December 1, 2013

Volume 1

Number 5 cases-anesthesia-analgesia.org 67
Copyright 2013 International Anesthesia Research Society
DOI: 10.1097/ACC.0b013e31829847bd
U
terine dehiscence, albeit uncommon, is a relatively
more common event than uterine rupture, and
results from uterine scar rupture, while the overly-
ing visceral peritoneum remains intact and the fetus, umbili-
cal cord, and placenta remain in the uterine cavity. The rate
of uterine wound dehiscence at the time of repeat, elective
lower segment cesarean delivery (LSCD) is not well estab-
lished. Risk factors include number of previous LSCDs,
arrested labor during the frst stage, preterm delivery, fetal
macrosomy, and augmented labor.
1,2
To our knowledge,
spontaneous uterine dehiscence during positioning and
performance of spinal anesthesia has never been reported;
however, it should be considered as part of the differential
diagnosis of unusual back pain while establishing spinal or
epidural block. We describe a case of severe unusual back
pain during the performance of subarachnoid block for elec-
tive LSCD, with the diagnosis of uterine dehiscence being
made during surgical dissection.
The patient was contacted and has kindly given both
verbal and written consent for publication of this case.
CASE DESCRIPTION
Our patient was a 37-year-old healthy gravida 4, para 2 at
38 weeks gestation with a singleton pregnancy, and elective
LSCD and bilateral tubal ligation were planned. The cur-
rent pregnancy had been complicated with vaginal spot-
ting during the second trimester and hyperemesis both of
which resolved with conservative management. Routine
ultrasound at 32 weeks gestation did not report any uterine
wall abnormality. Her obstetric history included 2 LSCDs
performed under spinal anesthesia, both of which were
uneventful. She had gestational diabetes in 2007 for which
she required insulin treatment. Her prepregnancy body mass
index was 24.5 kg/m
2
. Her previous surgery included a gas-
tric sleeve and dilation and curettage. At this presentation,
and after consultation with the anesthesiologist, the patient
chose to have the elective LSCD under spinal anesthesia.
Spinal anesthesia was performed under sterile conditions
with the patient sitting and rolled forward. One percent
lidocaine was infltrated subcutaneously, and a 25-gauge
Sprotte spinal needle was inserted into the L3/L4 lumbar
interspace. Left fank pain was described and the needle
was repositioned, with resolution of the pain. Clear cerebro-
spinal fuid fowed freely and a mixture of 2.4 mL of 0.5%
hyperbaric bupivacaine (12 mg bupivacaine) and 20 mcg
of fentanyl was injected into the subarachnoid space. After
completion of the spinal block, and as the patient was being
repositioned with left uterine tilt, she complained of severe
left-sided back pain. The pain was described as excruciating
and was very distressing to the patient; she had never expe-
rienced anything similar. The pain reported originated from
the back, was a strong sharp and sudden-onset pain, and
radiated to the left fank and front of the abdomen. She was
given 25 mcg of IV fentanyl for supplementary analgesia.
The ampules used for the spinal anesthetic were cross-
checked, and it was confrmed that the correct medications
had been drawn up and injected into the subarachnoid
space.
Initial observations revealed a systolic blood pressure
of 89 mm Hg with a heart rate of 59 beats per minute. This
was treated with 6 mg of ephedrine. The left fank pain
decreased as the spinal anesthetic block became established
and extended to a higher level. An ongoing arterial blood
pressure decrease was treated with a further 6 mg of ephed-
rine and a fuid bolus of 500 mL of Hartmann solution result-
ing in a sustained blood pressure to >100 mm Hg systolic.
The patient was positioned on the operating table with
left uterine tilt. After incision and dissection through the
layers of the anterior abdominal wall and on entry into the
abdomen, a full thickness dehiscence of the anterior uterine
wall with herniation of the amniotic sac through the uterine
wall was observed (Fig. 1). The dehisced anterior wall of
the uterus was noted to be thin-walled with minor bleeding
along the line of the dehiscence. The amniotic sac was
opened, a live baby girl was delivered, and the placenta was
removed without complication. Apgar scores were 9 and 9
Uterine dehiscence is a known but uncommon complication during pregnancy. The symptoms
of uterine dehiscence can be subclinical and usually occur during prolonged augmented labor
in women who had previous cesarean delivery and/or are carrying a macrosomic baby. It can
be associated with maternal and fetal hemodynamic compromise and complications. However,
to our knowledge, spontaneous uterine dehiscence during performance of spinal anesthe-
sia for an elective cesarean delivery has not been reported in obstetric anesthesia practice.
Here, we report a case of uterine dehiscence while subarachnoid block was being performed.
(A&A Case Reports 2013;1:678)
From the *Department of Anaesthesia, Fairfeld Hospital; and Department
of Anaesthesia, Fairfeld Hospital and St Vincents Hospital, Sydney, New
South Wales, Australia.
Accepted for publication March 27, 2013.
Funding: None.
The authors declare no conficts of interest.
Address correspondence to Erez Ben-Menachem, MBCHB, FANZCA,
FCICM, Department of Anaesthesia, Liverpool and St Vincents Hospitals,
390 Victoria St., Darlinghurst, NSW 2010, Australia. Address e-mail to erez-
ben@yahoo.com.
Uterine Dehiscence During Initiation of Spinal
Anesthesia for Cesarean Delivery
Eng Tiong, MBBS,* Nasreen Shammas, MBCHB, FRANZCOG,* and
Erez Ben-Menachem, MBCHB, FANZCA, FCICM
CASE REPORT E
68 cases-anesthesia-analgesia.org A & A CASE REPORTS
Uterine Dehiscence During Subarachnoid Block
at 1 and 5 minutes, respectively. The baby weighed 3330 g.
The patient was hemodynamically stable for the remainder
of the procedure and reported no further concerns. The full
thickness dehiscence was repaired by the obstetrician, and
the surgery was completed uneventfully.
The patient was followed up the next day and no fur-
ther back pain was reported. She had an uneventful recov-
ery and was discharged home on day 4 postoperatively.
Sudden uterine dehiscence at the time of performing the
spinal block was the most likely explanation for the sudden
severe back and abdominal pain she experienced.
DISCUSSION
Uterine dehiscence and potentially uterine rupture are well-
recognized complications of previous LSCD and a major rea-
son for elective repeat LSCD in preference to a trial of labor
after previous cesarean delivery. Defcient cesarean scars are
relatively common, with transvaginal ultrasound in gyne-
cological patients revealing 19% of women who had under-
gone previous LSCD had defcient scars.
3
Presumably the
factors associated with uterine dehiscence, such as a mac-
rosomic fetus or augmented labor, are factors that increase
the intrauterine pressure, and this in combination with a
thin-walled uterus or scar defect ultimately contributes to
dehiscence or rupture. In this case, it is likely that position-
ing during the spinal blockade; sitting and rolled forward,
and then swinging the legs up after completion of the sub-
arachnoid block caused a transient increase in intrauterine
pressure that ultimately led to dehiscence. Interestingly, it
has been shown with intrauterine pressure transducers that
the highest baseline pressure during labor is obtained with
the patient in the sitting position.
4
Reassuringly, the literature would suggest that uterine
dehiscence without extrusion of the fetus into the maternal
abdomen does not result in increased maternal or neona-
tal mortality or morbidity.
5
Uterine dehiscence may present
with a range of mild symptoms or be an incidental fnding
at the time of repeat LSCD. Logically, uterine dehiscence
would predispose to the more catastrophic scenario of com-
plete uterine rupture, which, if not diagnosed and managed
emergently can result in signifcant maternal and perinatal
mortality and morbidity.
6
This case acts as a reminder that potential complications
during obstetric anesthesia can occur at any point before
the delivery of the baby. Uterine dehiscence should be
included as a differential diagnosis of unusual abdominal
pain during performance and positioning of the parturient.
Additionally, if a uterine defect is known to be present, it
may be prudent to avoid the extremes of spinal fexion and/
or the sitting position during performance of the subarach-
noid block.
E
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J 2002;95:4315
3. Ofli-Yebovi D, Ben-Nagi J, Sawyer E, Yazbek J, Lee C, Gonzalez
J, Jurkovic D. Defcient lower-segment Cesarean section scars:
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Tanamura A, Mizutani S, Tomoda Y, Kasugai M. Determination
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outside the fetal membranes. Nihon Sanka FujinkaGakkai
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6. Leung AS, Leung EK, Paul RH. Uterine rupture after previ-
ous cesarean delivery: maternal and fetal consequences. Am J
Obstet Gynecol 1993;169:94550
Figure 1. Visible uterine dehiscence with intact visceral peritoneum
at the time of surgical dissection.