The phone call came as a rude awakening from a deep slumber. A colleague with an obvious urgency in his voice had informed me that he had a case of vaginal bleeding in a pregnant woman with the gestational age of the foetus at 36 weeks. Simply put, my attention was needed immediately.
When I looked at the time in my cell phone, it was just passed midnight and it was raining outside. As I drove along, the questions were rolling out: when did she come in? Was she a booked patient? What was the ultrasound report on the location and state of the placenta?
The answer was brief and straight to the point; Emma just come, she is an unbooked case and the foetal heart sound is still there. I increased the speed of my car on a road full of potholes. By the time I got to the facility, the patient was already on the operating table and my colleague had a SONICAID in his hands and was monitoring the heart beat of the unborn baby as it was gradually slowing down. When finally, I absorbed the reality and tension in the theatre, I broke all aseptic rules. There was no time to be wasted putting on scrubs and washing of hands. I simply put on an apron and surgical gloves and went for the abdomen.
We were lucky to get out the baby alive though moderately asphyxiated but was well resuscitated. On getting into the Uterine cavity, the whole place was so bloodied that trying to estimate the quantity of blood and liquor would have been an exercise in futility. Curiously, there were no challenges with the placenta and we couldn’t find any clotted blood in the uterine cavity. The uterine wound was sutured routinely like in any other Caesarian operation. There was no sign of rupture anywhere in the uterus.
Just, before we could reconstitute the outer peritoneal layer covering, my colleague called my attention to the left side of the lower segment of the uterus that looked bruised and was oozing with blood. We almost treated it as being inconsequential until we touched it with gauze and the tap opened up. The outpouring of blood was very frightening and could daze a rookie surgeon leading to a serious catastrophe. Obviously, we have been dealing with ANTE PARTUM UTERINE ARTERY RUPTURE without even suspecting it! We had to take a deep and wide figure 8 stitch to be able to stop the bleeding.
This technique was used bearing in mind that when middle to large size arteries are severed or ruptured, they tend to retract due to the elasticity of their wall. Thus an experienced caregiver would know that it is not where the blood is coming out from is where the cut end of the vessel is, especially if you factor in the PRESSURE in the vessel. There is always a danger of possible trauma to or ligation of the URETER in situations of desperation such that we had. The golden rule is to remember that water flows under a bridge. In this case, the uterine artery is the bridge under which urine flows in the ureter.
The Uterine artery is a branch of the HYPOGASTRIC, meaning that it lies below the stomach, which, on its own, is a branch if the INTERNAL ILIAC ARTERY. This vessel travels to the uterus through its side or the parametrium in the lower part of the broad ligament. Here, it is incorporated into the CARDINAL LIGAMENT of the uterus, which is the main support of the uterus in the pelvis. In its course, it lies on top of the ureter that carries urine from the kidney to the bladder. This vessel freely connects with the OVARIAN ARTERY in what is referred to in anatomy as anastomoses. Thus, surgically speaking in the event of ligation of the uterine artery, there is no fear of severe ischaemia of the uterus due to cut of blood supply from the vessel as circulation is eventually reestablished by the anastomosing branches.
Ironically in pelvic surgery involving the uterine artery, the surgeon is all too bothered about the ureter because of the vessel on top of it. This notwithstanding, the blood supply to the ureter is segmental in the sense that as it descends from the kidney various arteries like the ovarian, cervical and so on contribute to its blood supply. There are no anastomoses among the segmental branches of the vessels that supply the ureter.
Now, talking about bleeding in pregnancy often referred to as ante partum haemorrhage, the two main causes in our environment are low lying placenta known as placenta praevia and separation of the placenta from the endometrium while the foetus is still there. This condition is known as abruptio placenta.
Placenta praevia carries the best prognosis in the sense that the diagnosis can be made even before the bleeding starts with the aid of ultrasound scan. And depending on the gestational age of the baby, early surgical intervention can be life saving for mother and child.
In the case of abruptio placenta, there are two clinical types; the one whose haemorrhage is revealed or rather expressed and the one that the bleeding is concealed and not expressed. When in abruptio, the bleeding is revealed, alarm can be raised leading to quick response and good result. In case of concealed abruptio, by the time the bleeding become obvious, complication has already set in. The worst form of complication is the consumptive coagulation challenges. In this situation, as blood clots are formed behind the separated placenta, they are broken down by plasmin in the process leading to the depletion of fibrinogen. The consequence of this is uncontrolled bleeding by the patient that can be catastrophic.
Neither is the situation in our index case. We had a ruptured uterine artery in its course in the parametrium. And this has led to the asking of so many questions, which I doubt I can answer. A colleague had suggested a possible uterine artery aneurism, which I didn’t buy. The uterine is a very resilient vessel. Curiously, I noticed that there was this subdued anger and frustration among members of her family, especially her spouse. I had wanted to make enquiries about possible domestic violence, but I immediately realised that such was beyond my mandate.