Mode of delivery in placental abruption: A case report on difficulty in distinguishing between uterine rupture and placental abruption due to clinical features that overlap

Abstract

Amongst the indications for caesarean delivery (CD) in pregnant women presenting with placental abruption (PA), fetal demise near term, and a previous major uterine surgery are peritonitic abdomen and severe vaginal bleeding. When the presence of these two indications is equivocal, deciding on the mode of delivery becomes challenging, as uterine rupture is a differential diagnosis. This case report develops an algorithm for decision-making on the mode of delivery in this context. A 22-year-old woman (G2P1) with a previous CD presented with antepartum hemorrhage (APH) at 36 weeks of gestation. In the previous pregnancy, she developed pre-eclampsia, PA at 34 weeks of gestation, and had CD and stillbirth. In the index pregnancy, she declined aspirin and had no pre-eclampsia. The APH at index presentation was mild-moderate, making the decision on mode of delivery difficult, but CD was favoured due to the possibility of uterine rupture. Another support for this decision was that access to emergency CD might be limited at the busy hospital the patient attended if an attempt at vaginal delivery were employed and an obvious indication for CD developed later. The decision-delivery time was 95 min. Intra-operatively, Couvelaire uterus, retroplacental clot, and left lateral fundal uterine rupture were found. Lower segment CD was performed, and the uterus repaired in layers. In conclusion, individualized care is recommended for women with PA, fetal demise near term, and a previous major uterine surgery. The clinical condition and context are important considerations that should guide the preferred mode of delivery.