Perinatal/Neonatal Case Presentation

Perinatal/Neonatal ...... Case Presentation Vernixuria: Another Sign of Uterine Rupture

John Patrick O’Grady, MD CASE Michel Prefontaine, MD A 29-year-old G3 P2 was admitted at 37 weeks of gestation after Despina E. Hoffman, BA membrane rupture. She reported two prior cesarean deliveries. The initial surgery was performed for failure to progress. An elective repeat operation had been performed 4 years later. As documented by record review, both cesareans were uncomplicated, low, and Uterine rupture complicates approximately 1% of trials of labor after transverse operations. At the time of admission, fetal weight was cesarean. Classic signs and symptoms include loss of station, cessation of estimated at 3000 g. The clinical pelvimetry was normal. Following labor, vaginal bleeding, fetal distress, and abdominal pain. Other signs are counseling, a trial of vaginal delivery was planned. also possible. We report a case of uterine rupture at VBAC trial that includes The onset of labor was spontaneous. The rate of dilatation was an unusual clinical sign of uterine rupture: vernix caseosa observed in the normal, but descent of the presenting part proved tardy. Parenteral urine of the parturient. During labor, a bladder catheter was inserted to narcotics were the only labor analgesia. At 9 h after admission, a evaluate oliguria. Vernix caseosa and blood were found in the tubing. catheter was inserted into the parturient’s bladder to evaluate Prompt cesarean delivery followed. A tear extending from the original progressive oliguria. At that time, she did not complain of transverse scar into the bladder dome was found. Vernixuria is an additional discomforts that could be differentiated from those of normal labor. sign of uterine rupture. Concurrently, the fetal heart rate and the uterine contraction Journal of Perinatology (2003) 23, 351–352. doi:10.1038/sj.jp.7210897 pattern as recorded by external electronic monitoring devices were interpreted as normal. Combined abdominal – pelvic examination noted full cervical dilatation with a singleton, cephalic presenting fetus in a slightly deﬂexed OP presentation at À1 station. Vernix INTRODUCTION caseosa and frank blood were observed in the clear portion of the bladder catheter collection tubing. Prompt cesarean delivery under Potentially serious maternal or fetal complications occasionally general anesthesia followed. follow trials of labor after cesarean delivery (VBAC).1–4 Uterine At laparotomy, the fetus was noted to be partially extruded from rupture, the most serious complication, occurs in approximately the uterus. The vesicouterine space was obliterated by scarring. 0.5 to 0.8% of labor trials involving parturients with a prior low A tear extended from the original transverse myometrial scar into transverse cesarean scar. In 15 to 20% of rupture cases, potentially the dome of the bladder. The placenta remained implanted in the serious maternal or fetal morbidity occurs. Extension into major uterine fundus. A normal 2622 g fetus with Apgar scores of 7-8-9 at maternal vessels, the bladder, or severe myometrial tears may 1, 5, and 10 minutes, respectively, was delivered. The child necessitate blood transfusion, extensive reparative surgery, or even subsequently did well. hysterectomy. Severe asphyxial injury or death is rare, but remain The bladder and uterus were uneventfully repaired in layers. potential maternal/fetal risks. Herein, we report a case of uterine The patient was treated with antibiotics and 7 days of catheter rupture at VBAC trial that includes an unusual clinical sign of drainage. Transfusion was not required. No other complications uterine rupture: vernix caseosa observed in the urine of the ensued. parturient.

COMMENT Uterine rupture is associated with prior uterine scars, abruptio Department Of Obstetrics & Gynecology, Baystate Medical Center, Springﬁeld, MA, USA. placentae, Mu¨llerian abnormalities, multiparity, cocaine use, During a VBAC trial, vernix caseosa and blood were observed in Foley catheter drainage. At laparotomy, a uterine rupture extended into the bladder. multiple gestation, invasive trophoblastic disease, the administration of uterotonics, and, uncommonly, obstetrical Address correspondence and reprint requests to John Patrick O’Grady, MD, Department Of Obstetrics & Gynecology, Baystate Medical Center, 759 Chestnut Street, Springﬁeld, MA 01199, manipulations such as version and extraction, forceps operations, 4–7 USA. or, rarely, external trauma. A focus of concern and controversy

in recent years has been the risk of rupture in pregnancies chosen large fragments of vernix is a clinical sign of normal, advanced for VBAC trials.1–5 gestation. In our case, the appearance of easily identified vernix There are various signs and symptoms associated with uterine particles accompanied by gross hematuria in the tubing of the rupture. Classically, these include loss of station of the presenting bladder catheter were the principal clinical signs of uterine rupture. part, an altered uterine contour, cessation of labor, uterine These observations with the concomitant finding of a high, hypertonus, vaginal bleeding, fetal distress, and abdominal pain. malpositioned presenting part led to the prompt laparotomy. However, when the medical records from actual rupture cases are Fortunately, primary uterine repair was possible despite extension reviewed, these classic signs are quite variable in occurrence.5 of the tear into the maternal bladder. Fetal morbidity proved Infrequently, as in our case, minimal maternal or fetal signs and inconsequential. symptoms may be present despite a serious rupture.3 Even Trials of labor on a previous uterine scar continue to involve a intrauterine pressure recordings may appear normal despite small, but real, risk of serious maternal morbidity.3 The rupture. In some instances, an abnormal fetal heart electronic observation of vernix caseosa in a urine specimen obtained at tracing may be the only clinical sign of injury. catheterization can now be added to the previously described signs The severity of fetal and maternal morbidity from a uterine of uterine rupture. rupture varies from inconsequential to fatal injury. Important factors include the extent of the myometrial injury and associated hemorrhage, the degree of placental separation, and any extension of the tear into adjacent structures. Once the diagnosis is strongly References suspected, prompt laparotomy is mandatory. At surgical 1. Rageth JC, Juzi C, Grossenbacher H. Delivery after previous cesarean: A risk exploration, the infant is delivered and primary uterine repair is evaluation. Obstet Gynecol 1999;93:332–7. performed unless hemorrhage or severe injury force hysterectomy. 2. Flamm BL, Goings JR, Liu Y, Wolde-Tsadik G. Elective repeat cesarean Vernix caseosa is a waxy white-to-tan-colored substance that delivery versus trial of labor: A prospective multicenter study. Obstet Gynecol progressively coats the fetal skin in the third trimester. 1994;83:927–32. Histologically, vernix contains large numbers of fetal skin cells 3. Yap SOW, Kim ES, Laros RK. Maternal and neonatal outcomes after uterine embedded in a lipid matrix. Biochemically, the matrix contains rupture in labor. Am J Obstet Gynecol 2001;184:1576–81. sterol esters, free steroids, cholesterol, triglycerides, and waxes, 4. Zelop CM, Shipp TD, Repke JT, Cohen A, Caughey AB, Lieberman E. Uterine largely of sebaceous cell origin. The vernix coating of fetal skin rupture during induced and augmented labor in gravid women with one functions as a highly effective water barrier. Physiologically, this is prior cesarean delivery. Am J Obstet Gynecol 1999;181:882–6. believed to protect the developing epidermal cells from the potential 5. Phelan JP. Uterine rupture. Clin Obstet Gynecol 1990;33:432–7. adverse effects of prolonged exposure to amniotic fluid, while 6. Plauche WC, Von Almen W, Muller R. Catastrophic uterine rupture. Obstet Gynecol 1984;64:792–7. promoting normal skin cornification. With advancing gestation, 7. Hibbard JU, Ismail MA, Wang Y, Te C, Karrison T, Ismail MA. Failed vaginal minute fragments of vernix pass into the amniotic fluid resulting birth after a cesarean section: How risky is it? I. Maternal morbidity. Am J in its characteristic turbidity. This process of vernix passage into Obstet Gynecol 2001;184:1365–73. amniotic fluid is aided by surfactants from the fetal lung that 8. Narendran V, Wickett RR, Pickens WL, Hoath SB. Interaction between 8 progressively appear in the amniotic fluid. The presence of marked pulmonary surfactant and vernix: a potential mechanism for induction of turbidity in an amniotic fluid sample with the visualization of amniotic fluid turbidity. Pediatr Res 2000;48:120–4.

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