Point-of-care ultrasound (PoCUS) has recently emerged as a valuable tool in obstetrics for rapid bedside assessment of patients with pregnancy or labor disorders1. Although clinical examination remains the basis of obstetric management, PoCUS has shown greater accuracy and reproducibility than digital examination in assessing fetal head position and station during labor and is recommended by the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) guidelines for managing labor arrest2. PoCUS also has a well-established role in managing peripartum emergencies such as postpartum hemorrhage and maternal compromise, for which rapid bedside evaluation of the uterus, abdomen, inferior vena cava, lungs and heart may guide timely resuscitation3, 4. Herein, we describe the case of a woman with two previous Cesarean deliveries who was referred to our center (Gemelli Hospital, Rome, Italy) following the sonographic diagnosis of fetal demise at the 20-week anomaly scan. Upon admission, the patient was asymptomatic. Ultrasound examination at 21 weeks' gestation confirmed a non-viable fetus with no abnormal uterine findings. She received 600 mg oral mifepristone, followed 24 h later by 400 μg vaginal misoprostol (prostaglandin E1) every 3 h. After the third dose of misoprostol, the patient complained of abdominal pain, and administration was stopped. Intravenous infusion of remifentanil was started but offered inadequate pain relief. Vital signs were stable, with normal blood pressure and mild tachycardia observed. Cervical dilation was 2 cm, with the fetus in cephalic presentation and a head station of −2. Transabdominal PoCUS (Videoclip S1) revealed an abnormal left-sided uterine contour with evidence of intra-abdominal displacement of the fetal body and the fetal head positioned in the cervical canal (Figure 1). An emergency transverse laparotomy was performed; the fetus was located within the left broad ligament, still enclosed within the amniotic sac and covered by intact membranes. After abdominal delivery of the fetus, a full-thickness 5-cm uterine rupture along the left border of the previous Cesarean scar was confirmed (Figure 2). The rupture was repaired with a single-layer suture and the uterus was preserved, with blood loss of approximately 1000 mL. The patient received three units of packed red blood cells and was discharged in a stable condition. Written informed consent for the acquisition and publication of images and videos was obtained. This case underscores the critical role of PoCUS in the delivery room for the early diagnosis of potentially life-threatening complications, such as uterine rupture. During trial of labor after Cesarean section in the case of a viable fetus, uterine rupture is most commonly suspected based on abnormal fetal heart rate (FHR) findings indicative of acute hypoxic stress. In non-viable pregnancies, a prompt clinical diagnosis may be delayed due to the lack of abnormal FHR findings and as maternal vital signs may not immediately suggest hemorrhage. This may increase the risk of adverse maternal outcome. In this case, the bedside sonographic diagnosis of uterine rupture in its early stages paved the way for surgical conservative management. In line with the recent ISUOG guidelines on PoCUS4, we suggest that obstetricians should have easy access to bedside ultrasound on all labor wards and be trained to use this tool. Combining clinical examination with PoCUS should help to reduce maternal and perinatal morbidity and mortality. Open access publishing facilitated by Università Cattolica del Sacro Cuore, Rome, Italy, as part of the Wiley - CRUI-CARE agreement. Data sharing not applicable to this article as no datasets were generated or analysed during the current study. Videoclip S1 Transabdominal point-of-care ultrasound showing uterine rupture during second-trimester labor induction. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.
Tartaglia et al. (Fri,) studied this question.