Uterine rupture presenting as a vaginal prolapse of gangrenous small bowel

Abstract

The rupture of a gravid uterus is an obstetric disaster associated with high maternal morbidity and mortality [1,2]. To our knowledge, uterine rupture presenting as the vaginal prolapse of a gangrenous bowel has not been previously described. An unbooked 34-year-old woman (gravida 6, para 5 with a living set of twins) presented to Abia State University Teaching Hospital, Aba, Nigeria, with a 2-day history of colicky abdominal pain, vomiting, constipation, and fever. Her condition started after she was delivered at term in a maternity home. The midwives applied fundal pressure to accelerate the second stage of labor, which was reportedly prolonged. The patient eventually delivered a male neonate that died a few hours later. The placenta was said to have been completely delivered, but the patient had a massive postpartum hemorrhage and soon after developed severe colicky abdominal pain. On presentation she was anxious, dehydrated, markedly pale, and distressed with pain. On examination she had generalized tenderness and guarding, exaggerated bowel sounds, and a segment of gangrenous small bowel protruding into the vagina. A clinical diagnosis of ruptured uterus with a vaginal prolapse of gangrenous small bowel was made. As her hematocrit was 22%, resuscitation with intravenous fluids and antibiotics was initiated as preparation was made for emergency exploratory laparotomy. Four units of blood were cross-matched for her. Laparotomy revealed that a 35 cm segment of the ileum was herniated into a 3 cm vertical rupture in the right posterolateral wall of the uterus. The dead ileum segment was resected and end-to-end anastomosis was done, followed by the repair of the uterine rupture and bilateral tubal ligation. The patient had an uneventful recovery. To the best of our knowledge, this is the first report of a ruptured uterus presenting as the vaginal prolapse of a gangrenous small bowel. In this case, the cause of rupture was trauma from the obstetric practice of applying fundal pressure in a prolonged second stage of labor. This case illustrates an unfortunate feature of obstetric care in Nigeria, where many referring centers contribute to the morbidity and mortality of unbooked patients through inadequate care, injudicious interventions, and delay in referral [3,4]. This underscores the need for the better training, support, supervision, and continuous professional development of maternity care providers in Nigeria and other developing countries [2,3].