A case of traumatic uterine avulsion in pregnancy

Complete uterine avulsion is an extremely rare complication of trauma sustained during pregnancy. We present the case of a 21-year-old nullipara at 16 weeks' gestation who was involved in a high-speed motor vehicle collision with subsequent fetal demise. Initially she was hemodynamically stable and demonstrated small amounts of intraabdominal free fluid, therefore multidisciplinary conservative measures were undertaken. However, as her condition worsened, she was taken for exploratory laparotomy, revealing complete gravid uterine avulsion at the level of the cervicoisthmic junction. Due to hemodynamic instability and concerns for retroperitoneal bleeding, a supracervical hysterectomy was performed. Although a rare occurrence, our case demonstrates the need for a high level of suspicion for uterine avulsion in certain cases of trauma in pregnancy. This highlights the false reassurance provided by stable vitals in a pregnant patient that may mask ongoing bleeding and development of hemorrhagic shock, the importance of interpreting different imaging modalities together when the cause of instability is unclear, and the utility of a multidisciplinary approach. While our patient underwent hysterectomy due to hemodynamic instability, it is unknown whether earlier investigation with laparoscopy to confirm uterine integrity may have circumvented this and allowed for fertility-sparing management. As such, our case encourages the utilization of early diagnostic laparoscopy if there is concern for uterine avulsion for the consideration of alternative surgical interventions for management.