Seat belt placement resulting in uterine rupture.

A 20-year-old woman with a 27-week intrauterine pregnancy was admitted to a Level II trauma center after a motor vehicle crash. She had a seat belt abrasion over her lower abdomen. Fetal death was established, and subsequent computed tomographic scanning detected uterine rupture with intra-abdominal displacement of the fetus. This finding dispelled any thought of placental abruption and led directly to laparotomy with repair of the uterus and removal of the dead fetus. Recently, and 7 years after the trauma, the patient presented for prenatal care of a new pregnancy. Proper seat belt placement is reviewed and the value of abdominal computed tomographic examination is underscored. An updating comment about airbags is included.

Spontaneous major intra-abdominal arteriovenous fistulas: a report of several cases.

Most major intra-abdominal fistulas result from trauma or surgery. Spontaneous fistulas are rare with less than 100 reported cases since 1831. From a review of hospital records, five such spontaneous fistulas were identified among 215 cases of abdominal aortic aneurysm between 1975 and 1983. These cases are presented and supplemented by 73 similar cases collected from a literature review for discussion of the salient features of clinical presentation and management of spontaneous major fistulas. Major intra-abdominal arteriovenous fistulas usually present with a machinery bruit over a pulsatile mass, but may present more subtly with pain and otherwise unexplained hematuria. Because these fistulas lead to refractory heart failure, surgery should be expeditious. Closure should be performed from within the aneurysm with arterial and pulmonary artery pressure monitoring. Care must be taken to prevent pulmonary embolization.