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Delayed presentation of uterine rupture postpartum

Deepa M. Narasimhulu, MD; Susan Shi, MD

Case notes
FIGURE 2
A 32-year-old G2P1 with a history of cesarean delivery had
Computed tomography scan of pelvis: transverse view
an uncomplicated vaginal delivery at term. Two days after
giving birth, she developed high-grade fever, tachycardia, hy-
potension, lower abdominal pain, and right flank pain.
Computed tomography (CT) scan at that time revealed
bladder wall thickening and a small amount of pelvic free fluid.
She was started on broad-spectrum antibiotics for suspected
pyelonephritis and sepsis. However, urine cultures were

FIGURE 1
Computed tomography scan of abdomen and pelvis:
coronal view

Uterine wall defect is seen in cross-section.

Narasimhulu. Delayed presentation of uterine rupture. Am J Obstet Gynecol 2015.

negative and patient had persistent severe flank pain although

her fever and hemodynamic status improved. A repeat CT
scan performed 3 days later revealed a uterine defect in the
region of the previous cesarean scar with a pelvic collection
tracking into the right pararenal space (Figures 1 and 2). Pelvic
ultrasound also demonstrated the uterine rupture (Figure 3).
CT-guided drainage of this collection (Figure 4) resulted in
complete recovery, and the fluid drained did not grow any
organisms as patient was on antibiotics. Patient had no desire

FIGURE 3
Uterine wall defect is seen in region of previous cesarean scar on right side Pelvic ultrasound
with pelvic collection tracking into right pararenal space.
Narasimhulu. Delayed presentation of uterine rupture. Am J Obstet Gynecol 2015.

Department of Obstetrics and Gynecology, Maimonides Medical Center,

Brooklyn, NY.
Received Sept. 4, 2014; revised Dec. 29, 2014; accepted Jan. 9, 2015.
The authors report no conflict of interest.
Corresponding author: Deepa M. Narasimhulu, MD. dnarasimhulu@
maimonidesmed.org
Cite this article as: Narasimhulu DM, Shi S. Delayed presentation of uterine
rupture postpartum. Am J Obstet Gynecol 2015;212:680.e1-2.
0002-9378/$36.00
Uterine defect in region of cesarean scar is seen.
ª 2015 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajog.2015.01.020 Narasimhulu. Delayed presentation of uterine rupture. Am J Obstet Gynecol 2015.

680.e1 American Journal of Obstetrics & Gynecology MAY 2015

ajog.org
FIGURE 4
Computed tomographyeguided percutaneous drainage of pelvic collection
Narasimhulu. Delayed presentation of uterine rupture. Am J Obstet Gynecol 2015.
for future pregnancies and was counseled on the risks of
pregnancy in the setting of an unrepaired uterine defect.
Comments
When a vaginal birth is attempted after previous cesarean de-
livery, there is a 0.7% risk of uterine rupture.1 Uterine rupture
is usually diagnosed in labor or immediately postpartum
with serious consequences for the mother and baby especially
if surgical intervention is delayed, including severe fetal hyp-
oxia, fetal demise, massive postpartum hemorrhage, and
maternal death. A delayed presentation of uterine rupture such
as the one we describe here is extremely rare but possible.2
Image-guided percutaneous drainage has been shown to be
feasible and effective in treating abdominal and pelvic
Images in Gynecology
collections as an alternative to open surgery.3 Awareness of
the complication we describe may reduce delay in diagnosis
and facilitate appropriate management. -
REFERENCES
1. Landon MB, Hauth JC, Leveno KJ, et al. Maternal and perinatal
outcomes associated with a trial of labor after prior cesarean delivery.
N Engl J Med 2004;351:2581-9.
2. El-Kehdy GI, Ghanem JK, El-Rahi CC, et al. Rupture of uterine scar 3
weeks after vaginal birth after cesarean section (VBAC). J Matern Fetal
Neonatal Med 2006;19:371-3.
3. Laganà D, Carrafiello G, Mangini M, et al. Image-guided percutaneous
treatment of abdominal-pelvic abscesses: a 5-year experience. Radiol
Med 2008;113:999-1007.
MAY 2015 American Journal of Obstetrics & Gynecology 680.e2