Case presentation
The patient’s first pregnancy occurred at the age of 33 years; cesarean section was performed at a previous hospital by a transverse uterine fundal incision with a double layer closure of the uterine muscle due to placenta previa, in which the placenta covered the anterior uterine wall. Sagittal T1-weighted magnetic resonance imaging (MRI) with contrast revealed a cesarean section scar defect at the uterine fundus at 12 months postpartum (Figure 1). The patient was not recommended to become pregnant in the future considering the risk of uterine rupture. The couple wished for a second baby, and the patient conceived by in vitro fertilization at 38 years old and embryo transfer was performed at another clinic.
The patient received prenatal care (PNC) at our hospital at 9 weeks of gestation. At the first visit, transvaginal ultrasonography revealed that a part of the muscle layer in the uterine fundus was very thin or interrupted (Figure 2). Thus, the patient was informed of the risk of maternal and fetal morbidity due to uterine rupture. However, the couple strongly wished to continue the pregnancy.
The patient received PNC every 2 weeks, and an ultrasound study was performed for early detection of possible fetal membranes bulging outside the uterus. The patient was also diagnosed with total placenta previa, which was located in the posterior uterine wall, at 28 weeks of gestation. At 30 weeks of gestation, the patient was recommended to undergo an MRI study to evaluate the thickness of the uterine muscle layer and to be hospitalized until delivery, considering the maternal and fetal risks due to uterine rupture. However, she refused. At 33 weeks of gestation, the patient called an ambulance at home because of sudden severe abdominal pain. During transport, the patient developed cardiac arrest 10 minutes before arriving at our hospital, and CPR was initiated by paramedics.
Upon arrival, the patient was unconscious, with a Glasgow Coma Scale (GCS) score of E1V1M1, and exhibited asystole. Our emergency department (ED) doctor performed intubation immediately, and a central venous catheter was inserted. CPR was continued with the administration of epinephrine. The gravid uterus was displaced to the left side to relieve aortocaval compression to make resuscitation more effective. Arterial blood gas analysis showed the following results: a pH of 6.8, a pO2 level 16.6 mmHg, a pCO2 level of 90.0 mmHg, a hemoglobin level of 6.6 g/dl, a lactate level of 12.7 mmol/L, and a potassium level of 5.3 mEq/L. A point-of-care obstetrical ultrasound showed massive accumulation of free fluid in the abdominal cavity and fetal death. We suspected uterine rupture. The patient recovered from arrest by 6 cycles of CPR 19 minutes after arriving at our ED. The total duration time of CPR was 29 min. The decision was made to perform PMCD in the operating room.
She had exhibited asystole twice on the way to the operating room. PMCD was initiated 6 minutes after the decision. At laparotomy, there was a massive intraabdominal hemorrhage. PMCD was performed via a low transverse incision and a deceased male fetus weighing 1,984 g was delivered. An 8 cm-sized uterine rupture was detected exactly at the previous transverse uterine fundal incision site, and the amniotic membrane was intact. We repaired the ruptured site. The patient had also developed DIC due to the peripartum hemorrhage caused by uterine rupture and received blood transfusion with 14 units of packed red blood cells, 40 units of packed platelets, 10 units of packed fresh frozen plasma, 12 units of packed cryoprecipitate and 3 g of fibrinogen concentrate between arrival of the hospital and the end of the operation.
After PMCD, massive vaginal bleeding from the uterus was observed. Computerized tomographic angiography showed engorged bilateral uterine arteries supplying the whole uterus (Figure 3A). Interventional radiology (IVR) was required to control bleeding from the uterus. Embolization of the bilateral uterine arteries was performed by a radiologist, and her bleeding was controlled (Figure 3B). The patient was transferred to an intensive care unit (ICU) after IVR. Her vital signs gradually stabilized. Impairment of consciousness persisted (GCS: E4, Vt, M2). On the 119th postoperative day, the patient was discharged from our hospital and transferred to a rehabilitation facility.