intra-operatively, approximately 100 ml hemoperitoneum was discovered, along with a large right broad-ligament hematoma extending to the renal pelvis and retrovesically. Clot evacuation revealed a rupture of the right lateral uterine wall from the vaginal fornix up to the uterus––nearly approximating the fundus. A subtotal hysterectomy and right internal iliac artery ligation were performed to secure hemostasis, and an intra-peritoneal drain was placed.

Postoperatively, the patient responded to oral commands, was pale with cold extremities, and had adequate urine output and a 100 ml drain output. She was kept nil by mouth for 48 hours with Ryle's tube aspiration and continuous bladder drainage via Foley's catheter for seven days, with strict input-output charting. Three units of PRBCs were transfused. 

The patient showed significant improvement by postoperative day 12 and was discharged after appropriate instructions on avoiding activities like lifting weights and engaging in sex. On follow-up, she was recovering well, both physically and mentally, and resuming regular activities.

Source: Debbarma B, Chhabra D, Baidya JL, et al. Indian Obst and Gynaec. 2023;13(4).