Uterine rupture with fetal death following blunt trauma

A Rare Secondary Dysmenorrhea Resulted from Separation of Corpus Uteri from Cervix: A Case Report and Literature Review

Secondary dysmenorrhea is a pain associated with disease such as endometriosis, pelvic inflammatory disease, leiomyomas, and interstitial cystitis. Treatment of secondary dysmenorrhea always focuses on the causative pelvic pathology or medical condition. Here, we found a rare case with secondary dysmenorrhea that resulted from traumatic separation of the uterine corpus from the cervix. In this case, the patient experienced a childhood blunt trauma of the pelvic crush and was successfully diagnosed by magnetic resonance imaging and 3-dimensional ultrasonography. Moreover, laparoscopic anastomosis could be a minimally invasive way to resolve this problem.

Imaging evaluation of uterine perforation and rupture

Uterine perforation and rupture, denoting iatrogenic and non-iatrogenic uterine wall injury, respectively, are associated with substantial morbidity,and at times mortality. Diverse conditions can result in injury to both the gravid and the non-gravid uterus, and imaging plays a central role in diagnosis of such suspected cases. Ultrasound (US) is the initial imaging modality of choice, depicting the secondary signs associated with uterine wall injury and occasionally revealing the site of perforation. Computed tomography can be selectively used to complement US findings, to provide a more comprehensive picture, and to investigate complications beyond the reach of US, such as bowel injury. In certain scenarios, magnetic resonance imaging can be an important problem-solving tool as well. Finally, catheter angiography is a valuable tool with both diagnostic and therapeutic capability, with potential for fertility preservation. In this manuscript, we will highlight the clinical and imaging approach to uterine perforation and rupture, while emphasizing the value of various imaging modalities in this context. In addition, we will review the multi-modality imaging features of uterine perforation and rupture and will address the role of the radiologist as a crucial member of the management team. Finally, a summary diagrammatic depiction of imaging approach to patients presenting with uterine perforation or rupture is provided.

Risk of hysterectomy and salpingectomy or oophorectomy compared to repair after pelvic gynecologic trauma

PURPOSE

Pelvic gynecologic trauma (PGT) includes injury to the uterus, ovaries or fallopian tubes. We hypothesized Injury Severity Score (ISS) ≥ 25, hypotension on admission and age ≥ 51 (average age for menopause) would be independent risk factors for resection compared to repair.

METHODS

A retrospective analysis of the National Trauma Data Bank was performed between 2007 and 2015.

RESULTS

Of 2,040,235 female patients, 1938 (< 0.1%) presented with PGT with the majority sustaining injury to the ovary or fallopian tubes (52.9%). Most patients were managed nonoperatively (77.1 vs 22.9%). On multivariable analysis, in patients with injury to the uterus, ISS ≥ 25 (OR 3.52, CI 1.67-7.48, p < 0.05) was associated with higher risk for hysterectomy compared to repair. In patients with injury to the ovaries or fallopian tubes, gunshot wound (OR 3.73, CI 1.43-9.68, p < 0.05) was associated with a higher risk for salpingectomy or oophorectomy compared to repair. Age ≥ 51 and hypotension on admission were not independent risk factors for resection in patients with PGT. Operative treatment was associated with a lower risk for mortality in patients with an injury to the uterus (OR 0.27, CI 0.14-0.51, p < 0.001) or ovaries/fallopian tubes (OR 0.37, CI 0.19-0.72, p < 0.001) compared to those managed nonoperatively.

CONCLUSION

In the largest study reported, PGT occurred in < 0.1% of traumas involving women. Patients with ISS ≥ 25 have higher risk for hysterectomy compared to repair. Gunshot injuries have higher risk for salpingectomy or oophorectomy compared to repair. Hypotension on arrival or age ≥ 51 are not independent risk factors for resection in PGT. Operative management is associated with lower risk of mortality in PGT patients.

Blunt abdominal trauma with uterine rupture and fetal demise

Traumatic uterine rupture is rare, occurring in 0.6% of blunt trauma cases, and usually results from very violent accidents in which patients usually also sustain other major injuries. Following severe blunt abdominal trauma, fetal loss can result from maternal hypotension or hypoxemia, placental abruption, maternal death, and uterine rupture. Although less common, fetal loss can also occur in minor injuries. We report a patient who sustained an isolated anterior uterine rupture with fetal demise without any associated abdominal or pelvic injuries. This case report highlights the importance of proper seat belt usage and placement because both can reduce maternal and fetal morbidity and mortality in motor vehicle accidents.

Successful Management of a Periviable Pregnancy with Morbidly Adherent Placenta after Uterine Rupture

BACKGROUND

Although rare, trauma in pregnancy can cause uterine rupture. In a periviable pregnancy, uterine rupture can lead to premature delivery and significant morbidity.

CASE

A 29-year-old woman with four prior CSs presented with uterine rupture and a protruding morbidly adherent placenta at 23+4 weeks of gestation. Since the pregnancy was highly desired, the defect was repaired and the decision made to continue with the pregnancy. The patient presented at 29+3 weeks of gestation with preterm labour and subsequently delivered a healthy male infant of 1130 grams.

CONCLUSION

Expectant management followed by CS can be beneficial in certain cases of uterine rupture with morbidly adherent placenta following trauma. This is especially the case in a periviable pregnancy, since prolonging the pregnancy will improve neonatal outcomes. We recommend individualized management based on clinical presentation, imaging findings, and the patient's wishes.

Complete fetal transection after a motor vehicle collision

BACKGROUND

Motor vehicle collisions are the leading cause of fetal death related to maternal trauma, with rupture of the gravid uterus being one potential grave outcome.

CASE

We present a case of a woman at 22 weeks of gestation who presented to the emergency department after a "high-speed" motor vehicle collision. On initial presentation, she was hemodynamically stable, and the examination was significant for midabdominal transverse ecchymosis from seatbelt trauma. A computed tomography scan identified a probable uterine rupture. Laparotomy revealed a 1,500-mL hemoperitoneum and a completely ruptured uterus requiring hysterectomy. The fetus was completely transected at the level of the midabdomen.

CONCLUSION

Uterine rupture is possible for gravid women involved in motor vehicle collisions.

Pelvic ultrasonography

Pelvic ultrasonography is a valuable tool for the emergency physician in the evaluation of the wide spectrum of pelvic complaints presenting to the emergency department. The goal of this article is to outline pelvic problems that can be readily identified by the emergency physician using pelvic sonography early in the patient's evaluation. A special emphasis is placed on the sonographic diagnosis of ectopic pregnancy.