Rupture of The Uterus Weakened by Myomectomy Scars

Abstract

Fibroid uterus is a known cause of infertility as well as recurrent preterm losses. Myomectomy in selected cases improves the pregnancy rates as well as outcomes. However, there is an increased risk of rupture in subsequent pregnancy at term or in labour more so in cases where the cavity had been entered or where extensive myometrial tunnelling had been done. So these pregnancies are well-anticipated volcanoes. I can never forget this case I encountered about 18 years back. A third gravida was admitted to our hospital. She had previous two preterm deliveries; both the babies had died in the neonatal intensive care unit due to extreme prematurity. She was found to have a large fibroid for which she had undergone myomectomy before conceiving the third time. The documentation was unequivocal. A large anterior wall intramural myoma had been removed. The uterine cavity had been opened. She was under close supervision from the beginning of this pregnancy. We admitted her at 28 weeks of pregnancy. We planned an elective caesarean section for her at 34 weeks of pregnancy (end of the same week of the fateful day). There were no antenatal complications. The foetus was growing well. All investigations were normal. Anaesthetists had been consulted, and blood availability had been ensured. Elective caesarean section was scheduled in 2 days time. On a fateful night, she complained of shoulder tip pain and epigastric pain. The blood pressure was normal. There was mild tachycardia. Before one could recognize and realize, the abdominal examination revealed foetal bradycardia. She was in the operation theatre within 10 min, but alas it had become a full-blown rupture. The foetus had been extruded into the abdominal cavity, and there was large rent in the upper segment. She lost not only the baby but also her uterus. She had an otherwise uneventful recovery. I still remember clearly the bed on which she had stayed all this while. It was indeed very agonizing. It makes me wonder why God is so cruel to a few. Why a few women come very close but never get to mother a child? It leaves me wondering about the mysterious, powerful universal force that operates and limits human endeavour.