Gowri Dorairajan

Management and Complications

Management of ruptured uterus depends on the cause, the presentation, the need to preserve the uterus, and the part of the uterus involved in the rupture.

Tobacco use, exposure to second-hand smoke among pregnant women and their association with birth weight: A retrospective cohort study

Background: There is paucity of studies on prevalence of SHS among pregnant women and its association with low birth weight (LBW). Objectives: The study was designed to determine the proportion of tobacco use, exposure to second hand smoke among pregnant women and their association with LBW. Materials and Methods: A Retrospective cohort study was conducted from March–June 2017 among 1043 pregnant women admitted for delivery in the Department of Obstetrics and Gynecology, JIPMER. Socio-demographic and obstetric characteristics, tobacco use and exposure to SHS during pregnancy were assessed by interviews. Birth weight of the baby was also extracted. Data was analysed using STATA v12. Univariate analysis was used to assess the association of socio-demographic, obstetric characteristics and exposure to SHS with LBW. Results: Out of 1043 pregnant women, the mean age was 25 (±3.9) years. More than half (57.4%) of women were primigravida. The proportion of women exposed to SHS during pregnancy was 69.9% (95% CI: 67.0-72.6) among which 24% of the women belonged to family, where family members were smokers. Only four had ever used tobacco in the past. However, none used any form of tobacco during pregnancy. LBW was present in 21.4% of the babies. There was no association between exposure to SHS and LBW [PR:0.98 (95% CI:0.71-1.35)]. Conclusion: The study shows that there was no significant association between the SHS exposure of pregnant women and low birth weight.

Effect of Antenatal Steroids on Respiratory Morbidity of Late Preterm Newborns: A Randomized Controlled Trial

Objective The objective of this article was to study the effect of antenatal dexamethasone on the respiratory morbidity of late preterm newborns. Study design A randomized controlled trial, conducted in Obstetrics and Gynecology Department in collaboration with Neonatology department at JIPMER, India. In total, 155 women were studied in each group. Intention to treat analysis and per protocol analysis were done. Results Overall 31 (10%) newborns were admitted to intensive care unit. The composite respiratory morbidity (defined as respiratory distress syndrome and/or transient tachypnea of newborn) was observed in 64 (41.6%) infants in the study and 56 (36.2%) infants in the control group. On multivariable-adjusted analysis, use of steroids was not found to be associated with decrease in composite respiratory morbidity [adjusted relative risk 0.91 (95% confidence interval: 0.7-1.2)]. Conclusions Antenatal dexamethasone does not reduce the composite respiratory morbidity of babies born vaginally or by emergency cesarean to women with late preterm labor.

Rupture of Apparently Unscarred Uterus

There have been many occasions when a multigravida with neglected labour presented to the emergency room in shock with the clinical features of tachycardia (low volume pulse), hypotension, and severe pallor. The woman may not complain of much pain because the violent contractions have ceased. In a typical case, the abdominal examination would reveal free fluid (haemoperitoneum), superficial foetal parts, absent foetal heart sounds, and variable (usually mild) vaginal bleed. Vaginal examination in such a scenario would reveal recession of the presenting part or no foetal parts felt either through the os if it admits a finger or through the fornices.

Rupture in a Primigravida

The traditional teaching is that multigravidae rupture their uterus and primigravidae go for secondary inertia or arrest of labour or exhaustion. I would like to narrate a case I had seen 20 years back in the emergency room. A primigravida was brought to the emergency room by her husband and mother. Her husband had lifted her on his shoulders. Their journey to the hospital had taken 2 days changing from bullock carts to buses from a nearby state. When the husband seated the woman on the bench, the woman had the look of death on her face. She could barely move. The face was expressionless. It had surpassed all the possible pain. The eyes were sunken. She was severely pale. She had not eaten anything for 2 days and was in labour for more than a day before undertaking this journey. She had tachycardia. The blood pressure was 90/60 mm of Hg. Abdomen revealed tenderness all over with distension and absent foetal heart sounds. She was febrile. Vaginal examination revealed pus and slough at the vault. Cervix could not be delineated. The head was high up. I have never since encountered a case with such findings on vaginal examination. After resuscitation laparotomy was carried out. Laparotomy revealed a sloughed off lower segment. The head was visible through it. The lower edge of the lower segment was friable and oedematous. The sigmoid colon and bladder appeared unhealthy oedematous and blue. The foetus was extracted out. Hysterectomy was carried out. Prolonged continued bladder drainage failed to prevent vesicovaginal fistula. Eventually, she developed a high rectal fistula. Vaginal examination 2 weeks later revealed only sloughed out tissue everywhere in the pelvis with faeces and urine pouring from the vagina. Such agonizing could be the misery of obstructed labour. How cruel the health system could be which fails to prevent such a misery that even death would look like a gift. Fortunately, we can take pride that the whole health system has improved drastically with the upgrading of primary centres and community health centres to provide emergency obstetric services. In this case, the rupture was probably due to pressure necrosis and sloughing off of the lower segment due to prolonged pressure necrosis and infection as the patient was probably in active labour for nearly 36–48 h. Fortunate are the present-day residents who would never see such situations.

Rupture of the Uterus Weakened Due to Rare Causes

The search for newer and newer conservative approach for averting hysterectomy in a patient with atonic PPH has had its journey till B-lynch suture established itself as an accepted standard technique [3].

Ruptured Uterus in Gynaecological Situations

Perforations after surgical abortions or curettage are complications that most of the gynaecologists would have come across and managed. Fortunately, the perforations following illegal abortions with injuries to internal organs and frank peritonitis are on the decrease with the advent of medical methods of abortion.

Rupture of The Uterus Weakened by Myomectomy Scars

Fibroid uterus is a known cause of infertility as well as recurrent preterm losses. Myomectomy in selected cases improves the pregnancy rates as well as outcomes. However, there is an increased risk of rupture in subsequent pregnancy at term or in labour more so in cases where the cavity had been entered or where extensive myometrial tunnelling had been done. So these pregnancies are well-anticipated volcanoes. I can never forget this case I encountered about 18 years back. A third gravida was admitted to our hospital. She had previous two preterm deliveries; both the babies had died in the neonatal intensive care unit due to extreme prematurity. She was found to have a large fibroid for which she had undergone myomectomy before conceiving the third time. The documentation was unequivocal. A large anterior wall intramural myoma had been removed. The uterine cavity had been opened. She was under close supervision from the beginning of this pregnancy. We admitted her at 28 weeks of pregnancy. We planned an elective caesarean section for her at 34 weeks of pregnancy (end of the same week of the fateful day). There were no antenatal complications. The foetus was growing well. All investigations were normal. Anaesthetists had been consulted, and blood availability had been ensured. Elective caesarean section was scheduled in 2 days time. On a fateful night, she complained of shoulder tip pain and epigastric pain. The blood pressure was normal. There was mild tachycardia. Before one could recognize and realize, the abdominal examination revealed foetal bradycardia. She was in the operation theatre within 10 min, but alas it had become a full-blown rupture. The foetus had been extruded into the abdominal cavity, and there was large rent in the upper segment. She lost not only the baby but also her uterus. She had an otherwise uneventful recovery. I still remember clearly the bed on which she had stayed all this while. It was indeed very agonizing. It makes me wonder why God is so cruel to a few. Why a few women come very close but never get to mother a child? It leaves me wondering about the mysterious, powerful universal force that operates and limits human endeavour.

Rupture Due to Gestational Trophoblastic Disease

A woman was admitted with a diagnosis of molar pregnancy in her third pregnancy. She presented in her 4th month of pregnancy due to spotting from the vagina. At admission, she was mildly anaemic. Abdomen revealed a uterine size of 32 weeks with no foetal parts. Sonography confirmed a complete mole. She was planned for elective evacuation after all the preoperative investigations were done. A consultant uneventfully completed the suction evacuation. 2 h after the procedure, she was found to be tachypneic and pale. Her pulse was 120/min, and blood pressure was 90 mm of Hg systolic. She had tachypnea and dyspnea. Abdomen appeared distended. Initially, I thought that she has gone in for adult respiratory distress syndrome due to metastases of the mole, but the abdominal distension was not fitting into the diagnosis. I decided to do a scan, and to my surprise, I found that the uterus which was found to be 12 weeks size showed a possible invasion by the molar tissue on the anterior wall. We took her up for laparotomy as in spite of resuscitation her condition did not stabilize.

Rupture of the Uterus Scarred Due to Previous Caesarean Section

A 24-year-old primigravida married for 1 year was referred from a village in the second stage of labour with an intrauterine foetal demise to the emergency room. There was mild tachycardia. She was not anaemic. The blood pressure was normal. A midline vertical sub-umbilical scar on the abdomen was claimed to be for an ovariotomy done during adolescence. The patient was exhausted. There was secondary inertia of the uterus. Vaginal examination confirmed full dilatation with fully rotated vertex at +2 station. Forceps delivery was uneventfully performed to deliver a 2.8 kg dead baby. Massive postpartum haemorrhage followed the delivery. There was no trauma to the lower genital tract. Since the brisk bleeding very quickly started exsanguinating the patient, she was taken up for urgent laparotomy, only to realize there was transverse rupture of a previous hysterotomy scar (Fig. 2.1).