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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 2  |  Issue : 1  |  Page : 40-42

Why women still die of childbirth in the 21st century: A case report on uterine rupture in unscarred uterus


Department of Obstetrics and Gynaecology, AIIMS, Rishikesh, Uttarakhand, India

Date of Submission19-May-2020
Date of Decision13-Jun-2020
Date of Acceptance18-Nov-2020
Date of Web Publication25-Apr-2021

Correspondence Address:
Dr. Kavita Khoiwal
Department of Obstetrics and Gynaecology, AIIMS, Rishikesh, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JME.JME_61_20

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How to cite this article:
Khoiwal K, Agarwal A, Gaurav A, Yadav P, Chaturvedi J. Why women still die of childbirth in the 21st century: A case report on uterine rupture in unscarred uterus. J Med Evid 2021;2:40-2

How to cite this URL:
Khoiwal K, Agarwal A, Gaurav A, Yadav P, Chaturvedi J. Why women still die of childbirth in the 21st century: A case report on uterine rupture in unscarred uterus. J Med Evid [serial online] 2021 [cited 2022 Aug 12];2:40-2. Available from: http://www.journaljme.org/text.asp?2021/2/1/40/314633


  Introduction Top
Uterine rupture is a catastrophic obstetric emergency often associated with grave maternal and foetal prognosis. It is uncommon in an unscarred uterus. The prevalence of rupture in an unscarred uterus ranges from 0.006% in developed countries to 25% for women with obstructed labour in a least developed country.[1] The aetiology of rupture in an unscarred uterus can be categorised into antepartum and intrapartum factors. Antepartum factors can further be divided into maternal and foetal factors. Maternal factors include multiparity, contracted pelvis, maternal trauma as in motor vehicle crashes or due to a previous uterine curettage and less commonly congenital malformations of the uterus or inherent weakness of connective tissues. Schrinsky and Benson reported an incidence of 32% of unscarred uterine rupture in women with parity >4.[2] A high incidence of rupture due to obstructed labour is seen in juveniles with a contracted pelvis or in African women.[3],[4] Foetal factors include foetal macrosomia, malposition, malpresentation or congenital anomalies that may lead to obstructed labour. Rarely, overdistention due to multiple pregnancies can also result in an obstructed labour.[5] Placental aetiology is uncommon and is usually happens in patients with placenta percreta. Intrapartum factors are grossly mismanaged labour in the form of internal or external versions by untrained personnel, excessive uterine expressions, attempted forceps delivery, prolonged and excessive use of oxytocin and delay in referral to higher centre, all of which are still commonly witnessed in developing countries.[5] The most alarming aspect is the significant maternal (1%–13%)[1] and foetal mortality rates (74%–92%).[1] They can also affect patient's fertility potential as well as quality of life in terms of mental and physical health due to long-term complications such as vesico-vaginal fistula (VVF). In general, only 10–30 minutes is available from diagnosis to delivery before clinically significant foetal morbidity becomes apparent.[6] Hence, prompt surgical management at a centre equipped with operative facilities and blood availability is required to ensure a better outcome. Here lies the lacuna in most of the developing countries and the need to highlight and discuss such cases. Adding to the problems are illiteracy, adolescent marriages, unmet needs of contraception, lack of education regarding safe birth practices, deficit of money and other resources which prevent the woman from accessing adequate antenatal services during pregnancy and especially during labour. There is more acceptance for traditional birth attendants who give attempts at home delivery until it is often too late for the mother and her foetus to have a safe institutional delivery and a good outcome.[7] Mentioned below are two cases managed at our centre, aptly highlighting the plight of the women who are referred too late to a tertiary care facility.
  Case Report Top
Case 1 A 30-year-old G2P1L1, unbooked patient, belonging to low socioeconomic class, presented at 34 weeks, 6 days of pregnancy in obstructed labour with intrauterine foetal demise (IUFD), severe anaemia and gross haematuria. She had a history of labour pain and leaking per vaginum for 20 hours. She had been first attended by an untrained local woman at home for 4 hours due to lack of any transport facilities followed by a private hospital where she was kept for 4 hours and then referred in view of pedal oedema to a government hospital. She stayed there for 6 hours and gave a history of violent attempts at normal delivery by multiple people giving her fundal pressure at the government hospital. From there, she was referred to another district hospital where a decision for caesarean section was made, but on detection of haematuria during catheterisation, she was referred to another private hospital. At this third referral point, an ultrasound was done and IUFD was diagnosed at which the patient was finally referred to our centre in a worse state. On admission, she was dehydrated, was severely anaemic, had a pulse rate of 128/min and blood pressure of 90/50 mmHg, had minimal urine output (10 ml) and was haemorrhagic. A diagnosis of obstructed labour with the possibility of a ruptured uterus was made and planned for immediate laparotomy with consent of lifesaving hysterectomy. Intraoperatively, gross peritoneal-free fluid was present, the uterus was pushed towards the epigastrium and foetal parts were visible through a thin membrane [Figure 1]a. There was no delineation of utero-vesical space and an intact bladder was not seen. A dead foetus (fresh still birth; 2.8 kg; morphologically normal) and placenta were delivered through classical uterine incision. A rent was seen in the lower uterine segment extending through the fully dilated cervical rim into the proximal 8 cm of the anterior vagina. There was a similar rent on the juxtaposed posterior surface of the bladder extending from the dome of the bladder to the bladder neck involving the trigonal region [Figure 1]b. These findings suggested the diagnosis of a ruptured uterus, a cervix and a vagina with a ruptured bladder.
Figure 1: (a) Uterus pushed towards the epigastrium and foetal parts visible through a thin membrane (anterior bladder wall). (b) Ruptured posterior wall of the bladder (from the dome of the bladder to the bladder neck involving the trigonal region)

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Bilateral ureteric stents were placed, and the bladder was repaired in conjunction with a urologist. An attempt was made to repair the uterus, but on account of the persisting uterine atony and associated haemorrhage, a hysterectomy was performed as a lifesaving procedure. The patient received a total of 5 units of packed red blood cells (PRBCs) and 4 units each of fresh frozen plasma, cryoprecipitate and platelets during and after the surgery. The immediate post-operative period was uneventful, but she developed VVF as a chronic complication. Case 2 A 25-year-old female, unbooked G2P1L1, belonging to lower-middle socioeconomic class, at 39 weeks of pregnancy, presented to the emergency department with complaints of pain abdomen and not perceiving any foetal movements for 1 day. She had made 3–4 antenatal visits to a private clinic near her village and had got an ultrasound done 1 month back, which was normal. When she visited the same hospital with the complaint of labour pain, she was referred to the district hospital in view of meconium-stained liquor. She was already in the second stage of labour when she reached the district hospital but was referred to our centre due to non-availability of doctors. By the time the patient reached us, she had an obstructed labour, IUFD, uterine rupture and disseminated intravascular coagulation (DIC). Her general condition was poor with features of shock. Blood investigations revealed severe anaemia, thrombocytopaenia and deranged prothrombin time. The patient was immediately taken for emergency laparotomy with blood and blood products under high risk after taking informed and written consent. Intraoperatively, haemoperitoneum (200 ml blood and 200 ml clots) was present with left lateral uterine rupture [Figure 2] from the round ligament to the cervix, with the foetus and placenta lying partially in the peritoneal cavity. A dead foetus (fresh stillbirth; 3 kg; morphologically normal) was delivered through classical uterine incision followed by caesarean hysterectomy performed to control haemorrhage. The blood and blood products were transfused and the patient was shifted to the intensive care unit (ICU) on ventilatory support. Post-operatively, her general condition was poor, on ventilator support and maximum doses of vasopressors with poor renal status with deranged coagulation parameters. Two cycles of haemodialysis were given in view of decreased urine output. A total of 13 units of PRBC, 8 units of fresh frozen plasma, 26 units of random donor platelet and 10 units of cryoprecipitate were given during her hospital stay, but the patient did not improve, had cardiac arrest and died in the ICU on the 4th post-operative day.
Figure 2: Left lateral uterine rupture (from the round ligament to the cervix)

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  Discussion Top
Considering the relatively high prevalence of rupture of unscarred uterus in developing countries, a high index of suspicion is required in women who present with prolonged labour, exhaustion, foetal distress, easily palpable foetal parts beneath the abdominal wall, haematuria and features of haemodynamic instability. Most of these patients are unbooked and have unsupervised or poorly supervised pregnancy. Almost 69.2% of women received no antenatal care in a retrospective study from India.[8] Very high maternal (30.8%) and perinatal mortality rates (78.7%) have been reported from India.[8] Prompt surgical management at a centre equipped with operative facilities would ensure a better outcome. In the first case, the patient had to bear labour pain for nearly 20 hours with excessive and forceful attempts at normal delivery by untrained and semi-trained health workers at home and at centres which were not equipped to conduct emergency caesarean. She was referred from one such centre to another five times before being referred to the tertiary centre where definitive management was done. This wastage of time and money resulted in her losing the baby as well as her uterus and giving rise to the need of massive blood transfusion, bladder injury repair, prolonged hospital stay and long-term complication in the form of VVF. In the second case, the patient was even less fortunate and despite having made antenatal visits to a private hospital and after being referred through two centres to a tertiary centre, she reached in a state of hypovolemic shock with DIC. Even after surgical intervention, prompt ICU care and massive blood transfusion, she could not be saved. In both these instances, had the patients visited a trained midwife who could have timely referred them to a facility where emergency caesarean section could be performed, both the mothers and the babies could have survived. Improvements in healthcare services catering to the education of adolescent and adult women, in giving contraceptive and antenatal services to remote areas and in training healthcare workers/midwives in these areas to ensure safe deliveries and timely identification and referral to tertiary care centres of the complicated deliveries can go a long way in preventing such cases. Midwifery has a vital role in providing high-quality care to mothers and babies.[9] Government bodies can contribute to a major reduction in regional maternal mortalities by providing swift transportation services to women in need at subsidised rates. The community at large needs to be educated of the importance of contraception and the dangers associated with poorly managed pregnancy and childbirth.
  Conclusion Top
Uterine rupture is an ominous yet preventable condition. Timely identification of impending rupture by an observant trained healthcare worker and prompt referral to a well-equipped facility ensuring a safe transportation may optimise maternal–foetal outcome. The society at large needs to be educated about the perils of unsafe labour and deliveries and government policies need to address the socioeconomic causes leading to this grave situation. Strengthening of midwifery can play a vital role. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship No funding was required. Conflicts of interest There are no conflicts of interest.

 
  References Top

1.
Hofmeyr GJ, Say L, Gülmezoglu AM. WHO systematic review of maternal mortality and morbidity: The prevalence of uterine rupture. BJOG 2005;112:1221-8.  Back to cited text no. 1
    
2.
Schrinsky DC, Benson RC. Rupture of the pregnant uterus: A review. Obstet Gynecol Surv 1978;33:217-32.  Back to cited text no. 2
    
3.
Fisk NM, Shweni PM. Labor outcome of juvenile primiparae in a population with a high incidence of contracted pelvis. Int J Gynaecol Obstet 1989;28:5-7.  Back to cited text no. 3
    
4.
Cox ML. Contracted pelvis in Nigeria. J Obstet Gynaecol Br Emp 1963;70:487-94.  Back to cited text no. 4
    
5.
Ahmadi S, Nouira M, Bibi M, Boughuizane S, Saidi H, Chaib A, et al. Uterine rupture of the unscarred uterus. About 28 cases. Gynecol Obstet Fertil. 2003;31:713–7.  Back to cited text no. 5
    
6.
Holmgren C, Scott JR, Porter TF, Esplin MS, Bardsley T. Uterine rupture with attempted vaginal birth after cesarean delivery: Decision-to-delivery time and neonatal outcome. Obstet Gynecol 2012;119:725-31.  Back to cited text no. 6
    
7.
Rizwan N, Abbasi RM, Uddin SF. Uterine rupture, frequency of cases and fetomaternal outcome. J Pak Med Assoc 2011;61:322-4.  Back to cited text no. 7
    
8.
Vernekar M, Rajib R. Unscarred uterine rupture: A retrospective analysis. J Obstet Gynaecol India 2016;66:51-4.  Back to cited text no. 8
    
9.
Renfrew MJ, Ateva E, Dennis-Antwi JA, Davis D, Dixon L, Johnson P, et al. Midwifery is a vital solution-What is holding back global progress? Birth 2019;46:396-9.  Back to cited text no. 9
    


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