Clinical Practice and Cases in Emergency Medicine

Introduction: Uterine rupture is a rare but potentially fatal complication of pregnancy. The incidence of uterine rupture is estimated to be between 0.3 and 11 per 10,000. Additionally, uterine sacculation is a sac or outpouching of the uterus that can lead to uterine rupture in pregnancy. Here we describe a case of a patient who was found to have a uterine sacculation on point-of-care ultrasound in the emergency department (ED) that was complicated by uterine rupture.

Case Report: A 32-year-old female at approximately 18 weeks gestation presented to the ED with three days of abdominal discomfort. The patient’s medical history was significant for prior uterine fibroids requiring recent myomectomy. On arrival the patient was tachycardic, and her abdominal exam revealed distention with mild tenderness to palpation in all quadrants. A point-of-care transabdominal obstetric ultrasound was performed to evaluate the fetal heart rate, which was 157 beats per minute; it also revealed a defect in the uterine wall compatible with a uterine sacculation. The patient underwent magnetic resonance imaging, which revealed a sac-like structure in the fundal portion of the uterus containing a portion of gestational sac and pregnancy contents. Subsequently, she became hypotensive and tachycardic and was taken emergently to the operating room for concern for uterine rupture. Intraoperatively, uterine rupture was confirmed. The patient underwent surgical repair with evacuation of fetal tissue and recovered in the surgical intensive care unit.

Conclusion: Point-of-care ultrasound is a useful and readily available procedure to identify uterine sacculation. Early identification can help escalate the urgency of the patient complaint and may lead to a need for further maternal-fetal evaluation. Emergency physicians should keep a high index of suspicion when evaluating the pregnant patient with a history of uterine surgery.