This was a case of a 33 year old Gravida 5 Para 4 + 0 with 2 previous lower segment caesarean section scars, at 28 weeks of amenorrhoea using Naegele’s formula. She was a peasant farmer by occupation and her husband was a peasant farmer too. The indications for the previous caesarean sections were; cephalopelvic disproportion during the third pregnancy and then inadequate pelvis with one previous scar during the fourth pregnancy. She had two living children and these were the ones born by caesarean section after having lost the first two children during their perinatal stages. She had no family history of multiple pregnancy or hypertension or diabetes. She presented with lower abdominal pain for 11 h; the pain was vague in nature, non-radiating, relieved by lying down, exacerbated by walking, but not severe enough to affect daily activities. She had no vaginal bleeding or any vaginal discharge; she clarified that she had not had any flow of fluid from the vagina along her thighs. She had not any other gastrointestinal complaints or genitourinary complaints. We had no access to her antenatal care records because she had received antenatal care from another health unit, and she had not moved with her antenatal care documents; therefore we could not find out whether she had received medicines like NSAIDs that affect amniotic fluid volume during pregnancy. She had no pallor of mucous membranes, pulse rate was 72 bpm, blood pressure was 110/80 mmHg, had a subumbilical midline incision scar, fetal heart rate was regular at 150 bpm, cervix was thick and with a parous os. A decision to admit her due to possible preterm labour and concealed abruptio placenta was made, and she was given dexamethasone intramuscularly. Obstetric ultrasound scan was done and it revealed severe oligohydramnios with no measurable amniotic fluid pool; estimated gestation age was 29 weeks and 1 day and estimated fetal weight was 1300 g. There was not any placental abnormality. A diagnosis of severe oligohydramnios with 2 previous scars was made. A differential diagnosis of preterm premature rupture of membranes was also made as a possible explanation for the oligohydramnios. Her haemoglobin level was 11.1 g per decilitre (g/dl), white cell count was 11,010/ millilitre (ml), platelet count was 363,000/ml.
Decision was made to deliver her by emergency ceaesaren section; she received prophylactic antibiotics and intravenous fluids. Intraoperatively, we found a gravid uterus with a transverse rupture on the lower segment anteriorly and along the previous scar, about 6 cm long with a protruding fetal arm. There was no active bleeding from the uterus. The peritoneal fluid was observed to contain some vernix caseosa. A baby boy of apgar score 10 at 5 min and weight of 1200 g, was delivered and admitted to the neonatal intensive care unit, and there was no complication of the surgery with the patient recovering well after uterine repair. There were no postoperative investigations done because the patient recovered well. Bilateral tubal ligation was not done because she had not consented to it, but she got explanation about the risk of uterine rupture in a subsequent pregnancy and was given family planning counseling. Figure 1 showing the intraoperative findings and the timeline in Table 1 are attached to this case report article.
