A 32-year-old woman, gravida 3 para 2, at 38 weeks gestation comes to the hospital due to contractions. The patient's prenatal course has been uncomplicated. She had a cesarean delivery for breech presentation at 39 weeks gestation in her second pregnancy. Blood pressure is 100/60 mm Hg, pulse is 100/min, and respirations are 22/min. Fetal heart rate tracing shows moderate variability, multiple accelerations, and no decelerations. Uterine contractions are regular and occur every 4 minutes. The cervix is 6 cm dilated and 60% effaced, and the fetal vertex is at 0 station. After 2 hours, the patient is suddenly restless and has intense lower abdominal pain. Fetal heart monitoring shows recurrent late decelerations. On pelvic examination, there is moderate vaginal bleeding, the cervix is 6 cm dilated and 60% effaced, and the fetal vertex is at −3 station. Which of the following is the most likely diagnosis in this patient?

Question

A 32-year-old woman, gravida 3 para 2, at 38 weeks gestation comes to the hospital due to contractions.  The patient's prenatal course has been uncomplicated.  She had a cesarean delivery for breech presentation at 39 weeks gestation in her second pregnancy.  Blood pressure is 100/60 mm Hg, pulse is 100/min, and respirations are 22/min.  Fetal heart rate tracing shows moderate variability, multiple accelerations, and no decelerations.  Uterine contractions are regular and occur every 4 minutes.  The cervix is 6 cm dilated and 60% effaced, and the fetal vertex is at 0 station.  After 2 hours, the patient is suddenly restless and has intense lower abdominal pain.  Fetal heart monitoring shows recurrent late decelerations.  On pelvic examination, there is moderate vaginal bleeding, the cervix is 6 cm dilated and 60% effaced, and the fetal vertex is at −3 station.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_da15_52c8_bc81_4d3522e8ad04_MD0003_00 This patient with restlessness and intense, sudden-onset lower abdominal pain most likely has uterine rupture, a disruption of the uterine wall typically associated with contractions. Uterine rupture usually occurs in patients with prior uterine surgery (eg, cesarean delivery, myomectomy) because weakened uterine scar tissue can separate with the force of contractions. Patients can develop massive bleeding (ie, intraabdominal, vaginal) due to the highly vascular pregnant uterus. When the uterus ruptures, the sudden decrease in intrauterine pressure and partial fetal delivery into the maternal abdomen can result in loss of fetal station (eg, 0 to −3 station). Fetal parts may also become palpable abdominally (ie, an irregular protuberance). Patients typically develop an abnormal fetal heart rate tracing, including recurrent variable and late decelerations caused by umbilical cord compression and reduced uteroplacental blood flow, respectively. To prevent further maternal and fetal compromise, management includes emergency laparotomy and cesarean delivery. (Choice A) Abruptio placentae, the premature separation of the placenta from the uterus, can present with vaginal bleeding, abdominal pain, and an abnormal fetal heart rate tracing. However, it is not associated with loss of fetal station. Abruptio placentae (Choice B) A fetal nuchal cord, a loop of umbilical cord around the fetal neck, is a common incidental finding that may cause cord compression (eg, recurrent variable decelerations) during labor. However, it does not cause abdominal pain, vaginal bleeding, or late decelerations. (Choice C) Normal labor typically presents with painful contractions and light vaginal bleeding from cervical dilation. However, in normal labor, the presenting fetal part descends (eg, 0 to +2 station) with advancing dilation. (Choice E) Vasa previa, or fetal vessels overlying the cervix, is prone to tearing and can cause vaginal bleeding with an abnormal fetal heart rate tracing due to fetal blood loss. However, there is no associated abdominal pain or loss of fetal station, making this diagnosis unlikely. Vasa previa Educational objective: Patients with prior uterine surgery (eg, cesarean delivery) are at increased risk for uterine rupture, a disruption of the uterine wall typically associated with contractions. Uterine rupture may present with intense abdominal pain, vaginal bleeding, fetal heart rate tracing abnormalities, and loss of fetal station. References: ACOG practice bulletin no. 205: vaginal birth after cesarean delivery. (http://www.ncbi.nlm.nih.gov/pubmed/30681543)

A 32-Year-Old Woman, Gravida 3 Para 2, at 38 Weeks