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.