Monday, January 26, 2009

VBAC

This week is ob/gyn week!

A 30 year old G3P2 who had two prior low vertical C-sections is at 39 weeks, 3 days by LMP and attempting a vaginal birth after cesarian. She was in latent labor for over 48 hours and elected for pitocin induction. She dilated to 10cm, was completely effaced, and began pushing. About 30 minutes into pushing, the fetal heart tracing showed variable and late decelerations along with fetal bradycardia. Despite epidural anesthesia, the patient complains of severe abdominal pain. She becomes tachycardic and hypotensive. The tocometer stops picking up uterine contractions. An immediate cervical exam is unable to identify the fetal station. The diagnosis is made at laparotomy which shows this:

Challenge: What do you see?

Image shown under fair use.

4 comments:

Alex said...

partial mole?

CodeDog said...

Uterine Rupture
Vaginal Birth After Cesarean (VBAC) has a higher risk of uterine rupture.

deardoc said...

This is uterine rupture, most likely at the site of previous cesarian scar. The history of two previous C-sections ,fetal distress during labour, severe abdominal pain despite anesthesia, hypotension and sudden loss of uterine contractions all point to that.

I don't know if this answers the question, or something else was expected. For one thing,I wasn't able to make out any fetal parts in the photograph. Hydatidiform mole..? very very unlikely. So I'll go with uterine rupture.

Craig Chen said...

Uterine rupture is right! This was the only photo I could find. I can't really make out what's going on though.
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VBAC

This is uterine rupture. Attempting a vaginal birth after cesarian (or other uterine surgery) is a strong risk factor for uterine rupture and maternal and fetal morbidity and mortality. Incision location is important; low transverse incisions have the lowest likelihood (0.2-1.5%) while classical and T-shaped have the highest likelihood (4-9%). Uterine rupture is complete spontaneous disruption of the serosa, myometrium, and decidua accompanied by bleeding and possibly extrusion of the fetal-placental unit.

Sources: UpToDate; library.med.utah.edu.