Sunday, February 19, 2012

Rupture Uterus . . .

Kindly note that this post contains surgical images which are very revolting. Please use discretion in viewing them.

KwD came to Emergency sometime just before we start work for the day.

Dr Johnson was on call. He was almost sure that it was a rupture uterus.

The story was very familiar. The yearning for a male baby had landed yet another lady into yet another tale of misery and pain.

KwD was in her 5th pregnancy. All her previous pregnancies were home deliveries and all were girl children. As is the custom, everybody wanted a boy baby.

KwD’s fifth pregnancy was also uneventful. Couple of days back, she had done her antenatal check up with one of the private doctors in the town near her village and she was given a clean chit.

KwD went into labour sometime early afternoon yesterday. After having kept at home for some time, someone told the family that it would be good if they delivered in the hospital as it was her fifth pregnancy and as a bonus they could get some cash.

KwD’s elder brother took her to the government PHC nearby. They reached sometime around 6:00 pm. The nurses assured them that everything should be alright. However, nothing much happened till about 9:00 pm. Couple of intramuscular injections were also given.

The nurses sensed that something was not ok and therefore referred KwD to the nearest district hospital. The government ambulance in fact took them to the biggest private hospital in the district where they reached sometime around 11:00 pm. The nurses took a look at her and informed her that she looks quite bad and therefore she would need to take her elsewhere.

Off they left for the government hospital – however, nobody attended to them. Sometime early morning today, after KwD’s husband reached the hospital, a decision was taken to bring her to NJH.

And so she reached NJH at around 7 am. Nandamani, our surgeon was away for a day and therefore I told about our limitations. They also told me about their limitations to take her elsewhere. So, I decided to go ahead after all sorts of consents in hand including the terrible ‘death on the table’ consent.

Well, one of my obstetric professors had told me quite long back that she has never seen a rupture uterus in her life. And I had also realised that I never had pictures to show anybody. So, below are the pictures of what we found inside . . .

To tell you the truth – this was one of the worst rupture uteruses I’ve ever seen in my life. The snaps would tell you the rest of the story . . .
The external appearance. . . For an experienced obstetrician at one glance, it is obvious that something is amiss . . 
The view on opening the rectus sheath . . .
The badly injured uterus . . .
Posterior aspect of the uterus . . . 
Another view of the uterus. On the right is the cervix along with the bladder
Hematoma within the mesosalpinx . . . 
The operating team . . .
The retroperitoneal laceration. This view is after the uterus was removed. Note the meconium which has stained the retroperitoneum. The rent extended about 10 inches superiorly . . 

Well, what I need you to pay attention is the last photograph. Difficult it was, mainly because I did not have a firm lower vault to suture up the lower segment. It was all like mince meat.

But, what stumped me was the fact that the rupture after it had involved almost two third of the lower segment of the uterus had torn off into the posterior aspect exposing almost a third of the retroperitoneal contents.

The triangular area which you see in the last snap is the ripped open retroperitoneal region. On one side, I could visualise the ureter. One of the ureter could not be visualised. I hope that that is safe. If you also look careful, it is not easy to miss the meconium staining within the area.

It’s now about 24 hours since the surgery. RwD has done well so far. She recieved 3 pints of blood. She is putting out enough urine. However, I would reserve my prognosis until few days are over.

Please do remember RwD in your prayers . . . .

Lessons learnt . . . 

1. You cannot blame RwD for the predicament she is in. She went to the right places . . . But, she never got the right diagnosis and right treatment. Another justification for my plea for getting our health centres and hospitals equipped with qualified staff and adequate equipment, before we tom tom about need for adequate awareness amongst our countrymen regarding healthcare issues. 

2. The secondary status of women in Indian society. I was stunned to find out that RwD has already married off her first daughter . . . at a tender age of 15 years . . . It's already been one year . . . It is so difficult to dream of seeing light at the end of the tunnel for gender discrimination in our society. 


  1. :( its sad, in pakistan we are going through similar situation too. corruption at micro and macro level has destroyed health sector too. so .
    u did a nice job.
    . Dr. Adil

  2. Congrats! You did an excellent job. And still are. I some times even find sex discrimination extending to accepting a male healthworkers( Nurse/lab tech) words rather than the female gynaecologists! But that does'nt affect me much now a days. I just ask the male worker to do the counselling especially with donating blood.