A Case of Spontaneous Rupture of the Uterus at six and a-half Months

BY

HARRY BANKS, F.R.C.S. (Edin.).

Radiologist, Aberdare General Hospital.

Past history. UP to the year I ~ Z O Mrs S., net. 34, had no illness of any account, and earned her own living as a shop assistant. In 1920 she began to have graatric symptoms, and in November 1921, I performed posterior gastro-enterostomv on her for an ulcer upon the lesser curvature of the stomach. Following this operation she nearly died from haemorrhage, but ultimately made a good recovery and has not had any gastric symptoms since. She married in 1922. In 1923, I removed a chronic appendix from her. In 1924, she became pregnani and miscarried at six months. During this pregnancy she complained continuously of acute abdominal pain. The day after miscarriage I understand she was curretted, and, becoming septic, was in bed for three months with a foul discharge and pyrexia. In 1924, I operated on her for a fissure in ano. From then until the present illness, she has been in good health.

I was called to see the patient at 11.30 p.m. on April zgth, 1932. She was six and a half months’ pregnant, and had been in excellent health during the pregnancy until 6.30 p.m. on the evening I was called to see her.

Prior to the attack the patient had been sitting quietly upstairs in church, when she felt a very acute pain low down on the right side of her abdomen. She had just had tea in the vestry downstairs, and had walked upstairs and sat down feeling very well. She suddenly went very white and felt somewhat faint. In 10 minutes time she walked out of the church with difficulty, took a taxi home, and went upstairs to bed on her hands and knees. The pain became worse and tended to spread up the abdomen. She vomited several times after taking brandy and whisky.

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SPONTANEOUS RUPTURE OF THE UTERUS

Condition on Examination. The patient was lying on her back with her knees drawn up.

Temperature g7OF. pulse-rate weak (115) but regular, sighing respiration, She complained of pain in the lower part of the abdo- men. The abdomen was tender, particularly in the lower right half, and was uniformly distended to a size corresponding to a seven months pregnancy, The uterus could not be made out. There was not any bleeding per vaginam, and the cervix and 0s could not be felt. The pain was a continuous ache, together with cramp which came on every few minutes.

I was uncertain of the diagnosis and had her removed im- mediately to hospital. Morphine, gr was given, and she had a fair night, but vomited twice. The next morning, her condition being the same, I thought I could detect the fundus of the uterus midway between the umbilicus and the ensiform cartilage. Still there was not any loss fier vaginawz or dilatation of the 0s. The symptoms pointed to an internal haemorrhage, and a tentative diagnosis was made of either a concealed accidental haemorrhage or a right sided ruptured ectopic gestation.

Operation. Twenty-nine hours after the patient became ill her abdomen

was opened, and on displacing the omentum a quantity of dark blood-clot was seen, together with a large tumour lying free in the abdominal cavity. On removal of the tumour it w a s found to be a foetus surrounded by its placenta and mem- branes intact. The uterus, which had retracted well, was brought up into the abdominal wound, and was found to have a large irregular gaping tear in the front extending from one mrnu to the other. The tear measured approximately six inches by four. The edges were everted and the uterine muscle anaemic, There was not any active bleeding. The uterine wall appeared healthy and of normal thickness. Some pieces of placenta were removed from the interior of the uterus and an attempt made to dilate the cervix. This I failed to do using ordinary force. The tear was stitched up, blood clots removed, and the abdomen closed. The patient was placed in the lithotomy position, and after consider- able difficulty the 0s was located and dilated to No. 8 Hegar. The patient stood the operation well. Convalescence was rather dis- turbed. Paralytic ileus developed, and the bowels did not act until the fourth day when there followed a bad attack of diarrhoea. On the seventh day the temperature rose and a right- sided pelvic cellulitis developed, and after an abscess had burst

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JOURNAL OF OBSTETRICS AND GYNAECOLOGY

pcr vaginam her condition improved. The vaginal loss was very small all through her convalescence, and she had consider- able after-pains. The abdominal wound healed primarily and she was discharged in seven weeks.

The specimen removed from the abdomen shows a complcte ovum. There are in the placenta two dark areas consisting of blood-clot, evidently due to a concealed accidental haeniorr- hage .

A portion of the placenta was examined microscopically, and the report states : The specimen consists of chorionia villi which, although without areas of degeneration or necrosis, are abnorm- ally small for those of six-month’s placenta, with little or no trophoblast. The most probable diagnosis is syphilis, but there is no histological evidence of it, nor, indeed of any lesion except the marked hypo-plasia.

I examined Mrs. S. in October 1932, when she was in good health. The periods were regular, lasting two days as before with very little pain. The uterus was slightly enlarged and adherent to the abdominal wall. There was some thickening of the left parametrium. There had not been any difficulty with urination or defaecation. The cervix was palpable, small and conical in shape with a pin-hole 0s The blood Wasserman reaction on August 18th, 1932, was negative.

CONCLUSIONS. The cause in this case I take to be an intense uterine contrac-

tion occurring after concealed accidental haemorrhage, the 0s being of a particularly rigid nature. I t is particularly to be noticed that there is not any history of ill health during the pregnancy, or of violence.

The microscopical report is suggestive, yet the uterine muscle appeared healthy, and the blood Wasserman reaction was negative,

The operation was performed 29 hours after the occurrence of the rupture, yet there was no active bleeding owing to the retraction and contraction of the uterus. I have failed to find a report of a similar case in the literature, and I believe the case to be unique.

An Egyptian doctor writing recently in the British Medical Journal on the subject of rupture of the uterus, stated that in a series of over 120 cases that had been under his care, in every case the cause was obstructed labour at term.

Lastly as to treatment. There are two courses open in such 84

SPONTANEOUS RUPTURE OF THE UTERUS

a case, either to remove the uterus, or to stitch up the tear. I consider that the latter is to be preferred as it takes less time.

The case illustrates a point which has been eniphasized before, namely that haemorrhage is not necessarily dangerous to life in rupture of the uterus unless the tear involves the uterine arteries.