Atraumatic spontaneous rupture of the non-gravid uterus.

Sir,

Uterine rupture in a non-gravid patient occurs iatrogenically most often from pelvic trauma or spontaneously as a result of uterine leiomyomas, infections, or uterine carcinoma.[12] We report a non-pregnant female with spontaneous uterine rupture unrelated to trauma and unassociated with a pathological etiology.

A 30-year-old female with a history of bronchiectasis was admitted with pneumonia. The G1P0 patient had a dilation and evacuation during a pregnancy two years prior. Despite six months of amenorrhea, serum human chorionic gonadotropin levels confirmed the patient was not pregnant. During her hospital course, the patient began to complain of abdominal pain and developed vaginal bleeding. She subsequently became apneic and hypotensive and went into cardiac arrest. Cardiopulmonary resuscitation was performed and she was intubated. She responded to aggressive fluid and blood product administration. On physical examination, her abdomen was severely distended; her hemoglobin was 3.7 g/dl. A bedside abdominal ultrasonogram demonstrated free fluid in the abdomen and pelvis and the patient was taken emergently to the operating room for exploratory laparotomy [Figure 1].

Figure 1

A 30-year-old, non-pregnant female with acute onset of abdominal pain and hypotension. Bedside ultrasonography shows a large amount of echogenic free fluid throughout the abdomen (arrow)

Intraoperatively, several liters of blood and clot were removed from the abdomen; all quadrants were packed for hemostasis. A hemorrhaging uterus was found with a tear extending from the fundus posteriorly to the uterine neck. The uterus was repaired primarily with a running locking chromic suture and appeared hemostatic. A biopsy was taken of the uterus. Because the patient had become coagulopathic, acidotic, and hypothermic, the abdomen was packed and left open. The patient remained intubated on vasopressive support and transferred to the intensive care unit. Two days post-operatively, the patient no longer required vasopressors; abdomen closure was performed. The patient remained on ventilator support and dialysis for acute renal failure for several weeks. One month postoperatively, the patient was discharged to home from with full recovery of her renal function. Histopathology showed no evidence of an abnormal pathological process.

Uterine rupture most often occurs during pregnancy or as the result of trauma; the incidence is 0.07%.[1] Congenital uterine anomalies, multiparity, previous uterine myomectomy, cesarean deliveries, fetal macrosomia, labor induction, and uterine trauma increase the risk of uterine rupture.[12] The classic symptoms of uterine rupture include severe abdominal pain, shock, and vaginal bleeding. Abdominal pain is present in 13-60% of cases and vaginal bleeding occurred in 11-67%.[1-3] Maternal shock from hypovolemia was associated in 29-46% of patients.[1-3]

Our patient was not pregnant and had no trauma preceding the uterine rupture. Only two previous reports of spontaneous uterine rupture in a non-gravid uterus have been published in the English literature.[45] In one paper, the patient had multiple abdominal operations and deep cauterization of her cervix.[4] The patient in the other report had a fulminant pelvic infection preceding the rupture.[5]

Although rare, atraumatic spontaneous rupture of the non-gravid uterus should be included in the differential diagnosis of an acute abdomen and shock in a non-pregnant female of child-bearing age. Regardless of etiology, spontaneous uterine rupture is a life-threatening emergency that requires immediate resuscitation, identification, and surgical intervention with either primary repair or hysterectomy.