[Trends in therapeutic abortion management from 1986 to 1994]

OBJECTIVE

This study was performed in order to evaluate indications, techniques and maternal risks of medical abortions, and technical difficulties encountered in these procedures.

TYPE OF THE STUDY

A monocentric, descriptive and retrospective study.

MATERIALS AND METHODS

Four hundred seventeen medical abortions (MA) were performed in our fetal medicine Unit between 1986 and 1994, including 117 (28%) performed for maternal reasons and 300 (72%) for fetal reasons. Each indication was discussed in a collegial system and varied protocols of labor induction were used, mainly prostaglandins, RU 486, or feticide. MAIN PARAMETERS MEASURED: They were duration of the labor, maternal accidents, number of the fetal post-mortem examinations, counselling given to the couples. We considered that a MA is correctly managed when the intervention corresponded to the following criteria: expulsion by natural route without uterine damage, an examinable fetus and examination by a foetopathologist.

MAIN RESULTS

Mean rate of MA satisfying our definition was about 45% in 1988 and reached to 74% in 1994. Our results show that the procedure is rarely complicated and that vaginal expulsion can be obtained. The foetopathologist examination rate increased regularly over the period. The mean gestational age of MA due to maternal indications was 14.5 weeks vs 23.9 weeks when dealing with fetal indications. The infection rate is about 6.2%, hemorrhage rate following expulsion was about 5.9% and the rate of uterine rupture was about 0.48%.

CONCLUSIONS

These data suggest that medical abortion need to be evaluated regularly.

[Uterine rupture. A case of spontaneous rupture in a thirty week primiparous gestation ]

Uterine rupture is one of the major complications of pregnancy. Most spontaneous uterine ruptures occur during labor in parturients with a scarred uterus. Spontaneous rupture where the uterus is unscarred are more rare and occur more frequently in older multiparous patients. Starting from a case of uterine rupture occurring in a 40 year-old primiparous women, we will present a review of the literature concerning cases of rupture in healthy uteri with no obvious cause.

Uterine rupture and scar dehiscence. A five-year survey

A review of the medical records from two public hospitals in Sydney was undertaken to determine the incidence of this uncommon complication. Twenty-seven cases of uterine rupture were reported out of 31,115 deliveries with an incidence of 0.086% (versus 0.05% in the current literature). The incidence associated with previous caesarean section was 0.038% (versus 0.8% in the current literature). Predisposing and associated factors in this review were similar to those reported by others. There was no maternal mortality in our series but the fetal mortality rate was 5 out of 27 cases. Uterine ruptures in the midtrimester were associated with high rates of maternal morbidity and fetal loss. Forty-eight per cent of patients with uterine rupture received epidural analgesia. The associated factors and outcomes are discussed. The current literature is reviewed in relation to this high-risk group of patients.

Complications of midtrimester pregnancy termination: the effect of prior cesarean delivery

OBJECTIVE

Our purpose was to determine whether a prior cesarean delivery affects the incidence of complications in women having an indicated midtrimester medical pregnancy termination.

STUDY DESIGN

A retrospective review of women who underwent a midtrimester medical termination of pregnancy from January 1980 to July 1995 ascertained obstetric history, uterotonic agent(s), and the occurrence of uterine rupture, blood transfusion, or curettage. The frequencies of maternal complications were compared in women with and without a prior cesarean section.

RESULTS

Our study population included 606 women with a mean gestational age of 21.1 +/- 3.1 weeks and a mean maternal age of 26.3 +/- 7 years. Seventy-nine (13%) had undergone a prior cesarean section. There was no significant difference in the need for curettage between women with and without a prior cesarean section. However, there was an increased need for blood transfusions in women with a prior cesarean delivery (11.4% vs 5.3%, odds ratio 2.3, 95% confidence interval 1.1 to 5.0, p = 0.04). The incidence of uterine rupture was significantly higher among women with a prior cesarean (3.8% vs 0.2%, odds ratio 20.8, 95% confidence interval 14.1 to 104, p = 0.008).

CONCLUSION

Our data suggest that a prior cesarean section is a risk factor for uterine rupture and blood transfusion in women having a midtrimester pregnancy termination.

[Spontaneous rupture of the pregnant uterus in a primipara as an unusual complication of previous salpingectomy]

The case of spontaneous rupture of uterus in 38th week of pregnancy in a 24 year old primipara is describe. The rupture was localized the site of dexon sutures applied during left salpingectomy performed because of ectopic pregnancy nine months ago. Diagnosis was made during cesarean section performed as a life saving procedure. Conservative repair of uterus resulted in uneventful recovery of the patient.

Uterine rupture during labour in a primigravida

Uterine rupture is extremely rare in the absence of any of the commonly recognized risk factors. We describe here a case of incomplete uterine rupture in a woman in her first pregnancy who had no previous instrumentation to the genital tract. Her only significant history was that of 2 episodes of minor antepartum haemorrhage occurring prior to induction of labour with artificial rupture of membranes and intravenous oxytocin. The rupture was manifested by 450 mL blood in the peritoneal cavity when an emergency Caesarean section was performed for persistent fetal bradycardia.

Uterine rupture in first or second trimester of pregnancy after in-vitro fertilization and embryo transfer

We report five cases of early rupture of cornual pregnancy with history of previous salpingectomy and cornual resection following in-vitro fertilization (IVF) and embryo transfer. We discuss the predisposing factors, diagnostic and therapeutic modalities in these patients. A high index of suspicion is required for an early diagnosis. It is imperative that the physicians who care for the patients be fully aware of the possibility of such a complication in a high risk population; therefore, appropriate counselling and close follow-up might help to avoid such obstetrical catastrophes, by termination of pregnancy, either surgically or medically.

Spontaneous rupture of the uterus due to placenta percreta at 25-weeks' gestation: a case report

Placenta percreta is a rare but serious complication of pregnancy, and is rarely diagnosed in the second trimester of pregnancy. We report a very rare case of placenta percreta accompanied by spontaneous uterine rupture at 25-weeks of gestation. A 30-year-old woman with severe abdominal pain was admitted to our hospital at 25 weeks of gestation. A laparotomy was immediately performed because of intraabdominal bleeding. The uterus revealed a perforation of the fundus. A supra-vaginal hysterectomy was performed. A pathological investigation of the uterus revealed placenta percreta. The patient had neither gravity nor any prior uterine operation. It is very rare for placenta percreta to be recognized in a primigravida woman or in the second trimester of pregnancy.

Midtrimester uterine rupture. A case report

BACKGROUND

Uterine rupture during the second trimester is a rare obstetric emergency. There have been 31 reported cases since 1968, with 25 occurring during elective termination of pregnancy. Four cases occurred in patients with transverse lower uterine segment cesarean scars.

CASE

In this case, uterine rupture of a classical cesarean scar occurred during second-trimester termination.

CONCLUSION

This is the first reported case of rupture of a classical cesarean scar during second-trimester pregnancy termination.

Fatal spontaneous rupture of a gravid uterus: case report and literature review of uterine rupture

Spontaneous uterine rupture is a life-threatening obstetrical emergency encountered infrequently in the emergency department. The diagnosis of spontaneous uterine rupture is often missed or delayed, leading to maternal and fetal mortality. Emergency physicians must consider this diagnosis when presented with a pregnant patient in shock with abdominal pain. We present the case of a 38-year-old gravid female who presented to the emergency department in cardiac arrest 24 hours after an initial complaint of abdominal pain. We review the uterine rupture literature with specific focus on risk factors, signs and symptoms, diagnosis, treatment, and outcome.

Trial of labor in patients with a previous lower uterine vertical cesarean section

OBJECTIVE

Our purpose was to determine the efficacy and safety of a trial of labor in patients previously delivered at least once by a lower uterine vertical cesarean section.

STUDY DESIGN

A retrospective review was performed at a single tertiary perinatal center, The University of Florida Health Science Center, Jacksonville. The medical records of all patients with a previous low vertical cesarean section who underwent a trial of labor during a 72-month period from January 1988 until December 1993 were reviewed. The medical records of the next two patients who did not have a prior uterine incision admitted to labor and delivery after the index case served as the controls. The duration and outcome of labor, including mode of delivery, maternal and perinatal morbidity, and birth trauma were evaluated.

RESULTS

Of 77 patients with a previous low vertical cesarean incision, 11 (14.3%) had a repeat operation compared with 14 of 154 patients (9.0%) in the no previous cesarean section group (not significant). No differences were noted in the incidences of operative vaginal deliveries or prolonged duration of the first or second stages of labor, or in the rate or maximum dose of oxytocin infusion between the two groups. One patient in the previous cesarean section group had uterine rupture. The incidence of umbilical artery pH < or = 7.20 was similar. No difference in the number of infants with 1- or 5-minute Apgar scores < or = 7 was noted.

CONCLUSION

A trial of labor in women with previous low vertical cesarean sections results in an acceptable rate of vaginal delivery and appears safe for both mother and fetus.

An unusual fetal complication of traumatic uterine rupture

Rupture of the gravid uterus is reported in less than one percent of women involved in motor vehicle accidents. A 22-year-old nulliparous woman at 22 weeks gestation was involved in a motor vehicle accident. Evaluation revealed a uterine rupture with complete expulsion of placenta and decapitated fetus. Prompt surgical intervention and control of hemorrhage allowed preservation of fertility.

[Uterine rupture during labor following surgical hysteroscopy]

Two cases of obstetrical uterine rupture after operative hysteroscopy without perforation are described. One was treated for uterus septus, the other one for synechia. However, the uterus could have been fragilized in both cases: one had been perforated by a uterine device, the other case had a past history of repeated curetage. A review of the literature shows 7 other similar cases, published over last ten years, 6 of them having a past history of perforation during the operative hysteroscopy (5 cases) or by an intra-uterine device. These obstetrical complications, although rare, can lead to consider a uterus treated by hysteroscopy as being at risk for obstetrical rupture.

Uterine rupture following hysteroscopic lysis of synechiae due to tuberculosis and uterine perforation

A patient with genital tuberculosis who conceived with in-vitro fertilization and embryo transfer following hysteroscopic synechiolysis complicated by a fundal uterine perforation subsequently presented with uterine rupture at 36 weeks gestation. Immediate Caesarean section and repair of the ruptured uterus were performed. Women with a history of uterine perforation should be counselled regarding the risk of uterine rupture during their subsequent pregnancies.

[The prospective study of trial labor following previous cesarean section]

OBJECTIVE

To investigate the trial of labor following previous cesarean section.

METHODS

Three hundred and sixty one cases of pregnant women with history of previous low segment transverse cesarean section were prospectively studied on mode of delivery. 158 cases delivered by elective repeat cesarean section. 203 cases were allowed a trial of labor.

RESULTS

183 out of 203 patients had successful vaginal deliveries. One patient with uterine scar partly ruptured was noted on uterine exploration after delivery. There was no maternal death. The rate of spontaneous vaginal delivery was 79.2%. The rate of vacuum extractor and low forceps deliveries was 20.8%. The 1 minute Apgar score of 170 newborns was > or = 8. Neonatal asphyxia was found in 13 newborns and there was one neonatal death due to congenital abnormality.

CONCLUSIONS

Carefully selecting the indication of trial labor and monitoring the labor course are very important for increasing successful vaginal delivery rate and reducing repeat cesarean section.

[Peripartum hysterectomy. Report of eleven cases]

A series of hysterectomies performed during labor or shortly after delivery, all as emergencies is reported. The study covered the ten years 1982-1991, during which 65,488 deliveries resulted in infants with a birth weight of 500 g or more. There were no hysterectomies among the 21,998 primipara, the incidence in multipara being 1 per 3,954 deliveries. Five operations were performed for rupture of the uterus and six for cataclysmic bleeding. Seven of the 11 patients had history of caesarean section. In multipara, the existence of a caesarean scar multiplied the risk of emergency hysterectomy by a factor of 18. There were no maternal deaths but all patients required transfusion with more than 6 units of packed cells. These results emphasize the fact that a history of caesarean is the principal etiologic factor in patients experiencing complications of pregnancy which require emergency peri-partum hysterectomy.

Rupture of pregnant uterus in Shashemene General Hospital, south Shoa, Ethiopia (a three year study of 57 cases)

This study was carried out to determine the frequency of occurrence and outcome of treatment of uterine rupture in a rural hospital. Fifty seven patients with uterine rupture were admitted to Shashemene General Hospital (SGH) from September 1989 to August 1992. The age, parity, type of operation, outcome of treatment, site of rupture, post operative complications and duration of hospitalization of these cases were analyzed. Two thousand one hundred eighty five deliveries were conducted over the study period. The frequency of occurrence of uterine rupture was 2.6% or 1 in 38 deliveries. There were 9 deaths giving a case fatality rate of 15.8%. The mean duration of hospitalization among those who survived was 13 days (Range: 6 hours to 20 days). Fifty four (94.7%) of the cases were para 3 and above. Left lateral wall rupture was found in 28 (49%) of the cases. The commonest causes of rupture were neglected shoulder presentation (63.2%), brow and face presentations (29.8%). The age of the patients ranged from 16 to 59 years, with a peak incidence (42 (73.7%)) occurring between 25 and 34 years. Three patients had repair operation and fifty four had hysterectomy. The antibiotics used for treatment of associated infections were crystalline penicillin, ampicillin and chloramphenicol since other drugs were not available.