Uterine rupture and labor induction with prostaglandins

Uterine rupture in patients with labor induction with prostaglandin E2 application though uncommon is a very serious complication and preventable in obstetrics. We reported three cases of spontaneous uterine rupture following induction of labor with intracervical PGE2 gel administration in a dosage of 3-6 mg and two in whom labor was augmented with oxytocin infusion. To avoid such a complication, intracervical PGE2 gel administration should be started with a smaller dose and should augmentation with oxytocin be required careful evaluation and monitoring by a specialist is desirable.

[Uterine rupture in a prior cesarean section. Review of the literature and 2 case reports]

On the basis of two cases, the authors undertake a thorough review of rupture of the uterus affecting the uterus with cesarean section scarring. They evaluate etiological factors, monitoring methods and management. An extensive review of the literature is presented.

Risk factors associated with uterine rupture during trial of labor after cesarean delivery: a case-control study

OBJECTIVE

The purpose of our study was to thoroughly investigate the risk factors of uterine rupture in patients undergoing trial of labor after cesarean section.

STUDY DESIGN

We conducted a case-control study of 70 patients with prior cesarean delivery with uterine rupture during trial of labor between January 1983 and June 1990. The risk factors of uterine rupture were identified, and the estimates of the relative risks were reported.

RESULTS

The risk of uterine rupture was increased in patients who had an excessive amount of oxytocin, who had experienced dysfunctional labor, and who had a history of two or more cesarean deliveries. Epidural anesthesia, macrosomia, history of successful vaginal delivery after cesarean section, unknown uterine scar, and history of cesarean delivery because of cephalopelvic disproportion were not associated with uterine rupture.

CONCLUSIONS

We recommend that all patients with a history of cesarean delivery be observed closely for progression of labor. Recognition of an active-phase arrest disorder, despite adequate augmentation with oxytocin, requires operative delivery.

Third-trimester uterine rupture following hysteroscopic uterine perforation

BACKGROUND

As operative hysteroscopy becomes more common, long-term complications become apparent.

CASE

A 29-year-old woman had a hysteroscopic uterine septum resection. This was complicated by a small fundal puncture. In the ensuing pregnancy, uterine rupture occurred at 33 weeks and resulted in neonatal mortality and maternal morbidity.

CONCLUSION

Uterine rupture may follow uterine perforation at operative hysteroscopy; patients contemplating pregnancy after such perforation warrant appropriate counseling.

Neglected transverse lie with uterine rupture

We present a case of neglected transverse lie with uterine rupture, which is rarely encountered in modern obstetric practice. The prominent clinical features, including uterine rupture and fetal death, are described. Treatment entails resuscitative measures and Cesarean delivery.

Spontaneous uterine rupture after hysteroscopic metroplasty with uterine perforation. A case report

This is the first documented case of spontaneous uterine rupture during pregnancy following hysteroscopic metroplasty complicated by uterine perforation. This case emphasizes the importance of treating these patients as high risk throughout pregnancy.

Emergency peripartum hysterectomy and associated risk factors

OBJECTIVE

Peripartum hysterectomy at Los Angeles County-University of Southern California Medical Center was reviewed and associated risk factors were identified.

STUDY DESIGN

Retrospective descriptive and cohort analysis from January 1985 to June 1990 was carried out. Adjusted relative risks for hysterectomy with 95% confidence intervals for identified risk factors were calculated where possible.

RESULTS

There were 123 cases of emergency peripartum hysterectomy (incidence of 1.3/1000 births). Indications for hysterectomy were primarily placenta accreta (n = 61), uterine atony (n = 25), unspecified uterine bleeding (n = 19), and uterine rupture (n = 14). The relative risk of emergency hysterectomy was 95.5 (95% confidence interval 66.7 to 136.9) for cesarean delivery, 10.78 (95% confidence interval 7.56 to 15.37) for prior cesarean delivery, and 97.29 (95% confidence interval 70.28 to 134.70) for placenta previa.

CONCLUSIONS

Cesarean delivery, prior cesarean delivery, placenta previa, placenta accreta, and uterine atony were identified risk factors for emergency peripartum hysterectomy.

Uterine tear without a corresponding placental lesion in a mare

A 3-cm full-thickness tear near the tip of the previously gravid uterine horn of a 12-year-old Thoroughbred mare was diagnosed at surgery. The mare had delivered a foal with veterinary assistance 2 days prior to surgery. The mare subsequently developed muscle tremors, anorexia, and signs of depression. Physical examination revealed pyrexia, extended capillary refill time, muscle fasciculations, and fewer-than-normal borborygmi. Abnormalities of the uterus or vagina were not detected by palpation per rectum or per vagina. The chorioallantois underlying the area of the tear was intact. We propose that the uterine tear was caused by pressure created by the foal's stifle against the maternal pelvis or by blunt forces caused by the foal's foot, sufficient to tear the uterus, but not the chorioallantois.

Rupture of the pregnant uterus: Ramathibodi's experience 1981-1990

A total of seven women had uterine rupture at Ramathibodi Hospital, Bangkok, between 1981-1990. The incidence was 1 per 9,908 deliveries or 1.009 per 10,000 deliveries. All were related to oxytocic drug administration and two of them had induction with prostaglandins. The intraoperative and postoperative problems were intraoperative hypotension (57%), febrile morbidity (28%) and wound dehiscence (12.5%). Fetal mortality was 43 percent and there was no maternal death.

Uterine rupture during a trial of labor in a case with a unicornuate uterus and a previous cesarean section

We describe a case of uterine rupture during labor in a patient with a previous cesarean section and a unicornuate uterus. The case may encourage obstetricians to carry out elective repeated cesarean sections in cases with previous cesarean sections and uterine anomalies.

Late vaginal induced abortion after a previous cesarean birth: potential for uterine rupture

This descriptive study was conducted to evaluate the risk of uterine rupture in cases of late vaginal induced abortions among women with previous cesarean sections. 23 women were referred at a mean gestational age of 23.9 (SD 6.9) weeks of gestation after one or two cesarean sections. Indications for terminating the pregnancy were maternal diseases in 4 cases and fetal anomalies in 19 cases. RU 486 and/or prostaglandins were used for cervical ripening and to induce labor. Vaginal birth was obtained in 20 cases (86.9%) with an average duration of 72 (SD 52) h. Cesarean section was performed in the remaining 3 women because no cervical dilation could be obtained. One uterine rupture occurred and was treated with conservation of the uterus. Late termination of pregnancy in such cases can be achieved without cesarean section with a high success rate.

Combined cornual pregnancy and intrauterine twin pregnancy after in vitro fertilization and embryo transfer: report of a case

A case of combined cornual pregnancy and intrauterine twin pregnancy after in vitro fertilization (IVF) and transfer of six embryos is presented. The case was diagnosed as intrauterine triplets ultrasonographically at seven weeks of gestation. Unfortunately, the patient suffered from severe lower abdominal pain and hypovolemic shock at 10 weeks of gestation, and an emergent laparotomy was done. During the operation, a ruptured cornual pregnancy with accompanying hemoperitoneum was found. Because fetal heart beats were not detected by intraoperative ultrasonography in the other two intrauterine fetuses, evacuation of the gestational contents through the uterine defect was done, and the rupture site was repaired. The incidence, mechanism and management of heterotopic pregnancies after in vitro fertilization and embryo transfer are discussed.

Uterine dehiscence following laparoscopic myomectomy

BACKGROUND

Laparoscopic myomectomy is a new procedure that is growing in popularity. The natural history of pregnancy following laparoscopic myomectomy is unknown.

CASE

A 24-year-old white woman, gravida 0, with infertility and endometriosis, conceived after a laparoscopic procedure that included myomectomy. At 34 weeks' gestation, the patient experienced uterine dehiscence at the site of myomectomy. An emergency cesarean delivery was performed and the uterus was oversewn. Both mother and infant had satisfactory hospital courses.

CONCLUSION

Meticulous closure of the myometrial bed following myomectomy is difficult via the laparoscope, and this could interfere with the integrity of the scar. If further studies confirm this experience, then laparoscopic myomectomy may need to be limited to patients who do not desire further childbearing.

Delivery through the maternal bladder during trial of labor

BACKGROUND

The safety of trial of labor after cesarean has been documented by numerous studies. Large series have demonstrated that in a properly chosen setting, 75% of women can achieve vaginal delivery without undue risk to the mother or fetus. In a small percentage of cases, trial of labor deviates from the expected outcome.

CASES

Two infants were delivered through the maternal bladder, one after uterine dehiscence and the other after vaginal rupture at trial of labor.

CONCLUSION

Standard and unique complications are reported with trial of labor. Because these complications occur infrequently, they should not discourage an attempt at vaginal delivery after cesarean.

[Total uterine rupture of a cesarean section scar during attempted vaginal delivery under epidural analgesia]

A case of complete uterine rupture and abruptio placentae during an attempt of vaginal delivery under epidural analgesia in a woman with previous caesarean section is described and discussed. When using epidural analgesia for such a patient during vaginal delivery it is imperative that newly developed pain should be ascribed to the uterine scar and the diagnosis of threatening uterine rupture be made immediately.

Vaginal delivery after caesarean section

In a prospective study of 318 consecutive pregnancies complicated by previous Caesarean section, 193 (61%) had an elective repeat Caesarean section, 125 (39%) had a trial of labour and 80 (64%) of these women achieved a vaginal delivery. The incidence of uterine rupture was 0.8% (1 of 125). The vaginal delivery rate was not influenced by the indication for the first Caesarean section (including cephalopelvic disproportion), birth-weight, health insurance status, use of epidural analgesia or oxytocin in labour. Perinatal morbidity was unaffected by the mode of delivery and maternal morbidity was comparable following elective and emergency repeat Caesarean section. Patients having a vaginal deliver spent significantly less time in hospital. We conclude that vaginal delivery after lower segment Caesarean section is safe and should be considered in most patients after a critical review of the indication for the first Caesarean section.

Symptoms and signs with scar rupture--value of uterine activity measurements

To evaluate the symptoms and signs of scar rupture with special reference to intrauterine pressure measurement a retrospective analysis of labour records of those women who had trial of labour with a previous Caesarean scar in the National University Hospital over a period of 6 years (1985-1990) was carried out. Known symptoms and signs associated with scar rupture, cardiotocographic tracings and fetal and maternal outcome in these patients were studied. Of the 1,018 women with previous Caesarean scar (4.2% of our pregnant population at term) 722 (70.9%) had trial of labour; 70% delivered vaginally. There were 4 (0.55%) incomplete and 5 (0.69%) complete scar ruptures. All 9 women had an oxytocin infusion; 3 were diagnosed postdelivery (all 3 had complete ruptures); 3 of the 6 who had rupture prior to delivery had sudden reduction in uterine activity, 1 had scar pain and prolonged bradycardia and 2 had no symptoms or signs. Continuous cardiotocography with intrauterine pressure measurements may help to identify scar rupture early and may be of value especially in those who have an oxytocin infusion.

Routine previous cesarean scar exploration following successful vaginal delivery. Is it necessary?

Among the 960 women who successfully delivered by vaginal route after previous cesarean section, 10 (1.04%) had complete lower segment scar rupture over a 9 year period. All were sufficiently symptomatic in order to suspect a ruptured uterus prior to scar exploration. We conclude that lower uterine segment palpation should be reserved only for symptomatic patients.

Rupture of uterine scar with extensive maternal bladder laceration after cocaine abuse

A relationship between cocaine use and extensive rupture of a uterine scar has not been reported. We report such a case with extensive laceration of the maternal urinary bladder occurring after ingestion of cocaine.

[Uterine rupture in Denmark during the period 1980-1987]

A retrospective review was undertaken of 128 consecutive cases of rupture of the uterus during the eight-year period from 1 Jan 1980-31 Dec 1987. It was found that rupture of the uterus occurs most commonly after previous Cesarean section but that it may occur after other types of operation on the uterus. Rupture of the uterus does not occur in primiparae unless special conditions are present. Potent stimulation appears to involve a slightly increased risk for rupture of the uterus. A great proportion of the ruptured uteri occurred in women who had previously been submitted to Cesarean section on account of breech presentation as primiparae. In subsequent pregnancies, this resulted in three dead infants and four children with severe brain damage.