Taiwanese Journal of Obstetrics & Gynecology 55 (2016) 721e723

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Taiwanese Journal of Obstetrics & Gynecology

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Case Report

Severe abdominal pain exacerbated by fetal movement is an early sign

of the onset of uterine rupture
Ayaka Kawabe*, Liangcheng Wang, Atsuko Kikugawa, Yuko Shibata, Kenichi Kuromaki,
Akiyoshi Takagi
Department of Obstetrics and Gynecology, Warabi City Hospital, 2-12-18, Kitamachi, Warabi-shi, Saitama 335-0001, Japan

a r t i c l e i n f o a b s t r a c t

Article history: Objective: Uterine rupture is a rare but serious obstetric complication. However, prediction and diagnosis
Accepted 11 December 2015 at an early stage remain difcult. Herein, we report a case of primary uterine rupture found earlier by a
specic symptom.
Keywords: Case Report: A 29-year-old patient was scheduled to undergo a cesarean section (CS) due to placenta
cesarean section previa. However, at Week 35, she began experiencing abdominal pain and uterine contractions. Subse-
pregnancy
quently, she began experiencing severe pain, which was enhanced by fetal movements. An emergency CS
severe abdominal pain
was performed due to continuous uncontrollable pain. When the abdominal cavity was opened, we
uterine rupture
found that much of the amniotic cavity had prolapsed outside the uterus. Despite performing total
hysterectomy, both the mother and child had positive clinical courses. Uterine rupture was discovered
early because of emergency CS.
Conclusion: This case suggests that abnormal pain exacerbated by fetal movement can be a characteristic
early sign of uterine rupture.
Copyright 2016, Taiwan Association of Obstetrics & Gynecology. Published by Elsevier Taiwan LLC. This
is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/
4.0/).

Introduction Case Presentation

Uterine rupture during labor is a serious obstetric complication,
although the prevalence is as rare as one in 1235e4366 patients [1].
It can impact the prognosis of the fetus and result in a higher risk of
major hemorrhage and total hysterectomy. Although progressing
uterine ruptures exhibit a wide variety of symptoms, including
severe abdominal pain with tenderness, vaginal bleeding, and
hypovolemic shock, diagnosing a uterine rupture during the early
stages of onset remains difcult. Fetal heart rate monitoring is a
useful way to detect fetal distress. However, a study found no
specic abnormal fetal heart rate pattern available to detect early
stages of uterine rupture, except bradycardia, which indicates
serious fetal distress [2]. Herein, we present a case of complete
uterine rupture of an unscarred uterus in which both the mother
and child had positive clinical courses. We report the specic
symptoms of abdominal pain that we observed.
* Corresponding author. Department of Obstetrics and Gynecology, Warabi City
Hospital, 2-12-18, Kitamachi, Warabi-shi, Saitama 335-0001, Japan.
E-mail address: ayatama0628@gmail.com (A. Kawabe).
A 29-year-old woman (gravida 2, para 2) with no history of
uterine surgery was referred to our outpatient ward at gestational
Week 19 because of suspected placenta previa. Around Week 14 of
pregnancy, she was admitted to another hospital for abdominal
pain of unknown origin, and the symptom was relieved by the
administration of antibiotics. On medical examination at gestation
Week 33, a cesarean section (CS) was planned at Week 36 because
placenta previa presented in the posterior wall of the uterine. No
signs of threatened premature labor, such as uterine contractions,
were observed. Autologous blood preparing was planned at 33e35
weeks because of a high risk of postpartum hemorrhage. However,
on Day 2 of Week 35, she complained of abdominal pain and
uterine contractions. A diagnosis of threatened premature labor
was made, and she was admitted to our hospital.
On the 1st day, her abdomen was soft with no tenderness. Fetal
heart monitoring showed a reassuring pattern with a baseline of
160e165 beats/min, and uterine contractions were observed every
3e6 minutes. No obvious anomaly was found by transabdominal
ultrasound examination. The estimated fetal weight was 2499 g. No
genital bleeding was observed, although transvaginal ultrasound

http://dx.doi.org/10.1016/j.tjog.2015.12.021
1028-4559/Copyright 2016, Taiwan Association of Obstetrics & Gynecology. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).

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722 A. Kawabe et al. / Taiwanese Journal of Obstetrics & Gynecology 55 (2016) 721e723
showed total placenta previa. No abnormalities were found in the
blood test. The continuous intravenous administration of ritodrine
hydrochloride (100 mg/min) was started immediately after admis-
sion, and subsequently, the uterine contractions disappeared.
However, 1 day later, the patient complained that fetal movements
exacerbated her abdominal pain. The pain changed depending on
her posture and was eased in an anteexed position. On Day 2 in
the hospital, it became difcult for her to eat. On Day 3 (Week 35,
Day 4), the abdominal pain could not be controlled even after
increasing ritodrine hydrochloride to its maximum dose (200 mg/
min) so an emergency CS was performed for acute abdomen with
placenta previa. Preoperatively, the fetal heart rate monitor showed
a reassuring fetal status. On ultrasound examination, the amniotic
uid space had disappeared; instead, a small amount of ascitic uid
was seen, and the cervical canal length and placenta position were
indistinct. When the abdomen was opened under lumbar sub-
arachnoid anesthesia, ~575 mL of pink ascitic uid, which was
thought to be amniotic uid, was observed in the abdominal cavity.
The body of the uterus was contracting downward, and the myo-
metrium around the base of the angle of the right fallopian tube
was found ruptured where the amniotic cavity had been exposed
and only partial placenta could be seen. Approaching the fetus was
difcult because the anterior surface was entirely covered by the
placenta. Therefore, an incision was made from the uterine fundus
to the posterior wall. Although a healthy male newborn weighing
2540 g was delivered from the right upper abdomen, the wound of
the uterus was too extensive to repair, and the hemorrhage
immediately reached ~2000 mL. Therefore, emergency total hys-
terectomy was performed under general anesthesia. The appendix,
which strongly adhered to the uterus a few centimeters anterior to
the angle of the right fallopian tube, was also resected (Figure 1).
Intraoperative bleeding was 5926 mL after excluding the amniotic
uid. The patient received 900 mL of autologous blood, six units of
packed red blood cells, and six units of fresh frozen plasma during
the postpartum period. After conrming that her anemia had
improved, the patient was discharged on Day 7.
Figure 1. The excised uterus. It indicates the incision and the site of uterine rupture,
and the appendix strongly adhered to the uterus a few centimeters anterior to the
angle of the right fallopian tube.
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Although the pathological diagnosis showed that the starting
point of the uterine rupture was about 3 mm near the angle of the
right fallopian tube and the muscle layer on the right side of the
uterine fundus was extremely thin where placenta accreta tissue
was also observed, the association of uterine rupture and placenta
accreta was unclear. No inammatory ndings were observed in
the adhered appendix.
Discussion
To diagnose uterine rupture during the early stages of onset is
difcult. In the present case, a pregnant patient experienced
abnormal pain, which was exacerbated by fetal movements and
varied depending on her posture. Uterine rupture was found when
an emergency CS was performed for acute abdomen with placenta
previa. Therefore, we believe that abnormal pain stimulated and
exacerbated by fetal movements can be a characteristic early sign of
uterine rupture.
The most common risk factor of uterine rupture is a history of CS
[3,4]. The risk increases in those with single-layer closure scar and
large babies weighing 3500e4000 g, and during a nonpregnant
interval < 18 months after CS [4e6]. Other reported risk factors
include epidural anesthesia, the induction of labor, pre- or postterm
pregnancy, overweight, advanced age, dystocia, malpresentation,
preterm delivery, and high parity [7]. Although rare, it can also
occur during postpartum [8,9] or in patients with uterine leio-
myomas [10,11]. Overall, the recurrence rate is reported as 15.2%
[8]. A previous study reported that placenta accreta may cause
uterine rupture [12], which is consistent with the present case,
although the relationship between placenta accreta and uterine
rupture was unclear in pathological diagnosis.
The prevalence of primary uterine rupture is reported as rare,
occurring in one in 16,000 cases [1]. Since no specic symptom can
be used, it is considered difcult to make a diagnosis during the
early stage, although the maternal and fetal mortality are as high as
25% and 15%, respectively, making it a fatal obstetric disease [1]. We
assume that the mother and child in the present case had positive
courses because of the following reasons: (1) the decision to
perform emergency surgery was made comparatively early because
of a previous diagnosis of placenta previa; (2) blood ow may have
been limited in the area of rupture due to thinning of the muscle
layer; (3) the wound was covered by partial placenta, which
minimized exposure of the amniotic membrane; (4) blood ow in
the umbilical cord was well maintained because of the location of
the edge of the top of the placenta; (5) the fetus was near maturity
at 35 weeks with a weight of 2540 g; and (6) there were no signs of
maternal shock and no abnormal fetal heart patterns that would
require an urgent response, so the operation was able to begin
under lumbar anesthesia. Among these reasons, the presence of
abdominal pain symptoms that were difcult to explain by placenta
previa played a major role in making an early decision to perform
emergency CS.
Although abdominal pain is a main symptom of uterine
rupture, in obstetrics it has little diagnostic signicance to
differentiate from placental abruption, rupture of the uterine
varix, or even predelivery labor pains. Many studies have re-
ported a similar experience, in that a diagnosis of uterine rupture
was not considered until the mystery was solved by intra-
operative ndings. Patricio et al [13] discovered uterine rupture
during emergency laparotomy for abdominal pain at Week 20 of
pregnancy; the wound was repaired, and a live baby was deliv-
ered by CS at Week 34. However, generally, it is uncommon to
decide to perform emergency CS only based on the presence of
acute abdomen. To date, reports on uterine rupture have
described abdominal pain using a variety of terms: acute
 A. Kawabe et al. / Taiwanese Journal of Obstetrics & Gynecology 55 (2016) 721e723
abdominal pain, severe abdominal pain, abdominal pain with
rebound abdominal tenderness, and dragging pain [13,14]. In
the present case, the patient experienced severe abdominal pain
that was not periodic and dull such as pain in uterine contrac-
tions. The pain occurred and was enhanced by fetal movements,
or it eased when the mother was at rest or in an anteexed po-
sition. We assumed that the visceral or parietal peritoneum,
which is stimulated by the fetus or amniotic uid, was the origin
of pain, and we think that the characteristic of pain can be a sign
of uterine rupture.
Fetal heart rate monitoring has been considered useful to detect
fetal distress. However, as Ridgeway et al [2] reported, no specic
abnormal fetal heart rate pattern was found in the present case
prior to delivery. Bradycardia may only be useful to make a diag-
nosis of progressing fetal distress in uterine rupture.
In conclusion, the present case suggests that among acute
abdominal pain during pregnancy, severe pain exacerbated by fetal
movements in particular may be an early sign of onset of uterine
rupture. This can be useful for diagnosing this disease early and
helping save the lives of mothers and children. Further case studies
are required to verify the usefulness of the present evidence.
Conicts of interest
The authors have no conicts of interest relevant to this article.
Acknowledgments
The authors would like to thank Editage (www.editage.jp) for
English language editing.
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723
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