A 17 y.o. woman in a high speed MVC presents with abdominal pain

What is wrong?

Our patient sustained a uterine rupture after a motor vehicle collision.

While uterine rupture is a rare cause of mortality in the US, it is frequent in Africa, presumably because of the limited access to C sections (it accounts for 36% of maternal deaths in the last 10 years in Ethiopia).  Uterine rupture occurs in 0.6-1.6% of patients with blunt abdominal trauma. Fetal mortality approaches 100% in these cases, with maternal mortality at 10%. It is estimated that only 10-37 minutes of viability remain for the fetus after uterine rupture if the fetus is expelled from the uterus. If the fetus remains in the uterus even though it is ruptured, a viable infant may be delivered.

US with arrow pointing to the placenta, which is outside the uterus.

Trauma affects 6-7 % of preganancies in the US. While uterine rupture causing fetal demise is not common, abruption of the placenta is seen more frequently.  Ultrasound detects only 40-50% of post-traumatic abruptions, so clinical suspicion must remain high and tocometer monitoring should be performed in cases of trauma.

There is no universal treatment for uterine rupture, but total hysterectomy, subtotal hysterectomy, or repair of the uterus are options.

In the case of this patient, the infant had no heartbeat on arrival, and the mother was resuscitated and taken to the OR for uterine repair.  During the ex-lap, a small liver laceration was repaired along with the uterus, and the patient recovered.   Thanks to Dr. Creel for this case.

References 

Woldeyes W, Amenu D, Segni H. Uterine rupture in pregnancy following fall from a motorcycle: a horrid accident in pregnancy—a case report and review of the literature. 2015. Case Reports in Obstetrics and Gynecology vol 2015, article ID 715180.  http://dx.doi.org/10.1155/2015/715180.

Smith JF, Wax JR. Rupture of the unscarred uterus, Up to Dat 21.2, March 2012. http://uptordate.com/contents/rupture-of-the -unscarred-uterus.

Njoku O, Joannes U, Christian M, Azubike O. Trauma during pregnancy in a Nigerian setting: patterns of presentation and pregnancy outcome. International Journal of Critical Illness and Injury Science,2013  vol 3., no 4, pp269-273.