Aust. N.Z. J. Surg. (1999) 69, 685–686

CASE REPORT

SPONTANEOUS MID-TRIMESTER UTERINE RUPTURE

RAVI KASHYAP AND JOHN R. FLIEGNER

Royal Women’s Hospital and Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Victoria, Australia

Key words: cornual pregnancy, hysterectomy, uterine rupture.

Correspondence: Assoc. Prof. J. R. Fliegner, Royal Women’s Hospital,Department of Obstetrics and Gynaecology, University of Melbourne, Parkville,Vic. 3052, Australia.

Accepted for publication 6 July 1998.

INTRODUCTION

Uterine rupture during the second trimester of pregnancy is arare obstetric emergency. It is essential to establish the diagnosisrapidly and to perform effective treatment, since the unexpectedoccurrence of this catastrophe adds to its inherent seriousnessand potential mortality. Because of the obscure nature of thehaemoperitoneum, the general surgeon is frequently involveddue to the possibility of a hepatic or splenic cause, especiallythat associated with rupture of a splenic artery aneurysm. Wedescribe such a case and review the recent literature.

CASE REPORT

A 25-year-old gravida 4 para 3 at 16 weeks gestation was referred to the emergency department of the Royal Women’s Hospitalwith acute abdominal pain and signs of massive haemoperi-toneum. Immediate laparotomy was performed and revealed aruptured uterus with a fundal perforation and extrusion of theamniotic sac into the abdominal cavity. Apart from an earliertermination of pregnancy, the patient had no previous surgery.

Peritoneal toilet was carried out and a supra-vaginal hysterec-tomy was performed. Pathological examination of the uterusrevealed complete rupture of a right-sided cornual pregnancy in therudimentary horn of a previously unsuspected bicornuate uterus.

In all, the patient received 8 units of blood and made anuneventful convalescence.

DISCUSSION

When a patient presents with acute abdominal pain and signsof haemorrhagic shock in the mid-trimester of pregnancy, anumber of differential diagnoses must be considered. Sponta-neous rupture of the uterus due to a placenta percreta, andrupture of a classical caesarean section scar are possibilities.1,3

The latter occurrence has been most widely reported followingmedical termination of pregnancy with prostaglandin and intra-venous oxytocin.2

Uterine rupture may also rarely occur at the site of a previouslyunrecognized perforation following curettage. Again, sponta-neous rupture in mid-pregnancy has been reported after metroplastyand tubal re-implantation.4

Spontaneous rupture of a cornual pregnancy is a rare but life-threatening event.5–7 Classically, the rupture occurs at ~ 15–16weeks gestation, as in the present case. The diagnosis prior torupture is rarely made, although occasionally ultrasonographymay allow early detection of the pre-rupture situation.

Rupture of the liver or spleen (secondary to trauma) may not beimmediately apparent in view of the time lag, sometimes occurring7–10 days after the initial insult. Again, hepatic and splenicrupture in pregnancy, usually in the third trimester, has beenreported in association with toxaemia, haemangiomas, hepa-tomas, syphilis and malaria.8

Perhaps the widely reported condition is that of splenic arteryaneurysm rupture. There have been 99 case reports of this con-dition, most of which have been in the third trimester.9 Morethan 95% of all splenic artery aneurysm ruptures are asymptomaticprior to the event. Maternal and foetal survival depends onacute awareness of this possibility during pregnancy or labour,prompt recognition of the symptoms and signs of the condition,and immediate surgery to arrest intra-abdominal haemorrhage. Thedefinitive cause of splenic artery aneurysm rupture is unknown,although localized arteriosclerosis is commonly present at thesite. Once the aneurysm has ruptured, immediate resuscitation,clamping of the splenic hilum, and splenectomy is essential.Foetal survival is unusual.

In the present case, the diagnosis prior to laparotomy was dif-ficult. Possible differential diagnoses were cornual pregnancy,spontaneous rupture at the site of a uterine perforation, haemorrhagicrupture of an ovarian cyst, and rupture of a splenic artery aneurysm.Because the latter diagnosis was considered to be distinctly possible,a long mid-line incision was performed.

The question remains as to whether to repair the rent in theuterus or perform a hysterectomy. This largely depends on thecircumstances and seriousness of the situation and must beindividualized. If the patient is of low parity and desirous offurther children, then primary closure of the defect in the uterusis clearly a possibility. However, if the patient is gravely ill, or ifsuture is not technically feasible, then a subtotal hysterectomy isthe wisest course to follow.

REFERENCES1. Kanoshita T, Ogawa K, Yasumizu T. Spontaneous rupture of the

uterus due to placenta percreta at 25 weeks gestation. A casereport. J. Obstet. Gynaecol.1996; 22: 125–8.

2. Levrants G, Wingate M. Mid-trimester uterine rupture. J.Reprod.Med.1996; 41: 186–90.

3. Smith L, Muller P. Abdominal pain and haemo-peritoneum in thegravid patient. Am. J. Emerg. Med.1996; 14: 45–7.

4. Halvorson LM, Aserkoff RD. Spontaneous uterine rupture afterhysteroscopic metroplasty with uterine perforation. J. Reprod.Med. 1993; 38: 236–8.

5. Chang WS, Lin HH, Ho HN et al. Ultrasound diagnosis of rudi-mentary horn pregnancy at 14 weeks gestation. Asia Oceania J. Obstet. Gynaecol.1994; 20: 279–82.

6. Ron ELR, Langer R, Herman A et al. Term delivery following mid-trimester rupture of a cornual pregnancy with combined intra-uterine pregnancy. Br. J. Obstet. Gynaecol.1988; 95: 619–20.

7. Maher PJ, Grimwade JC. Cornual pregnancy: Diagnosis beforerupture. A report of 2 cases. Aust. N.Z. J. Obstet. Gynaecol.1982; 22: 172–4.

8. Bis KA, Waxman B. Rupture of the liver associated with preg-nancy. Obstet. Gynecol. Surv.1976; 31: 763–72.

9. Angelakis EJ, Bair WE, Baroneje, Lincer RM. Splenic arteryaneurism ruture during pregnancy. Obstet. Gynecol. Surv.1993;48: 145–8.

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