Case 9-1998

Abstract

A 38-year-old woman (gravida 5, para 1) was admitted to another hospital in spontaneous labor.The patient's first pregnancy, six years earlier, had ended successfully at 36 weeks' gestation. A low transverse cesarean section was performed because of a breech presentation, and a uterine leiomyoma was resected. Subsequently, the patient had three spontaneous abortions in the first trimester. The most recent abortion occurred a year before admission, at six weeks' gestation. An ultrasonographic examination showed a nonviable fetus and a leiomyoma, 5 cm in diameter, adjacent to the gestational sac. A suction dilation and curettage was performed without complications.With the current pregnancy, the patient was admitted to the other hospital at 41 weeks' gestation, after an uncomplicated, carefully supervised pregnancy, during which she did not smoke or ingest alcohol or medications. An antenatal ultrasonographic examination revealed a left lateral placenta, a vertex presentation, and a leiomyoma. Continuous lumbar epidural anesthesia was begun when the cervix was dilated to 4 cm. At the next examination, cervical dilatation was 7 cm. An attempted amniotomy yielded no fluid. The fetal heart tones were satisfactory. Deceleration of the fetal heart rate to the mid-70s occurred three times, with each deceleration lasting two or three minutes and responding to conservative measures. Labor progressed to complete cervical dilatation, and after a 30-minute second stage, a female infant was delivered with an episiotomy. The Apgar scores were 8 at one minute and 9 at five minutes. DeLee suction was performed during delivery of the head and after delivery of the shoulders. Epi-dural anesthesia was discontinued. Immediately after delivery there was brisk bleeding, with blood loss of 500 ml. The placenta did not emerge spontaneously or after gentle traction. There was an additional blood loss of 500 ml. The blood pressure fell to 60/20 mm Hg, and the heart rate rose to 115, with tachypnea and dusky skin coloration. Boluses of fluids and ephedrine were given intravenously, without an immediate response. There was another gush of blood (200 ml). Manual exploration of the uterus disclosed a rent in the anterior wall that was consistent with a rupture; no cleavage plane was detectable along the right lateral aspect of the placenta. The free portion of the placenta was removed.Hypotension persisted. Another intravenous catheter was inserted. Hetastarch, a plasma-volume expander, was administered. Vital signs became undetectable. The trachea was intubated, cardiopulmonary resuscitation was begun, and full pressure was placed on the abdominal aorta. Sinus tachycardia at a rate of 160 occurred after 10 minutes, with a blood pressure of 100/60 mm Hg. Within a minute the rhythm deteriorated into sinus bradycardia, followed by asystole. An incision revealed minimal intraabdominal blood despite a rent in the right lower uterine wall. A hysterectomy was performed rapidly during the transfusion of packed red cells and fresh-frozen plasma. A spe...

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