Uterine rupture is a potential complication of attempted vaginal birth after Cesarean (VBAC).
The most reliable indication that uterine rupture may have occurred is:
Correct Answer B:
Uterine rupture occurs in 0.2%-1.0% of women in labor after one previous low transverse cesarean section. Obviously, this can have devastating consequences for the mother and baby, so vigilance during labor is paramount. Uterine pain, cessation of contractions, vaginal bleeding, failure of labor to progress, or fetal regression may occur, but none of these are as consistent as fetal bradycardia in cases of uterine rupture during labor for VBAC patients.
The most common and the first manifestation of uterine rupture during labor is:
Correct Answer A:
Fetal distress with prolonged, variable, or late deceleration and bradycardia is often the first and only sign of uterine rupture. Studies showed that abnormal patterns in fetal heart rate were the first manifestations of uterine rupture in about 87% of patients. Some reports show that vaginal bleeding occurred in 11-67% of cases. Vaginal bleeding in uterine rupture is always painful.
A 28-year-old secundigravida at 40 weeks’ gestation is undergoing a trial of labor. Her prior delivery was complicated by cephalopelvic disproportion and required a low transverse cesarean section for delivery. For the last 4 hours, she has been on augmentation medication for her contractions. About 30 minutes ago she started complaining of persistent lower abdominal pain. Repetitive variable deceleration began at the same time. Your exam of the patient notes that she is 3 cm dilated, has moderate vaginal bleeding, and the presenting part is no longer palpable.
What is the most likely diagnosis?
Correct Answer D:
Given the prior cesarean section, the sudden onset of repetitive variable deceleration along with the sudden loss of fetal station is highly suspicious for uterine rupture. This occurs in about 0.5-1% of all women undergoing a trial of labor with a prior low transverse segment cesarean section. Classical uterine incisions have a much higher risk of uterine rupture, and labor is contraindicated in these women. Since uterine rupture can be catastrophic for both the mother and fetus, women who wish a trial of labor should deliver at a facility where emergency cesarean deliveries can be performed in a prompt and timely fashion.
→ Abruption is often associated with uterine pain and bleeding, but should not be accompanied by a loss of fetal station.
→ Previa is more often associated with painless vaginal bleeding. Also, the placenta would have been palpated during your pelvic exam.
→ Uterine hyperstimulation can be associated with late deceleration and uteroplacental insufficiency. No loss of fetal station should occur.
→ Cord prolapse would be palpable on pelvic exam. Loss of fetal station will increase this risk of this complication. Prolapse is not associated with bleeding and persistent pelvic pain.
A woman at 33 weeks’ gestation is brought to the emergency room following an automobile accident. Her temperature is 36.7°C (98°F), pulse 110 bpm, and BP 80/50 mmHg. She is conscious, with no obvious head injury. Her skin is cool and clammy. The lower portion of her abdomen is tense and tender. Uterine contractions are absent, bowel sounds are decreased and the fetal heart tones are absent.
The most likely diagnosis is:
In a car accident, the gravid uterus in the third trimester will have a rapid deceleration within the abdominal cavity which can increase the risk of a placental abruption, as well as uterine rupture. Most cases of abruption occur within 24 hours of the accident. In this case - the fetal heart tones are absent, her abdominal wall is tense and there is a clinical evidence of hypovolemia - one should suspect the more serious condition of uterine rupture. With her vital sign changes, evaluation and correction of DIC as well as maternal blood volume replacement are indicated. The blood loss will continue until the uterus is repaired, therefore, Cesarean delivery of the fetus is indicated.
→ Ruptured spleen (choice A) can definitely be associated with significant hemorrhage and shock. But, the lower abdominal tenderness is more likely to be from a pelvic origin.
→ Perforated viscus (choice C) is uncommon without penetrating trauma.
→ Abruption placentae (choice D) is a common occurrence in abdominal trauma of this nature. Due to the absent heart tones, tense abdomen, and signs of significant hypovolemia, uterine rupture is more likely.
→ Ruptured bladder (choice E) is not associated with absent fetal heart tones.
Which one of the following has proven most useful in preventing vertical transmission of HIV infection from mother to neonate?
Antiretroviral treatment has been proven to reduce vertical transmission of HIV from mother to child. Benefits have been shown for antenatal, intrapartum, and postpartum treatments. Zidovudine and nevirapine have the most well established track record.
Maternal vitamin A therapy has not proven to reduce HIV transmission. It was hoped that it would help maintain mucosal integrity. Chlorhexidine vaginal rinses in early labor have also not proven to reduce HIV transmission to the neonate. Cesarean section decreases the frequency of neonatal transmission of HIV, but with current viral suppression therapy the risk-to-benefit ratio of Cesarean delivery is questionable. The immunologic benefits of breastfeeding do not balance the increased risk of HIV transmission to neonates who are breastfed by HIV-infected mothers.
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