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Zorluk: OrtaObstetric Complications

A 33-year-old gravid 3, para 2 woman at 38 weeks of gestation is evaluated in the labor unit. She was admitted in active labor 2 hours ago. Her past medical history is notable for a laparoscopic myomectomy three years ago that required extensive entry into the uterine cavity. She has been comfortable on continuous epidural analgesia until 10 minutes ago, when she reports the sudden onset of severe, tearing lower abdominal pain that radiates to her left shoulder. Her blood pressure is 82/4882/48 mm Hg, and her pulse is 132132/min. The tocodynamometer reveals a sudden cessation of previously regular uterine contractions. Fetal heart rate monitoring demonstrates an abrupt deceleration to 8080/min that has persisted for 4 minutes without recovery. On sterile vaginal examination, the fetal presenting part has receded from 00 station to −3-3 station. Which of the following is the most appropriate next step in management?

  1. Emergency laparotomy and cesarean deliveryCevap
  2. B
    Initiation of an amnioinfusion
  3. C
    Expectant management with continued labor observation
  4. D
    Administration of intravenous broad-spectrum antibiotics
  5. E
    Transfer for an urgent computed tomography scan of the abdomen

Cevap

Emergency laparotomy and cesarean delivery
The correct answer is immediate emergency laparotomy and cesarean delivery. This patient's presentation—sudden severe tearing pain, referred shoulder pain (Kehr sign from hemoperitoneum), maternal hemodynamic instability, cessation of contractions, loss of fetal station, and sudden fetal bradycardia—is highly specific for uterine rupture. Her history of a laparoscopic myomectomy with extensive entry into the uterine cavity leaves a full-thickness uterine scar, which carries a risk of rupture similar to a prior classical cesarean delivery. Once uterine rupture is clinically suspected, immediate laparotomy is mandated to deliver the fetus, control maternal hemorrhage, and repair or remove the uterus.

Adım Adım Çözüm

1
Analyze the maternal vital signs and symptom onset.
The patient has acute hypotension (82/4882/48 mm Hg), tachycardia (132132/min), and severe tearing abdominal pain radiating to the shoulder.
These findings indicate hemorrhagic shock and hemoperitoneum (causing diaphragmatic irritation and referred shoulder pain).
2
Evaluate the obstetric and fetal findings in the context of the patient's medical history.
There is a sudden cessation of uterine contractions, loss of fetal station (00 to −3-3), and profound fetal bradycardia in a patient with a prior transmural myomectomy.
A prior surgery entering the uterine cavity significantly increases the risk of uterine rupture during a subsequent trial of labor.
3
Synthesize the findings to establish a diagnosis.
The combined presentation of maternal shock, loss of fetal station, and fetal distress confirms an acute uterine rupture.
The fetus and amniotic fluid have likely extruded into the maternal abdomen, stopping labor mechanics and severely compromising fetal oxygenation.
4
Determine the definitive next best step in management.
Immediate progression to emergency laparotomy and cesarean delivery is required.
Definitive surgical intervention is life-saving for both the mother and the fetus to control hemorrhage and accomplish delivery.

Anahtar Kavram

Diagnosis and management of acute uterine rupture.
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Konular

Obstetric Complications

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