■ SHORT COMMUNICATION ■

THIRD-TRIMESTER SPONTANEOUS RUPTURE OF

AN UNSCARRED UTERUS WITH MASSIVE
INTRA-ABDOMINAL HEMORRHAGE DURING TOCOLYSIS
IN A PREGNANT WOMAN WHO HAS HAD
MULTIPLE INSTRUMENTAL ABORTIONS
Yi-Hui Lin, Chih-Ping Chen*, Jen-Ru Lin, Li-Fan Yeh, Tze-Chien Chen
Department of Obstetrics and Gynecology, Mackay Memorial Hospital, Taipei, Taiwan.

SUMMARY

Objective: Uterine rupture is a rare and catastrophic event. We present a case of spontaneous rupture in an
unscarred uterus with massive internal bleeding during tocolysis in the third trimester.
Case Report: A 31-year-old woman, gravida 5, para 2, was admitted to our hospital at 32 weeks of gestation
because of lower abdominal pain, fever, and chills. She had no history of gynecologic surgery except for two
suctional dilatation and curettage procedures because of intrauterine fetal death. Her husband was a balanced
reciprocal translocation carrier. On admission, cardiotocography (CTG) showed irregular uterine contractions,
and an intravenous beta-sympathomimetic agent was given along with antibiotics. Following the medication,
maternal tachycardia was observed without any obvious change in blood pressure. One hour after the treatment,
however, CTG showed persistent moderate variable decelerations of fetal heart beats and a decrease in maternal
blood pressure. Emergency cesarean section was performed under the impression of acute fetal distress. A
1 cm laceration over the left uterine cornus was noted, with active bleeding and hemoperitoneum of 1,500 mL.
A male baby weighing 2,250 g was delivered; his Apgar scores at 1 and 5 minutes were 1 and 5, respectively.
Primary repair of the uterus was performed. The postoperative course was uneventful. The infant was doing
well at age 2 months.
Conclusions: The present case provides evidence that spontaneous rupture of an unscarred uterus may occur
during tocolytic management in the third trimester in pregnant women with a history of multiple instrumental
abortions. We suggest that the feto-maternal condition be closely monitored during tocolytic management
of such patients. Any change in the vital signs of the mother as well as the fetus should alert one to the possibility
of spontaneous uterine rupture. [Taiwanese J Obstet Gynecol 2004;43(3):172–174]

Key Words: dilatation and curettage, intra-abdominal hemorrhage, multiple instrumental abortions,
spontaneous uterine rupture, unscarred uterus

Introduction
*Correspondence to: Dr. Chih-Ping Chen, Department of Obstetrics
and Gynecology, Mackay Memorial Hospital, 92 Chung-Shan Spontaneous uterine rupture during labor is a well-
North Road, Section 2, Taipei, Taiwan. documented obstetric complication and is often asso-
E-mail: cpc_mmh@yahoo.com
Received: November 21, 2003
ciated with high feto-maternal mortality. Risk factors for
Revised: November 21, 2003 intrapartum spontaneous uterine rupture include pre-
Accepted: November 21, 203 vious uterine surgery, grand parity, malpresentation,

172 Taiwanese J Obstet Gynecol • September 2004 • Vol 43 • No 3


cephalopelvic disproportion, oxytocin stimulation, and
abnormal placentation [1]. Among these, previous ce-
sarean section is the most common factor. Rupture
of an unscarred and non-laboring uterus without ob-
vious risk factors is rare. We present the case of a
third-trimester spontaneous rupture of an unscarred
uterus with massive intra-abdominal hemorrhage
during tocolysis in a pregnant woman who has had
multiple instrumental abortions.
Case Report
A 31-year-old woman, gravida 5, para 2, presented at
32 weeks’ gestation with lower abdominal pain, fever,
and chills. The cervix was dilated 2 cm, the fetal head
was at station –1, and cardiotocography (CTG) showed
irregular uterine contractions. Ultrasonography showed
a singleton with normal biometry consistent with the
gestational age and a cephalic presentation, adequate
amniotic fluid, and normal placentation. She was
admitted because of premature uterine contractions
and suspected chorioamnionitis. An intravenous beta-
sympathomimetic agent, ritodrin, was given along with
antibiotics. She had previously given birth to a malformed
baby with an unbalanced chromosomal translocation
inherited from the father. The father’s karyotype was
46,XY, t(4;7)(p10,q10). In another pregnancy, a Down
syndrome fetus was detected by genetic amniocente-
sis because of paternal chromosomal translocation,
and she underwent second trimester termination of the
pregnancy. Subsequently, she had suctional dilatation
and curettage (D&C) twice because of intrauterine fe-
tal death.
During tocolytic management in this pregnancy,
maternal tachycardia was observed without any ob-
vious change in blood pressure. Chorioamnionitis was
suspected because of the appearance of leukocytosis.
Tocolytic management was interrupted, after which the
patient complained of abdominal distension and dys-
pnea. Repeat transabdominal sonography did not de-
tect any remarkable finding except for some subphrenic
fluid. Initially, vital signs in both the mother and fetus
were stable but, 1 hour later, persistent moderate varia-
ble decelerations of fetal heart beats and a decrease in
maternal blood pressure occurred. The cervix was dilat-
ed 3 cm and the station of the fetal head was –1. An
emergency cesarean section was performed under the
impression of acute fetal distress. A hemoperitoneum of
1,500 mL and a laceration about 1 cm in length over the
left cornus, with active bleeding, were noted. A male
baby weighing 2,250 g was delivered with Apgar scores
of 1 and 5 at 1 and 5 minutes, respectively. Primary
Taiwanese J Obstet Gynecol • September 2004 • Vol 43 • No 3
Spontaneous Rupture of an Unscarred Uterus
repair of the uterus was performed. The postoperative
course was uneventful. The infant did well and was
discharged home 2 months later.
Discussion
Rupture of a gravid uterus is an unpredictable and
catastrophic complication. It is usually encountered
in the scarred uterus [2]. Rupture in an unscarred uter-
us is relatively rare and always occurs intrapartum
[3]. The reported incidences of spontaneous rupture
of the unscarred uterus range from 1 in 8,000 to 1 in
15,000 deliveries [4]. Rupture of the unscarred uter-
us is associated with fetal or uterine anomalies,
endometriosis, injudicious oxytocin stimulation, ab-
normal placentation, macrosomic infants, advanced
maternal age, and grand parity [4–6].
Spontaneous uterine rupture in the unscarred uterus
may occur in a non-laboring uterus without any risk
factor. Langton et al reported a case of spontaneous
uterine rupture that occurred at 32 weeks’ gestation in
a non-laboring uterus without previous risk factors [3].
Their patient presented with sudden onset of right
abdominal pain and unstable vital signs. She had not
undergone any gynecologic surgery and her antenatal
care was uneventful. Emergency laparotomy revealed
a vertical tear above the insertion of the uterosacral
ligament. deRoux et al presented a case of fatal hemo-
peritoneum and spontaneous uterine rupture caused
by placenta percreta [7]. The patient had undergone
curettage six times for abortions and miscarriages. She
presented with abdominal pain of several days’ dura-
tion and died of cardiovascular collapse. Our patient
did not have any history of gynecologic surgery except
for two suctional D&Cs. It was likely that these result-
ed in an undiagnosed uterine perforation or weakness,
and the weakened area was further stressed by this
pregnancy. This provides further evidence that a histo-
ry of multiple instrumental abortions adds to the list
of risk factors for spontaneous uterine rupture.
The diagnosis of spontaneous uterine rupture is not
˘ easy due to lack of specific symptoms and signs.
always
Saglamtas et al reported that the most common symp-
toms in patients with uterine rupture were tachycar-
dia, hypotension, uterine bleeding, abdominal pain or
tenderness, absence of fetal heart sounds, and abnor-
malities of various severity on fetal monitoring [8]. In
the present case, maternal tachycardia was obscured by
the effect of a beta-sympathomimetic agent. However,
recent reports suggest that ultrasonography is useful in
antenatal diagnosis of spontaneous uterine rupture.
The reported sonographic findings include extraperi-
173
Y.H. Lin, et al
toneal hematoma, intrauterine blood, free peritoneal
blood, an empty uterus, a gestational sac above the
uterus, and a large uterine mass with gas bubbles [9].
Our case also had sonographic evidence of subphrenic
fluid accumulation implying possible uterine rupture,
but this finding was ignored. Accurate diagnosis of
spontaneous uterine rupture may be hampered by an
enlarged uterus, inexperienced practitioners, a scanty
amount of internal bleeding, obscure symptoms, and
the uncertainty of sonographic diagnosis.
In conclusion, we have presented a rare case of
spontaneous uterine rupture of an unscarred uterus.
Our case shows that spontaneous rupture of an un-
scarred uterus may occur during tocolytic management
in the third trimester in pregnant women with a history
of multiple instrumental abortions. We suggest that the
feto-maternal condition be closely monitored, especially
during tocolytic management of such patients, because
the use of beta-sympathomimetic agents may mask
the warning of maternal tachycardia in uterine rupture.
Any change in the vital signs of the mother as well as the
fetus should alert one to the possibility of spontaneous
uterine rupture. Close observation of the maternal and
fetal condition as well as detailed ultrasound exami-
nation are the keys to optimal maternal and perinatal
outcomes.
174
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