Authors: Brent Mitchell Bodily, Eric Michael Schmitt, Jamie Humes.
Uterine rupture is a potentially catastrophic obstetrical complication that could lead to maternal and fetal morbidity and mortality. It is typically detected after fetal monitoring reveals abnormalities in the fetal heart tracing or when the mother experiences abdominal pain, which occurs even in the presence of epidural anesthesia. This case report aims to highlight an unusual presentation of uterine rupture where the presenting symptom was shoulder pain rather than fetal tracing abnormalities or abdominal pain. This rare presentation is poorly described in existing literature, and lack of awareness of this possible presentation can cause significant morbidity and mortality to both mother and child.
A 33-year-old gravida 4 para 2-0-1-3 presented to the labor and delivery unit for a planned repeat cesarean section at 39 weeks 0 days gestation. The fetal heart rate tracing was unremarkable, however, the patient reported 5 out or 10 shoulder pain that started the night prior. During her operation she was incidentally found to have a uterine rupture. After delivery and repair of this defect, the shoulder pain quickly resolved.
Medical providers are typically taught that the classic presentation of uterine rupture involves intense abdominal pain accompanied by abnormal fetal heart rate patterns. However, this case report highlights referred shoulder pain alone in the absence of these other findings as an atypical presentation of uterine rupture. The proposed explanation is that the irritation of the phrenic nerve by the free abdominal amniotic fluid resulted in the patient perceiving pain in her right shoulder region. Providers evaluating a term patient with shoulder pain, especially in the setting of risk factors for potential rupture such as a prior cesarean delivery, must consider uterine rupture in their differential diagnosis.
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