Written by Dr. Chris Hanuscin
Edited by Dr. Wesley Chan
Great teamwork by Drs. Jordan Dow, Chris Hanuscin, Paladino, Janairo, and Fan!
Case:
Notification: “This is FDNY calling in a 41-year-old female, 7 months pregnant with hypotension. BP 70/50, HR 89, ‘Satting’ 99% on RA. ETA 7 min.”
We immediately called the OB suite to notify them.
Patient arrives: 12:56 am
41-year-old female G3P2, 29 weeks pregnant, history of one prior C-section and myomectomy brought in by EMS for abdominal pain that started exactly 30 min prior to arrival after eating Mexican food. When EMS arrived at the scene, the patient was lethargic laying in a left lateral decubitus position with a blood pressure of 70/50 mm Hg.
On ED arrival, the patient was in moderate distress from pain, pale-appearing and lethargic, however, she responded to her name and complained of “abdominal cramps”. There was a gravid uterus that was diffusely tender. Heart rate was 79/min and blood pressure was 76/54 mm Hg.
As two large-bore IVs were placed, we performed the RUSH exam. As a reminder, the RUSH exam stands for Rapid Ultrasound for Shock and Hypotension. The mnemonic HIMAP can be used to remember the components of the RUSH exam:
Heart – cardiac tamponade
IVC – inferior vena cava size
Morison’s Pouch – free fluid in the right upper quadrant
Aorta – abdominal aortic aneurysm
Pulmonary – large pleural effusion or pneumothorax
We started with Morison’s Pouch since the patient had abdominal pain.
Morison’s Pouch
Spleno-renal space
As seen, the patient has a FAST exam with free fluid in her right upper quadrant (Morison’s Pouch) and left upper quadrant. The OB team arrived at the bedside within five minutes of the patient’s arrival.
The fetal heart rate clip is below:
The transabdominal ultrasound demonstrated fetal bradycardia at about 80 per minute (normal fetal heart rate is between 120-180 per minute). Since the fetus was in distress, and the patient was hypotensive with free, intraperitoneal fluid, an emergent C-section was indicated. The OR, Anesthesia, and NICU were immediately notified.
Disposition time: 1:05 am, 9 minutes later
Case Resolution:
In the OR, the patient was found to have uterine rupture and about three liters of blood in the abdomen. According to OB, the “baby was in the abdomen” when the initial incision was made. The patient received four units of packed red blood cells, underwent a hysterectomy, and is doing well. The neonate was immediately intubated after delivery for apnea and transported to the NICU.
Uterine Rupture
Description: Uterine rupture is the spontaneous tearing of the uterus. This may result in the fetus being expelled into the peritoneal cavity. Uterine rupture most likely happens in the late third trimester or during active labor when the uterine wall is at its thinnest.[1]
Risk Factors:
- • Previous uterine rupture
- • Prior c-section
- • Grand multiparity (>3) [2]
- • Fetus risk factors (malpresentation, labor dystocia)
- • Uterine anomalies (bicornuate uterus)
- • Abnormal placentation (placenta accreta)
- • Connective tissue disorders (Ehlers Dahlos)
- • Prior myomectomy
- • Misoprostol use [3]
Management:
- 1. Pelvic US to identify disruption of myometrium, free peritoneal fluid, empty uterus, fetal anatomy outside of the uterus, or abnormal fetal heart rate in the uterus
- 2. Fluid and blood product resuscitation
- 3. Emergent Obstetrics and NICU consultation for emergent fetal delivery
Key Learning Points from Case
- • Ultrasound your undifferentiated hypotensive patient (RUSH exam – think HI-MAP)
- • Have uterine rupture high on your differential for late-term pregnant patients in distress
- • Fluid resuscitation and emergent delivery of the fetus is key for both maternal and fetal outcomes
References
- 1. Porreco RP, Clark SL, Belfort MA, Dildy GA, Meyers JA. The changing specter of uterine rupture. Am J Obstet Gynecol. 2009 Mar;200(3):269.e1-4. doi: 10.1016/j.ajog.2008.09.874. Epub 2009 Jan 10. PMID: 19136093.
- 2. Gibbins KJ, Weber T, Holmgren CM, Porter TF, Varner MW, Manuck TA. Maternal and fetal morbidity associated with uterine rupture of the unscarred uterus. Am J Obstet Gynecol. 2015;213(3):382.e1-382.e3826. doi:10.1016/j.ajog.2015.05.048
- 3. American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Obstetrics. ACOG Practice Bulletin No. 205: Vaginal Birth After Cesarean Delivery. Obstet Gynecol. 2019;133(2):e110-e127. doi:10.1097/AOG.0000000000003078
Wesley Chan
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