In the latest Case Record of the Massachusetts General Hospital, a 27-year-old woman was admitted to a hospital in Ethiopia because of severe abdominal pain during labor, with cessation of contractions. She had been in labor at home, pushing for 24 hours. On arrival at the hospital 3 hours later, she was in shock. A procedure was performed.
The differential diagnosis of abnormal abdominal pain during labor includes pregnancy-related and pregnancy-unrelated causes. Any acute abdominal events that can occur in the nonpregnant state can also occur in pregnancy, often with different signs and symptoms, and these events should be considered during the evaluation. Acute abdominal pain that is related to contractions alerts the clinician to consider mainly those causes that are related to pregnancy.
• What is the typical presentation of chorioamnionitis?
The most common cause of a change in labor pain is chorioamnionitis. Infection of the amniotic fluid can result in endomyometritis, with uterine tenderness and pain. Chorioamnionitis is a relatively common disorder in pregnancy. Women with prolonged labor and ruptured membranes who have had frequent pelvic examinations are at risk for amniotic-fluid infection.
• How does severe placental abruption present, and what are the risk factors?
Severe placental abruption can present with sudden exacerbation of abdominal pain during labor and heavy vaginal bleeding followed by shock. In addition, sudden fetal death can accompany abruption if the abruption is complete. Placental abruption occurs when all or part of the placenta is pushed off the endometrial wall by maternal arterial blood. The sudden loss of placental perfusion and, therefore, of fetal oxygenation lead to fetal death and maternal hemorrhage. Although many maternal factors have been associated with an increased risk of placental abruption (e.g., hypertension, trauma, exposure to tobacco smoke, alcohol consumption, cocaine use, history of a previous acute abruption, history of premature delivery, a multiple gestation, multigravidity, and advanced maternal age), most appear to be idiopathic.
Morning Report Questions
Q: What are the causes of uterine rupture?
A: In the developed world, rupture of a gravid uterus is generally due to trauma and occurs most often if the uterus is scarred. Uterine scars may be due to cesarean section, myomectomy, or metroplasties. Traumatic uterine rupture may occur during the use of uterotonic drugs, instrument-assisted deliveries, and obstetrical procedures such as version of the fetus. In areas where obstetrical care is limited, spontaneous uterine rupture accounts for 75% of gravid uterine ruptures. Spontaneous rupture of a scarred uterus can occur without labor or, more commonly, as a complication of labor. Spontaneous uterine rupture can occur in unscarred uteri as a sequela of prolonged and obstructed labor. Spontaneous uterine rupture during labor is most often due to cephalopelvic disproportion but can also be caused by breech, brow, and face malpresentations and congenital malformations (e.g., fetal ascites or conjoined twins).
Q: How does a patient with uterine rupture present, and what is the appropriate management?
A: Uterine rupture typically presents with a sharp, piercing abdominal pain during labor followed by the cessation of contractions, the cessation of the urge to push, and vaginal bleeding. Shock with tachycardia, tachypnea, dehydration, fever, and confusion may follow rapidly owing to blood loss. Abdominal examination may reveal easily palpable fetal parts, areas of tenderness, no fetal heart beat, and signs of fluid collection. The management of a ruptured uterus starts with resuscitation with crystalloid fluids, the intravenous administration of blood, gastric decompression with insertion of a nasogastric tube, urinary catheterization, and treatment with broad-spectrum antibiotics. Laparotomy is the standard treatment in all cases of a ruptured uterus or in cases of extreme uterine pain, tetanic contractions, and a history of prolonged labor that are worrisome for imminent uterine rupture. Management can range from repair with or without tubal ligation to total abdominal hysterectomy.