Chapter 5: Obstetrics and Gynecology

Case 5-1: Rupture of 26-week-old uterine cornu ectopic pregnancy

Patient Presentation

A 27-year-old female who was 26 weeks pregnant presented to an outside institution with sudden onset of shortness of breath followed by syncope. She was tachycardic and diaphoretic. A computed tomography (CT) pulmonary angiogram was performed that was negative for pulmonary embolus but did show a hemoperitoneum on the inferior CT images. The patient was transferred to our facility with 2 units of packed red blood cells transfusing.

Clinical Features

The patient was pale but awake and in mild painful distress. She remained hypotensive and tachycardic. Her abdomen was gravid with the uterus palpable above the umbilicus.

Differential Dx

• Heterotopic pregnancy

• Placenta abruption

• Uterine rupture

• Ectopic pregnancy

• Trauma with liver and/or spleen hemorrhage

• Aortic or other large vessel catastrophe

Emergency Care

Bedside abdominal ultrasound demonstrated a very large hemoperitoneum and a fetal heart rate of 140 bpm. The massive transfusion protocol was instituted. The patient was given a dose of dexamethasone for fetal lung maturity and 4 g of magnesium for neuroprotection. The patient, despite her hypotension and tachycardia, appeared clinically stable. Given her clinical appearance, known hemoperitoneum, and the lack of a diagnosis, the patient had a contrast-enhanced abdominal CT scan that demonstrated a large hemoperitoneum with active hemorrhage and what was initially interpreted as an intrauterine pregnancy with possible placental abruption. The patient was taken to the operating room.

Outcome

Upon entering the peritoneal cavity, there was a large hemoperitoneum with the fetus found floating freely within the abdominal cavity and a ruptured uterus. The placenta was attached to the uterine cornu. Apgar scores were 4, 7, and 8 at 1, 5, and 10 minutes, respectively. The infant subsequently had multiple clinical issues related to prematurity.

The images for this case demonstrate, in retrospect, a ruptured uterus with significant extravasation of contrast indicative of active hemorrhage, with the fetal head outside of the uterine cavity.

Key Learning Points

• Uterine cornu ectopic pregnancies compose 1% to 3 % of all ectopic pregnancies. They can be difficult to distinguish from an intrauterine pregnancy with pelvic ultrasound and frequently present with uterine rupture and significant life-threatening hemorrhage.

Further Reading