Case of traumatic rupture of the pregnant uterus

NZMJ, 1923

By Archer Hosking, M.B.

The case here described occurred in the practice of Dr. Johnston, of Carterton, by whose consent I am enabled to publish the details of an uncommon condition.

Mrs. X., aged 35 years, a healthy woman, and mother of six children, was injured by the overturning of a motor car. She was struck violently over the right abdomen and her clothing torn off. She was at this time six months pregnant. She suffered from shock, and complained of pain on right side of abdomen, most marked in upper segment. She was driven 15 miles in a motor car to the nursing home: on arrival her clothing was found to be wet, and there followed a slight blood-stained discharge. P.V. the parts appeared normal. She rallied quickly, and in three days was feeling well except for pain under ribs on right side.

For 15 days her general condition improved. Temperature rose daily to 100deg. F. and pulse 100. On the 16th day temperature was 101 F. Feeble labour pains set in and os was softening. Under an anæsthetic Dr. Johnston dilated the cervix. She was given pituitrin, and, though irregular pains continued, there was no result. On 18th day there was some loss of blood with heavy odour, and temperature rose to 104deg.

I saw her in consultation, after pains had persisted over 48 hours. Her temperature was then 101deg. F. Examination showed dullness in right flank extending to the ribs. Under anæsthetic membranes were found protruding from a soft and easily dilated cervix. Placenta, low and detached, was removed, a foul smelling blood discharge following. The hand entered the uterus easily: A foetal leg was brought down, but the body resisted gentle traction. Exploration revealed head and body protruding through a rent in right side of uterus. There was no serious hæmorrhage, but patient showed signs of shock. A towel was packed in the cervix, and patient returned to bed, saline being injected with adrenalin. Two hours later, assisted by Dr. Tweed, and Dr. Johnston giving the anæsthetic, I opened the abdomen in the middle line. A much-macerated foetus was found completely outside the uterus except for one leg. It lay in a space formed by adherent bowel and omentum, and more or less walled off in right flank. It was easily removed after disentangling from its surroundings. Blood clot filled the right kidney pouch. The uterine tear extended from above the external os in front of the right broad ligament. A hand was easily passed to remove the packing towel from the cervix.

The patient’s condition was now very serious and hysterectomy out of the question. Blood clot was cleaned up, and some adhesions being freed from the fundus, the uterus contracted fairly firmly. A drain was placed in flank to right kidney pouch. A long strip of gauze was introduced through the rent into the uterus, then in front of the broad ligament, and behind it into Douglas’ pouch. This was brought up to the abdominal wall, and the wound partly closed, but leaving a free opening in the lower end for the gauze packing to come through. Patient returned to bed collapsed. She was given 1/2c.c. of pituitrin three-hourly for the next 24 hours. She rallied well. There was free discharge from vagina, and through gauze packing and tube to kidney pouch. On the fourth day after operation I removed the gauze pack. It was foul smelling but dry. A lesser quantity was replaced, drainage being quite satisfactory. After operation the temperature remained at about 103deg. F. for a week, gradually coming down till it reached normal at the end of a month. The patient made steady progress and a month later was attending to some of her household duties.