Gravid uterine dehiscence: MR findings

Gravid uterine rupture can be a difficult diagnosis, both clinically and radiologically. Ultrasound has been successful in detection of some indirect signs of uterine rupture but thus far has shown little success in demonstrating the myometrial defect. We present the MR findings in a case of gravid uterine dehiscence in which the actual uterine wall defect was well demonstrated. Gross pathologic correlation is provided.

A trial of labor complicated by uterine rupture following amnioinfusion

Amnioinfusion has become accepted in the management of intrapartum cord compression, meconium-stained fluid, and oligohydramnios. Limited experience exists regarding amnioinfusion in patients undergoing a trial of labor after cesarean section and its potential complications. We report a case of trial of labor in which uterine rupture occurred following intrapartum amnioinfusion. This case demonstrates the need for careful attention to amnioinfusion volumes and administration in patients with a previous cesarean section.

The partograph in the management of labor following cesarean section

OBJECTIVE

To determine whether graphic labor record (partogram) can be used to predict the risk of uterine scar rupture in labor following lower segment cesarean section.

METHODS

Between 1988 and 1991, 236 women had a trial of labor following cesarean section. After the onset of the active phase (3 cm cervical dilatation), a 1 cm/h line was used to indicate an alert line on the partogram. All the active phase partograms were divided into five time zones: A (area to the left of the alert line), B (0-1 h after the alert line), C (1-2 h after the alert line), D (2-3 h after the alert line), and E and F (> 3 h after the alert line). For the action line, different lag times after the alert line were defined according to the time zones. Sensitivity, specificity, cesarean section rates and rupture rates were calculated for the different lag times after the alert line, and a receiver-operating characteristic curve was constructed.

RESULTS

Fifty-five (23.3%) trials of labor ended in a repeat emergency cesarean. There were seven (2.9%) cases of scar rupture. Of the 181 vaginal deliveries, 151 (83%) occurred within 2 h after the progress of labor had crossed the alert line (zones A-C). Five out of seven cases of scar rupture occurred more than 2 h after the alert line had been crossed (zones D-F). The 2- and 3-h lag time after the alert line had a sensitivity of 71% and 43%, respectively, and a specificity of 78% and 96%, respectively, in predicting uterine scar rupture. If cesarean sections were performed at 2 or 3 h after crossing the alert line, the projected cesarean rates would have been 36% and 27%, respectively. The scar rupture rates would in turn be 0.8% and 1.6%, respectively.

CONCLUSION

In women undergoing a trial of labor following cesarean section, the partographic zone 2-3 h after the alert line represents a time of high risk of scar rupture. An action line in this time zone would probably help reduce the rupture rate without an unacceptable increase in the rate of cesarean section.

Uterine rupture in association with alkaloidal ("crack") cocaine abuse

The use of alkaloidal ("crack") cocaine in pregnancy can result in systemic and focal vasoconstriction and abnormal uterine contractions forceful enough to cause the complete rupture of a gravid uterus along a previous vertical cesarean section scar. A 43-year-old woman was admitted to the emergency department with acute abdominal pain at 34 weeks' gestation. She had had a low vertical cesarean section 3 years previously for breech presentation with acute fetal distress at 28 weeks' gestation. The patient had a history of heavy "crack" abuse and admitted to inhaling "crack" throughout the day until 4 hours before admission. Within 15 minutes after presentation a laparotomy was performed, revealing an infant floating in the abdominal cavity. A live baby was promptly delivered, and the ruptured uterus was repaired. The patient was discharged 4 days post partum. "Crack" cocaine, through its known effects on the vasculature and contractility of the myometrium, likely facilitated the uterine rupture in this patient. The edges of the rupture wound were surprisingly clean, with little bleeding, perhaps owing to the drug's vasoconstrictive effects. It was therefore feasible to repair the uterus as an alternative approach to hysterectomy.

Trial of labor after cesarean delivery with a lower-segment, vertical uterine incision: is it safe?

OBJECTIVE

Our purpose was to assess maternal and perinatal outcomes associated with a trial of labor and attempted vaginal birth after prior low-segment vertical cesarean delivery.

STUDY DESIGN

During a 10-year period in a single tertiary hospital, all patients with a prior low-segment uterine incision (whether vertical or transverse) were considered candidates for a trial of labor in the absence of other contraindications or patient refusal. Among the 1137 women who underwent low-segment vertical cesarean delivery, 262 were subsequently delivered of 322 live-born infants, and 174 (54%) of them were identified retrospectively as having attempted vaginal birth. The maternal and perinatal outcomes of patients who did or did not undergo a trial of labor were analyzed and compared.

RESULTS

No significant differences between the two patient groups were observed regarding demographic characteristics, antepartum complications, gestational age at delivery (mean 37.4 weeks), birth weight, and cord pH at delivery. Vaginal delivery was accomplished successfully in 144 of 174 (83%) patients who underwent a trial of labor. Abdominal delivery was necessary for 17 mothers with labor disorders and 13 with suspected fetal distress. Postpartum hemorrhage occurred more often in the trial of labor group (7/174 [4.0%] vs 2/148 [1.4%], p not significant), but endometritis developed significantly more often in patients with elective repeat cesarean delivery (16.9% vs 6.3%, p = 0.006). Rupture of the low-segment vertical cesarean scar occurred in 2 patients during a trial of labor (1.1%) versus none in the elective repeat cesarean group. Neither mother experienced fetal extrusion or adverse maternal or fetal sequelae. Frequency of serious neonatal complications (8.1% vs 10%) and neonatal mortality (1.7% vs 2.0%) were similar between groups. All neonatal deaths were a result of extreme prematurity or congenital anomalies.

CONCLUSIONS

Our experience indicates that a mother with a prior low-segment vertical cesarean delivery can undertake a trial of labor with relative maternal-perinatal safety. The likelihood of successful outcome and the incidence of complications are comparable to those of published experience with a trial of labor after a previous low-segment transverse incision.

Spontaneous rupture of the unscarred uterus

OBJECTIVE

By presentation of cases of spontaneous (nontraumatic) ruptures of previously intact uteri, we sought to emphasize important aspects of this rare and dangerous event.

STUDY DESIGN

Two case presentations of oxytocin-associated unscarred uterine rupture and review of pertinent literature are used to study risk factors and accompanying clinical characteristics.

RESULTS

Both spontaneous ruptures of previous unscarred uteri were associated with low-dose oxytocin augmentation, bradycardia, and uterine hyperstimulation monitor patterns and occurred at the onset of the second stage of labor.

CONCLUSION

Because of its rarity, further investigation of spontaneous uterine rupture will depend on case presentations where the associated events listed are noted and uterine hyperstimulation, fetal bradycardia, and second-stage onset are proved or disproved as valid clinical associations.

Uterine rupture during pregnancy after laparoscopic myomectomy

A 31 year old patient presenting with primary infertility underwent an operative laparoscopy for the treatment of bilateral hydrosalpinges, during which a myomectomy was also performed. The uterus was repaired using interrupted sutures. At follow-up laparoscopy seven weeks later, a uterine fistula was diagnosed and was oversewn using a single 'figure of eight' suture. One year later the patient became pregnant through in-vitro fertilization. At 34 weeks gestation, she required an emergency laparotomy for acute abdominal pain and the presence of fetal bradycardia. The operative findings revealed a uterine rupture at the site of the previous myomectomy scar. This was then enlarged with a scalpel and a live baby was delivered. The uterus was repaired in two layers. The postoperative period for both mother and baby was satisfactory. This complication raises the problem of the quality of uterine repair following laparoscopic myomectomy, together with the question of how to prevent this type of life-threatening situation.

Recurrent uterine rupture diagnosed by ultrasound

A case of recurrent rupture of the uterus is presented. The patient had a history of left cornual uterine rupture, which was repaired, and she was considered to be suitable for a subsequent pregnancy. During the subsequent pregnancy, attempts were made to evaluate the condition of the uterine scar by ultrasound in order to anticipate threatening rupture of the scar. No signs of dehiscence could be detected until the patient presented with clinical signs. Ultrasound examination revealed protrusion of the membranes at the fundus uteri. Uterine rupture is a rare, but hazardous, obstetric complication that can affect both mother and child. The possible role of ultrasound in cases of elevated risk for uterine rupture is discussed.

[Uterine rupture after twenty-two weeks of amenorrhea due to placenta praevia percreta. A case report]

The authors report a case of rupture of the uterus 22 weeks after the LMP, due to placenta praevia percreta and requiring emergency hysterectomy to arrest bleeding, followed by urinary complications. With the predisposing factors of the scars of 4 previous cesarean sections and the low anterior insertion of the placenta, this exceptional case--in terms of its rarity and gravity--led the authors to undertake a review of the literature seeking other cases of this greatly feared obstetric complication. They review the clinical, ultrasonographic (notably the use of color Doppler) and paraclinical (MRI, cystoscopy) diagnostic approach necessary to make an accurate diagnosis of placenta percreta (if possible before any hemorrhagic complications). This situation virtually invariably requires hysterectomy to arrest bleeding, under very difficult conditions because of the massive hemorrhage involved. Mortality remains high and morbidity principally concerns the urinary complications frequently encountered.

[Uterine rupture: 50 cases]

The author reports 50 cases of rupture of the uterus among 11,060 labors i.e. one rupture per 220 labors. This study shows that rupture of the uterus occurs in women in poor socio-economic circumstances. Uterine scarring seems to be a more important factor than age and multiparity. Traumatic rupture is also common, resulting from obstetric procedures but above all from abdominal expression, most often performed outside hospital. Rupture of the uterus may present in many different ways. It was diagnosed in 32 cases before delivery while in 18 cases it was discovered during cesarean section or extraction of retained placenta. The lower segment was the elective site of rupture. With regard to treatment, suture was possible in 42 cases while hysterectomy proved necessary in the other 8 cases in view of the poor local tissue state. The prognosis remains gloomy, with a high risk of maternal death and, above all, a 58% fetal death rate.

Rupture of the uterus

OBJECTIVES

To investigate the frequency of ruptured uterus, possible etiologic factors and fetomaternal outcomes.

METHODS

The birth records of 58262 deliveries at Dr Zekai Tahir Burak Women's Hospital from 1 January 1990 to 31 December 1992 were reviewed and the results compared with those of two previous studies reported from this hospital on the same subject.

RESULTS

Forty uterine ruptures occurred between 1990 and 1992, with a frequency of 0.068% (1/1457). All occurred spontaneously but 10 (25%) had no previous surgery, whereas 30 followed previous cesarean section. There was no traumatic uterine rupture during this period. Fetal mortality was 32.5% and no maternal deaths were recorded.

CONCLUSION

The rate of ruptured uterus has declined among our hospital population as etiologic factors responsible for the complication have been reduced.

[Uterine rupture during labor. Report of 106 cases at the Maternity Center of Tunis (Tunisia)]

This study involves 106 cases of the uterus seen at the Rabta Maternity and Neonatology Center (Tunis) over a period of 6 years. The incidence was 1.51% of labors and 75.4% of cases involved rupture of a scarred uterus. Rupture of a healthy uterus accounted for 24.6% of cases. The clinical picture was asymptomatic in 66.25% of cases involving a scarred uterus. Treatment of rupture of the uterus was essentially conservative by suture of the tear (73.6%). Maternal mortality was 2.8%. Perinatal mortality was high at 37.7%.

[Complications of intrauterine devices]

Abdominal migration of intrauterine devices is very rare. However, during the puerperium when the uterus is small and the uterine wall thin, the risk of perforation increases. A device removed by coelioscopy is described.

Caesarean birth rates worldwide. A search for determinants

High caesarean birth rates are an issue of international public health concern. Determinants of caesarean birth are reviewed in order to formulate strategies to reduce these high rates. A strong independent profession of highly qualified midwives, who care for women with low-risk pregnancies, may contribute to a relatively low caesarean birth rate. Different clinical policies which influence the intervention rate, are discussed for the most frequent reasons to perform caesarean section: dystocia, repeat caesarean birth, breech delivery and foetal distress. The risks and safety of caesarean birth differ from place to place in this world. As the relative safety of the procedure is an important factor contributing to the rise of caesarean birth, the fact that this has only been achieved in some parts of the world should restrict the indications to perform the operation in the best interests of pregnant women.

[Unusual twin pregnancy: one in the pseudo-unicornate uterus and the other in the rudimentary uterine horn. Discussion on the diagnosis and management during pregnancy]

An unusual twin pregnancy was diagnosed echographically at 18 weeks gestation and confirmed by magnetic resonance imaging. One foetus was in a pseudo unicornis uterus and the other in a rudimentary uterus cornu. The risk in such cases, as also reported in the literature, is rupture of the rudimentary cornu at about 20 weeks gestation. In this case the patient was carefully monitored to 23 weeks when the pregnancy in the rudimentary cornu stopped spontaneously. The foetus in the pseudounicornis developed normally to 38 week term. This exceptional observation emphasizes the risk of pregnancy in a blind uterus cornu.

[Spontaneous rupture of an unscarred uterus during labor and epidural anesthesia]

We report a case of spontaneous rupture of unscarred uterus, during labour and under epidural analgesia in a 43 year-old patient at her third pregnancy and third delivery. The tear was vertical and took place on the left postero-lateral side of the uterus, occurring in the whole height of the lower segment and overlapping towards the uterine corpus and cervix. Analysis of medical, surgical, gynaecological and obstetrical past history has displayed no predisposing factors explaining this rare occurrence. This clinical case reminds us that spontaneous rupture is always possible even on an unscarred uterus.

Spontaneous rupture of a low transverse cesarean scar

Uterine rupture occurs in less than 1% of pregnancies. The literature over the past several years confirms the safety of the low transverse uterine scar. We report a case of spontaneous rupture of a low transverse cesarean scar at 36 weeks' gestation, resulting in fetal death.