A propósito de un caso: presentación atípica de rotura uterina / A case report: unusual presentation of uterine rupture

RESUMEN La rotura del útero gestante se define como una solución de continuidad patológica de la pared uterina, situada con mayor frecuencia en el segmento inferior. La rotura de un útero intacto es muy rara, su incidencia está estimada entre 1/5700 y 1/20000 embarazos. Su prevalencia ha aumentado dado el incremento de parto vaginal con cesárea anterior. Actualmente oscila entre el 0.3 y el 1 %, siendo mayor en mujeres en las que tiene lugar un intento de parto vaginal tras cesárea (0,78%) que en aquellas en las que se lleva a cabo una cesárea electiva (0,22%). En cuanto a su diagnóstico, suele ser precoz, dada la clínica de gravedad con la que debutan. En este caso se presenta una evolución atípica de rotura uterina, donde la paciente se mantiene asintomática hasta que acude a urgencias cinco días después del parto con fiebre y dolor abdominal; gracias a la ecografía abdominal y trans-vaginal se pudo establecer rápidamente el diagnóstico y así proceder a su inmediata reparación quirúrgica.

ABSTRACT Rupture of the pregnant uterus is defined as a solution of pathological continuity of the uterine wall, most often located in the lower segment. The rupture of an intact uterus is very rare, its incidence is estimated between 1/5700 and 1/20000 pregnancies. Its prevalence has increased given the increase in vaginal delivery with previous caesarean section. Currently, it ranges between 0.3 and 1%, being higher in women with a vaginal delivery after caesarean section (0.78%) than in those who undergo an elective caesarean section (0.22%). Their diagnosis is usually early given by the severity of the debut. In this case, there is an atypical evolution of uterine rupture where the patient remains asymptomatic until she goes to the emergency room five days after delivery with fever and abdominal pain; Because of the abdominal and transvaginal ultrasound, the diagnosis could be quickly established and thus proceed to immediate surgical repair.

A rare association of puerperal ovarian venous thrombosis with pseudomembranous colitis

Ovarian venous thrombosis is a rare but serious complication associated with early puerperium. The risk of this complication increases with associated puerperal infection or inflammatory condition. The present case report is of a 36-year-old lady who presented after emergency caesarean with puerperal fever and abdominal pain along with diarrhoea post antibiotic cover. Patient presented with moderate ascites and uterine subinvolution on examination. Contrast enhanced computed tomography (CECT) showed evidence of bowel wall edema due of colitis along with ovarian vein thrombosis. Patients had persistent symptoms despite receiving an empirical course of injectable cephalosporins. Stool culture confirmed growth of Clostridium difficile. Patient developed a rare infection after a course of antibiotic i.e. pseudomembranous colitis caused by Clostridium difficile. Patient then received a course of injectable vancomycin after which colitis subsided. This case increases our vigilance on management of puerperal fever which could get complicated with life-threatening events like deep vein thrombosis.

Study on the 19th century puerperal fever epidemic: Semmelweis-an often neglected pioneer epidemiologist / 中华流行病学杂志

Puerperal fever was a major cause of maternal death in Europe in the 19th century.Many efforts were made to investigate the cause of the epidemic but failed.In 1846,Semmelweis,a young obstetrician in Vienna General Hospital,started his historical investigation.His breakthrough was largely due to his doctor friend's accidental injury during autopsy and his consequential death.Semmelweis found the pathological findings in his friend's post mortem examination were very similar to puerperal fever.He postulated his friend's death might be caused by "cadaverous particles"from cadavers and further inferred that puerperal fever might also be caused by the cadaverous particles that doctors brought to the delivering women after autopsy classes.He advocated hand-washing with chlorinated lime solution to wash off those particles,which rapidly reduced the maternal mortality in his department by 80％ (from 10.65％ to 1.98％).However,what his unprecedented work brought him was only denial,mockery and career setback rather than support,honor and compliments.Under substantial psychological pressure,he had a mental breakdown and died in a psychiatry asylum at the age of 47.He was a pioneer in epidemiological investigations before John Snow and in aseptic techniques before Joseph Lister,but his work is still often neglected.

Study on the 19th century puerperal fever epidemic: Semmelweis-an often neglected pioneer epidemiologist / 中华流行病学杂志

Puerperal fever was a major cause of maternal death in Europe in the 19th century.Many efforts were made to investigate the cause of the epidemic but failed.In 1846,Semmelweis,a young obstetrician in Vienna General Hospital,started his historical investigation.His breakthrough was largely due to his doctor friend's accidental injury during autopsy and his consequential death.Semmelweis found the pathological findings in his friend's post mortem examination were very similar to puerperal fever.He postulated his friend's death might be caused by "cadaverous particles"from cadavers and further inferred that puerperal fever might also be caused by the cadaverous particles that doctors brought to the delivering women after autopsy classes.He advocated hand-washing with chlorinated lime solution to wash off those particles,which rapidly reduced the maternal mortality in his department by 80％ (from 10.65％ to 1.98％).However,what his unprecedented work brought him was only denial,mockery and career setback rather than support,honor and compliments.Under substantial psychological pressure,he had a mental breakdown and died in a psychiatry asylum at the age of 47.He was a pioneer in epidemiological investigations before John Snow and in aseptic techniques before Joseph Lister,but his work is still often neglected.

Semmelweis's Work: Hand-washing Lowered Maternal Death Rate Dramatically / 병원감염관리

Semmelweis correctly concluded that puerperal fever could be spread from necrotic discharge from living patients, as well as autopsy material. And maternal death rate was decreased dramatically by washing hands in chlorinated lime. Semmelweis may be credited with having for the first time constructed a statistically tested system of asepsis (keeping germs away from the patient) before the germ theory had arrived.