Labisia pumila as a Culprit of Primary Uterine Rupture Alongside Abruptio Placentae: A Case Report

Introduction

Uterine rupture is a rare obstetric emergency but is often associated with a catastrophic obstetric complication with an overall incidence of 1 in 1536 pregnancies.^1,2 Traditionally, unscarred uteri without risk factors are considered immune to rupture.³ Complementary and alternative medicine (CAM) is commonly used by some pregnant women in some countries due to local beliefs that it is beneficial to facilitate labor.⁴ In the case presented, we present a patient with spontaneous uterine rupture, who regularly had a few glasses of herbal water made from boiled water of Kacip Fatimah (Labisia pumila) leaves. The extract may induce continuous abnormal contraction of her uteri.⁵ An irrational use of complementary and alternative medicine could be a global concern due to a popularity increase of CAM usage recently.⁶ This case presents an effect of irrational use of one CAM, one of such is primary spontaneous uterine rupture due to consumption of Kacip Fatimah leaves boiled in water.

Case Report

Chief Complaints

A 35-year-old pregnant woman was admitted due to abdominal discomfort 3 hours before admission.

History of Present Illness

She initially came to the midwife with labor pain that was getting more frequent one day before admission. After an overnight observation, she felt the labor pain getting more frequent and stronger until she felt an abdominal discomfort, no fetal movement felt, and the fetal heart rate was hard to find by the midwife. Later she was referred to Otto Iskandar Dinata Hospital due to suspicion of intrauterine fetal death. After an in-depth interview, she gained the water from boiled herbal medicine that her neighbor gave, who suggested she drink the extracted herbal water to help her when the labor comes, which is believed to help for better labor progress. She said the water was made from boiled water of rumput Fatimah from her neighbor. During hospital admission, she complained about abdominal discomfort that felt like a muscle cramp and being torn apart.

Personal History and Family History

Her obstetrical history stated that she was G2P1A0, her last menstruation cycle was on 31 September 2022, and current gestation age was 41 weeks. There was no complication in her previous pregnancy; local delivery taker assisted her labor, and the baby weighed 2600 grams. She was married when she was 21 with her current husband, who was eight years older than her. During her pregnancy, she had routine control with the midwife every month. There was no relevant family history.

Physical Examination

The patient’s blood pressure was 80/60 mmHg, heart rate was 128 bpm, respiratory rate was 20 times per minute, body height was 152 cm, body weight was 58 kg, and prior to pregnancy her body weight was 58 kg. The obstetric examination found that her abdomen was stiff and tense, the contraction was hard to access, fetal heart sound was negative, no sign of a ring of bundle, and fundus height was 32 cm. From VT, the membrane was positive, and cervix opening was 3 cm.

Final Diagnosis

Final diagnosis of this case was G2P1A0 parturient aterm latent phase; acute abdomen due to suspicion of placentae abruption dd/ ruptur uteri; and Intrauterine Fetal Death.

Treatment

Exploratory laparotomy was decided due to the acute abdominal pain state. During the procedure, there were no signs of life from the baby, the baby was female, her weight was 2350 grams, and her length was 44 cm. The operator also found that placentae was located outside and her uterus was already ruptured, approximately 15–18 cm (Figure 1). The operator decided to do subtotal hysterectomy on the patient due to the remote setting and a blood transfusion was not available, so it is risky to perform hysterorrhaphy.

Figure 1 Uterine rupture: (a) intra-operative image of uterine rupture of the anterior side; (b) intra-operative image of uterine rupture from the lateral side; (c) gross specimen of primary uterine rupture after supravaginal hysterectomy.

Outcome and Follow-Up

The baby could not be saved due to stillbirth. Her final diagnosis was spontaneous uterine rupture >15 cm in P2A0 post-term; stillbirth. Later she was hospitalized for few days, and then her condition getting better. The patient was sad about the birth result, but thankful to the doctor because the team were able to rescue her. She said she will become more careful about what she consumes, especially traditional medicine.

Discussion

Traditionally, unscarred uteri without risk factors are considered immune to rupture.³ In the case presented, there is no history of uterine trauma or another risk factor of uterine ruptures or other risk factors for primary uterine rupture such as a contracted pelvis, fetal macrosomia, contracted pelvis associated with macrosomia, malpresentation, and dystocia associated with oxytocin and traditional medicine labor augmentation.^5,7 However, after further history taking from the patient, she said she regularly drank a herbal water made from boiled water of Labisia pumila (LP) leaves, also known as rumput Fatimah.

Labisia pumila is a traditional herb commonly used as post-partum medication and was known to facilitate childbirth.⁸ LP is one complementary and alternative medicine (CAM) commonly used by pregnant women in some countries such as Indonesia and Malaysia, due to local beliefs that it is beneficial to facilitate labor.⁴ Most women use CAM based on information from the Internet or their family as main sources.^6,9 They believe CAM posed no danger to them or their unborn children.^6,9 Additionally, having the freedom to choose a CAM treatment without requiring authorization from their healthcare practitioner empowered them to have greater control over their own health and body. Hence, pregnant women may infer that CAM are efficacious and secure alternatives to ease their complaint.⁹ Healthcare providers must participate in CAM usage, they could start by asking of any alternative supplementation that was used by the patient, and educate them regarding the normal use.⁶

Previous study found LP extract is beneficial in treating female reproductive diseases such as postmenopausal and polycystic ovarian syndrome.¹⁰ This plant is rich in phytoestrogen and is commonly utilized for augmenting vitality, improving energy levels, alleviating dysmenorrhoea, and strengthening the perineal muscles.¹¹ Pregnant women are commonly administered a water decoction made from the roots or entire plant of Labisia pumila, typically one to two months prior to delivery, meanwhile in Indonesia they usually use their leaves. This practice is considered to stimulate and hasten the process of childbirth.¹² However, Yusof et al found another result, that there is strong association between the usage of Kacip Fatimah during pregnancy and premature labor, with a prevalence rate of 28.6%.⁴ This could be attributed to the phytoestrogen concentration in Kacip Fatimah that can enhance myometrial activation with improved receptivity by modulating membrane receptors and gap junctions.⁴

The Labisia pumila effect in the human body is dose-dependent.¹³ The dose-dependent effect is of great concern to users because it is closely related to the safety issue for long-term consumption of L. pumila.¹³ Some studies suggest LP extracts may induce estrogenic activity and contain compounds with binding affinities for estrogen receptors Erα and Erβ.⁸ ERα was present in both myometrial and endometrial compartments of the uterus. At the same time, ERβ was isolated solely to the endometrial compartment.¹⁴ Thus, the uterotonic action of E2 in the human myometrium is thought to be mediated by ERα signalling. As circulating E2 levels rise toward term and de-repression of ERα66/ERα46 isoforms, specifically in the myometrium, promote enhanced uterotonic action of E2 at term and the onset of labor.¹⁴ The patient admitted that she drank LP extract waters prior to admission; due to irrational LP extract consumption, E2 levels may rise and then induce the contractions that act like a birth induction treatment in this patient. Sequential labor induction was believed a major risk factor of uterine rupture.² Induction of labor at 41^3/7 or 41^5/7 weeks increases the risk of uterine rupture.¹⁵

Based on the patient story, her uterus might continuously be stimulated since a few weeks prior to admission due to the herbal water consumption, thus causing placental abruption (PA). Placental abruption may contribute to uterine rupture and peripartum hysterectomy in this patient.¹¹ The management of PA is still challenging, even for the most experienced obstetricians. One of the most essential matters in this case is time. A prolonged decision-to-delivery interval increases perinatal morbidity and mortality.¹⁶ Currently no guideline could be used as an outline of the PA risk group, however there were some attempts to discover placental abruption markers at 1st or 2nd trimester. A mother who has PAPP-A protein <5th percentile, AFP >95th percentile, and inhibin-A <5th percentile or >95th percentile was at higher risk for developing PA.¹⁷ Early pregnancy serum metabolomic profiles connected with abnormal vaginal bleeding may serve as predictors of PA.¹⁸ Daily antepartum low-molecular-weight heparin injections seemed to reduce the risk of PA, although the data were inconsistent.¹⁹

Conclusion

Uterine rupture is a rare obstetric and surgical emergency but is often associated with a catastrophic obstetric complication. Uterine rupture might happen due to hyperstimulation, which in this case is due to consumption of herbal water. Rational usage of herbal medicine must be implemented to avoid unwanted complication; hence healthcare providers must participate regarding this issue.