A 39-year-old woman, gravida 4 para 0 aborta 3, at 35 weeks gestation comes to the hospital due to intense, constant lower abdominal pain. The patient conceived via in vitro fertilization; her prenatal course has been uncomplicated. Over the past 10 years, the patient has had 3 spontaneous abortions, all attributed to uterine leiomyoma. Two years ago, she had an abdominal myomectomy during which the uterine cavity was entered. Temperature is 36.7 C (98 F), blood pressure is 130/80 mm Hg, and pulse is 100/min. The fetal heart rate tracing shows a baseline rate in the 140s with moderate variability and persistent variable decelerations to the 90s. Contractions occur every 2-3 minutes and last for 45 seconds. The cervix is 4 cm dilated and 100% effaced. Which of the following is the best next step in management of this patient?

Question

A 39-year-old woman, gravida 4 para 0 aborta 3, at 35 weeks gestation comes to the hospital due to intense, constant lower abdominal pain.  The patient conceived via in vitro fertilization; her prenatal course has been uncomplicated.  Over the past 10 years, the patient has had 3 spontaneous abortions, all attributed to uterine leiomyoma.  Two years ago, she had an abdominal myomectomy during which the uterine cavity was entered.  Temperature is 36.7 C (98 F), blood pressure is 130/80 mm Hg, and pulse is 100/min.  The fetal heart rate tracing shows a baseline rate in the 140s with moderate variability and persistent variable decelerations to the 90s.  Contractions occur every 2-3 minutes and last for 45 seconds.  The cervix is 4 cm dilated and 100% effaced.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_da93_353f_bc81_8b7cf5fc57b8_MD0003_00 The risk of uterine rupture is greatest in laboring patients with prior uterine surgery, particularly a prior classical (vertical) cesarean delivery or a prior myomectomy that was extensive or entered the uterine cavity (eg, during removal of intramural or submucosal fibroids). Given this patient's previous myomectomy, her intense constant abdominal pain and abnormal fetal heart rate tracing (eg, persistent variable decelerations) are concerning for uterine rupture. Other possible manifestations of uterine rupture include vaginal bleeding, abdominally palpable fetal parts, loss of fetal station, and change in contraction pattern. The presentation of uterine rupture varies based on the extent and exact location of the rupture and the presence or absence of regional anesthesia. intramural or submucosal fibroids uterine rupture Vaginal delivery is safe after a low transverse (horizontal uterine incision) cesarean delivery. In contrast, patients with either a classical cesarean delivery or an extensive myomectomy are delivered via cesarean delivery at 36-37 weeks gestation. When these patients present in labor, urgent laparotomy and cesarean delivery are required. Further management is determined by intraoperative findings. If uterine rupture has occurred, delivery is typically through the rupture site and a uterine repair is performed. If the uterus is unruptured, a hysterotomy (ie, cesarean delivery) is performed. Expectant management for a vaginal delivery is generally contraindicated in patients with prior classical cesarean delivery or extensive myomectomy (Choice A). (Choice B) Amnioinfusion involves the placement of an intrauterine pressure catheter for an intrauterine infusion to decrease umbilical cord compression and resolve variable decelerations. Amnioinfusion is contraindicated in a patient with a history of uterine surgery. (Choice D) An operative vaginal delivery can be used to expedite a vaginal delivery in patients with abnormal fetal heart rate tracings. However, patients must be completely (10 cm) dilated. (Choice E) Terbutaline is a tocolytic administered to relax the uterus when contractile abnormalities such as tachysystole (>5 contractions in 10 minutes) or tetanic contractions (contractions lasting >2 minutes) are causing fetal heart rate abnormalities. This patient's contractions are normal, occur every 2-3 minutes, last 45 seconds, and cause pain and cervical dilation. Educational objective: Labor and vaginal delivery are contraindicated after a classical cesarean delivery or extensive myomectomy due to significant risk of uterine rupture. Laboring patients at high risk of uterine rupture require laparotomy and cesarean delivery. References: Optimal timing and mode of delivery after cesarean with previous classical incision or myomectomy: a review of the data. (http://www.ncbi.nlm.nih.gov/pubmed/21962624) Uterine rupture following myomectomy in third trimester. (http://www.ncbi.nlm.nih.gov/pubmed/27017729)

A 39-Year-Old Woman, Gravida 4 Para 0 Aborta 3, at 35