[Vaginal birth after cesarean delivery: can the trial of labor be extended]

Based on a retrospective analysis of 1000 cases of scared uteri following cesarean section(s) (one cesarean, n = 857, 85.7%); two n = 129, 12.9%; three n = 14, 1.4%), we tried to answer two questions. Is trial of labor in case of low segment uterine-scar (excepting pelvic abnormalities, corporeal scar and more than two scars) free of risk for the mother and child? Can trial of labor be extended to cases of breech presentation, two previous cesarean sections, twin pregnancy and suspected macrosomia? In this series, the cesarean was indicated before labor in 138 cases (13.8%). Trial of labor was conducted in 862 cases (86.2%), and led to vaginal birth in 728 (84.5%). Successful trial of labor was observed in 75% of twin pregnancies, in 100% of breech presentations and in 69.6% of macrosomic infants. Uterine rupture occurred in 23 cases (2.7%), especially in cases with unknown corporeal scars (15 cases). No case of perinatal death related to uterine rupture was observed in this series.

Disruption of prior uterine incision following misoprostol for labor induction in women with previous cesarean delivery

BACKGROUND

Although induction of labor in women with prior cesareans is controversial, we compared misoprostol to oxytocin in such women in a randomized trial. The investigation was terminated prematurely because of safety concerns.

CASES

Disruption of the prior uterine incision was found in two of 17 misoprostol-treated women. The first woman underwent repeat cesarean delivery at 42 weeks because of fetal tachycardia and repetitive late decelerations. A 10-cm vertical rent in the anterior myometrium was discovered. The second woman underwent induction for fetal growth restriction. Loss of fetal heart tones and abnormal abdominal contour prompted emergent cesarean for suspected uterine rupture. An 8-cm longitudinal uterine defect was found.

CONCLUSION

When misoprostol is used in women with previous cesareans, there is a high frequency of disruption of prior uterine incisions.

Rupture of rudimentary horn pregnancy: a case report

A rare case of rupture of a noncommunicating rudimentary horn pregnancy is presented. The pregnancy continued to 16-weeks' gestation, when the rudimentary horn ruptured. The patient had signs and symptoms of massive hemoperitoneum. An emergency exploratory laparotomy revealed a ruptured rudimentary horn and an intact amnionic sac. Prompt excision of the rudimentary horn was performed. The relative literature and factors associated with a rudimentary horn pregnancy are reviewed and discussed.

Vaginal birth after cesarean delivery: results in 310 pregnancies

OBJECTIVE

To assess and compare the risk associated with a trial of vaginal birth after cesarean section (VBAC) with the risk of an elective repeat cesarean section.

METHODS

A retrospective review of the records of 310 consecutive women who, at the Jichi Medical School Hospital in the 6-year period of 1990 through 1995, had previously undergone a primary cesarean section and gave birth to a singleton infant weighing > or = 2,000 g at > or = 36 weeks of gestation in a subsequent pregnancy.

RESULTS

Elective cesarean sections were performed on 96 (31%) of 310 women, and VBACs were attempted by 214 women (69%). Vaginal deliveries were successful in 132 (43%) of the 310 pregnancies. No maternal death or perinatal deaths occurred in either group. A uterine rupture occurred in 2 (0.9%) of the 214 women who attempted a VBAC, and 5 women (2.3%) gave birth to neonates with a 1-minute Apgar score < or = 6. None of the 96 women who underwent an elective cesarean section had such complications, although the difference in these complication rates did not reach a significant level.

CONCLUSIONS

A trial of a VBAC significantly reduced the rate of cesarean sections. Although the rates of uterine rupture and neonatal asphyxia were slightly higher in women who attempted a VBAC than in women who underwent an elective cesarean section, obstetricians should offer the option of a trial of labor, because more than one-half of the women with a previous cesarean delivery might have successful vaginal deliveries, and the VBAC-related maternal mortality rate does not reportedly differ between women undergoing a trial of labor and women undergoing an elective repeat cesarean section.

Spontaneous rupture of a primigravid uterus secondary to placenta percreta. A case report

BACKGROUND

Uterine rupture secondary to placenta percreta has been observed in multiparous patients. These cases are typically associated with a prior history of uterine trauma or infection: hysterotomy, myomectomy, cornual resection, dilatation and curettage, manual removal of the placenta or endometritis. Spontaneous rupture of the primigravid uterus without a history of trauma or infection is an exceedingly rare occurrence. This case represents the second reported in the medical literature and the first to result in a live-born infant.

CASE

A 23-year-old, African American primigravida at 26 weeks' gestation presented with acute-onset abdominal pain, severe hypotension, tachycardia and fetal heart rate decelerations. Blood product replacement was initiated, and an emergency laparotomy was performed for a presumptive diagnosis of intraabdominal hemorrhage. A significant hemoperitoneum was encountered, with the fetus floating freely in the peritoneal cavity. The uterus had a fundal rupture with a clinically apparent placenta percreta that necessitated performing a total abdominal hysterectomy. The patient recovered uneventfully, and the infant survived without significant morbidity.

CONCLUSION

Spontaneous rupture of the primigravid uterus can occur in the absence of a history of uterine trauma or infection. If a gravid woman presents with hypotension, abdominal pain and fetal distress, the differential diagnosis should include rupture of the uterus, regardless of parity or gynecologic history. Rapid diagnosis, blood product replacement and emergency laparotomy are the key steps in successful management.

[Eighty cases of uterine rupture at the maternity service of the National Hospital Center of Ouagadougou , Burkina Faso]

In this retrospective study, we recall the frequency of uterine ruptures within a national health center of West Africa and propose solutions in order to reduce the incidence. This very high frequency was 23/1000, i.e. one uterine rupture for 44 deliveries. The feto-maternal prognosis was poor with a high stillbirth rate and maternal mortality. Maternal mortality which was 35% of cases represented 22.7% of the causes of maternal mortality observed within the unit during the survey. The stillbirth rate was 95% representing 145/1000 of the hospital stillbirth rate recorded during the survey. Maternal morbidity was also high because 14% of those who survived presented a parietal suppuration with the release of suture during the immediate postsurgical period. The seriousness of the feto-maternal prognosis is linked to a lack of adequate patient management. The importance of uterine ruptures in the obstetrical activity of the unit needs a joint and urgent action of all intervening parties within the sanitary system in order to contend with this scourge, which is the sign of poor quality health care in Obstetrics.

Spontaneous uterine rupture at thirty-three weeks subsequent to previous superficial laparoscopic myomectomy

Obstetric uterine rupture has previously been reported after the laparoscopic removal of deep intramural myomas, but never has it been reported to follow the removal of superficial myomas. A 39-year-old primigravid woman with a history of a superficial subserous laparoscopic myomectomy was seen for acute abdominal symptoms at 33 weeks of gestation. Emergency cesarean laparotomy confirmed a spontaneous rupture of the uterine fundus with extrusion of the intact fetal sac into the upper abdomen. This is the first reported case of obstetric uterine rupture subsequent to the removal of a superficial myoma by laparoscopic techniques.

First-trimester spontaneous uterine rupture after traditional myomectomy: case report

We reported a case of spontaneous uterine rupture in the first trimester of a woman who had had a traditional myomectomy operation 2.5 years earlier. Although uterine rupture is very rare in early pregnancy, it should be taken into consideration--in the differential diagnosis of acute abdomen--in all terms of pregnancy, especially when a predisposing factor exists.

Endoscopic laser treatment of uterine malformations

Hysteroscopic resection of an intrauterine septum may benefit patients suffering from infertility or recurrent pregnancy loss. A partial or complete uterine septum can be easily resected using a Nd-YAG laser. If present, the vaginal septum may also be removed during the same procedure. The reproductive outcome of women treated by operative hysteroscopy for an intrauterine septum is reviewed. To avoid pregnancy in a non-communicating rudimentary horn, the removal of the horn and the homolateral tube may be performed by either bipolar coagulation or a CO2 laser.

[Anencephaly associated with uterine rupture during induced abortion. A clinical case]

A 32 year old woman, at the 23rd week + 3 days gestational age, was admitted to our institute for a therapeutic abortion decided because of an ultrasonographic diagnosis of anencephaly. This woman had already had a cesarean section caused by acute fetal stress during labor in 1992. We decided for a labor induction with prostaglandin analogues: we used gemeprost vaginal tablets and after injectable sulproste. During this treatment we observed increasing abdominal pain, slight genital haemorrhage, vanishing HFR, an elevated reduction of haemoglobin (7 g): so, we thought of a uterine rupture. During the intervention, we observed a conspicuous haemoperitonei caused by a complete yielding of the old hysterotomic suture at the cervix border; the placenta and its adnexals get out from the uterine breach and the fetus fluctuated in the abdominal cavity, also enclosed in his unruptured amniotic fluid. Post-intervention course was satisfactory and we discharged the patient during the 7th admission day. Our personal experience shows the importance of a careful monitoring of maternal and fetal conditions during labor induction, particularly in those cases in which a woman was already submitted to a hysterotomy, and especially when the use of different types of prostaglandin drugs may be necessary.

Intrapartum rupture of the unscarred uterus

OBJECTIVE

To examine risk factors and maternal and neonatal outcomes in ten cases of intrapartum rupture of the unscarred uterus.

METHODS

Uterine ruptures in women without previous cesarean deliveries were identified from an ongoing log for a 12-year period beginning January 1, 1983. Detailed information was obtained by review of hospital records.

RESULTS

From January 1, 1983, through December 31, 1994, we identified 13 uterine ruptures in women without previous cesarean deliveries. Three resulted from motor vehicle accidents and were excluded from analysis. Ten occurred during labor and are the subjects of our report. The incidence of intrapartum rupture of an unscarred uterus was 1 in 16,849 deliveries. Associated factors included oxytocin use (four cases), prostaglandin use (three cases), use of vacuum or forceps (three cases), grand multiparity (two cases), and malpresentation (two cases). Intervention was prompted by fetal heart rate decelerations in seven cases and by severe hemorrhage in three. Uterine rupture was associated with acute abdominal pain in six cases, maternal tachycardia in five, and severe hypotension in two. Neonatal outcomes were normal in nine cases. There were no maternal or perinatal deaths.

CONCLUSION

Intrapartum rupture of the unscarred uterus is a rare obstetric emergency. Maternal and perinatal outcomes are optimized by awareness of risk factors, recognition of clinical signs and symptoms, and prompt surgical intervention.

[Ultrasonic diagnosis of placenta percreta. Apropos of a case with hemorrhagic complication]

Placenta percreta is a rare but severe disease, which is more and more frequent. The reported case shows that diagnosis can be made with B mode and color Doppler ultrasonography. Extension of high-vascularized placenta to the myometrium, abnormal placental-subplacental complex and vascular flow through the myometrium were suggestive of the diagnosis. Early diagnosis should decrease mortality and morbidity.

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.

A case of uterine choriocarcinoma with spontaneous rupture twenty-three years following the antecedent pregnancy

A 53-year-old woman went into shock with a spontaneous uterine rupture due to choriocarcinoma that occurred 23 years after an elective abortion in the first trimester, and she underwent an emergency hysterectomy. After 4 courses of uneventful postoperative chemotherapy, she suffered from severe pneumonia. Fortunately, however, she recovered and has remained in complete remission at 2.5 years follow-up. This is a case of uterine choriocarcinoma with a spontaneous rupture after the longest latent period yet reported.

Trial of labor or repeated cesarean section. The woman's choice

OBJECTIVE

To develop recommendations for the preferred delivery method for a pregnant woman who underwent a previous low transverse cesarean section and who has no contraindications to labor.

DATA SOURCES

MEDLINE searches and the references from retrieved articles yielded 759 citations. Search terms included trial of labor (TOL), trial of scar, vaginal birth after cesarean section (VBAC), and uterine rupture.

STUDY SELECTION

Articles with primary outcomes data contrasting TOL and elective repeat cesarean section (ERCS) were analyzed. Studies from developing countries or before 1980 were excluded.

DATA EXTRACTION

Data from 292 articles were extracted independently by at least 2 team members using a structured form.

DATA SYNTHESIS

Outcome data were combined using commercially available software and are presented as absolute differences per 10,000, with 95% Bayesian confidence intervals. Maternal outcomes showed that TOL increased the risk for uterine rupture (23.9 [0.24%]); ERCS increased the risk for infection (522 [5.22%]) and bleeding (58.6 [0.59%]). Infant outcomes differed only for 5-minute Apgar scores of less than 7, which were more likely for infants whose mothers underwent TOL (85 [0.85%]). Other outcomes (eg, disability), patient preferences, and cost data did not lend themselves to meta-analysis and were examined separately. While two thirds of women desired TOL, one third preferred ERCS. Costs were 1.7 to 2.4 times greater for ERCS.

CONCLUSIONS

A woman should be given information on both delivery methods and encouraged to undergo TOL, but her preference for ERCS should be respected.

Prostaglandin E2 for cervical ripening: a multicenter study of patients with prior cesarean delivery

To evaluate the maternal and fetal outcomes of a large cohort of women treated with prostaglandin E2 (PGE2) gel for cervical ripening prior to trial of labor after previous cesarean delivery. Beginning in 1990 all pregnant patients with previous cesarean delivery presenting for prenatal care at 10 California hospitals were prospectively studied. We analyzed multiple parameters to compare outcomes of cases in which PGE2 gel was used to outcomes in a control group in which PGE2 was not used. Data were examined by X2 testing. During the study period 5022 patients underwent trial of labor after prior cesarean delivery. Of these 5022 patients, 453 (9%) were treated with PGE2 gel. There was no significant difference in the incidence of uterine rupture between the PGE2 group and the control group. Indicators of maternal and perinatal morbidity were not significantly higher in the prostaglandin treated group. The use of PGE2 gel for cervical ripening appears to be relatively safe in patients with prior cesarean delivery.