P031: CONCURRENT INTRAOPERATIVE UTERINE RUPTURE AND PLACENTA ACCRETA: DO PREOPERATIVE CHRONIC HYPERTENSION, PRETERM PREMATURE RUPTURE OF MEMBRANES, CHORIOAMNIONITIS AND PLACENTAL ABRUPTION PROVIDE WARNING TO THIS RARE OCCURRENCE?
M. Anthony Cometa, MD, Scott M Wasilko, MD, Adam L Wendling, MD; University of Florida
Introduction: Uterine and placental pathology raises special clinical concerns for the parturient and infant. When presenting alone, placental abruption, uterine rupture or placenta accreta can result in peripartum hemorrhage, requiring aggressive surgical and anesthetic management; however, the presence of multiple concurrent uterine and placental pathologies can result in significant morbidity and mortality.
Case presentation: A 33-year-old G5P1213 parturient with chronic hypertension presented to the labor and delivery unit with PPROM, chorioamnionitis, vaginal bleeding and active contractions at 33 weeks and 6 days gestation. The decision was made to proceed to the operating room for urgent cesarean delivery due to non-reassuring fetal tracing in the setting of suspected evolving placental abruption. Additional intraoperative findings were significant for uterine rupture and placenta accreta. A cesarean-hysterectomy was performed safely with good outcomes for both the mother and baby.
Discussion: The overall risk of uterine rupture in an unscarred uterus is estimated to be approximately 1 out of 20,000. However, it has been reported that uterine rupture has occurred in previously unscarred uteri in parturients with increased parity and placental abruption. Our patient had no prior history of uterine surgery and we suspect that her multiparous obstetric history coupled with her chronic hypertension and clinical presentation of PPROM and chorioamnionitis resulted in placental abruption, subsequently precipitating a uterine rupture. The risk of placenta accreta without concurrent previa is 0.2% for parturients undergoing their first cesarean delivery . A population-based study of placenta accreta showed no association of chorioamnionitis and placenta accreta (OR 0.83, CI 0.28 – 2.78, P value 0.83) and we suspect the finding of accreta in our patient was a separate, but incidentally concurrent pathology.
Conclusion: Multiple uterine and placental pathologies in a parturient can be met with significant obstetric morbidity and mortality and present significant anesthetic concerns. A high degree of clinical suspicion may be warranted when evaluating parturients with chronic hypertension, PPROM and chorioamnionitis to facilitate anesthetic vigilance and preparedness. Future population-based research may be able to explore the relationship between chronic hypertension, PPROM, chorioamnionitis, placental abruption and uterine rupture.