Uterine rupture following conservative surgery for interstitial pregnancy

A case of uterine rupture following conservative surgery for interstitial pregnancy is presented. Even though the uterine cavity was not opened during removal of the ectopic pregnancy, attenuation of the muscle lead to subsequent rupture of the uterus in the second trimester. The option for medical termination of ectopic pregnancies located in the cornual portion of tubes is discussed.

Misdiagnosis of interstitial pregnancy followed by uterine cornual rupture during induced midtrimester abortion

We present a case of interstitial pregnancy causing uterine cornual rupture during induction of prostaglandin midtrimester abortion. As the clinical and ultrasonographic diagnosis of advanced ectopic gestation may be difficult, the possibility of ectopic pregnancy should be considered in cases of unsuccessful attempts of induced abortion.

Rupture of rudimentary horn pregnancy

A rare case of rupture of an noncommunicating rudimentary horn pregnancy is reported. The pregnancy proceeded to 25 gestational weeks, when the rudimentary horn ruptured. The patient had signs and symptoms of massive hemoperitoneum. An emergency exploratory laparotomy revealed rupture of the gravid rudimentary horn and the fetus was lying free in the peritoneal cavity, was delivered breech and died 2 hours later. This reproductive complication was treated successfully by prompt exploratory laparotomy. Some of the factors associated with pregnancy in a rudimentary horn are discussed.

[Management of the scarred uterus]

On the basis of 899 cases of uterine scarring following cesarean section, the authors carried out a prophylactic cesarean in 42% of cases. Labor ended in childbirth by the genital tract in 44% of cases. The very low incidence of uterine rupture since segmental hysterotomy has become widespread and the improved fetal and maternal prognosis are all reasons to prefer delivery by the genital tract. One of the factors in choosing the method of childbirth is radiopelvimetry and estimation of the fetal weight; however, the suspicion of a threshold pelvis is not a contraindication to the labor test which was successful in 70% of the authors cases. On condition that strict obstetrical monitoring is possible, oxytocic drugs can be used to induce labor or correct hypokinesia and to administer a peridural analgesic. Routine extraction is no longer necessary during the expulsion phase but the authors remain faithful to uterine revision. In general, the labor test should be suggested as often as possible and should receive the same monitoring and treatment methods as for an intact uterus.

Rupture of gravid uterus: a eight-year clinical analysis and review of the literature

Nine cases of ruptured gravid uterus occurred at the Chang Gung Memorial Hospital from July 1983 to June 1991. The incidence is 1/3871. Six (66.7%) of the nine cases of uterine rupture involved rupture of intact uteri. The remaining three (33.3%) occurred in uteri scarred by a previous cesarean-section. The common contributing factor to rupture of an intact uterus was injudicious use of a uterine stimulant; whereas the common etiology of rupture of a scarred uterus was a previous scar rupture or dehiscence. In this series, there was no maternal mortality; however, three (33.3%) of the infants died. The fetal death rate was higher with rupture of an intact uterus, 50.0%, as opposed to 0% with rupture of a scarred uterus. Abnormal labor course and clinical features (palpable fetal part or regression of head, profound shock and cessation of uterine contraction) were the important tools for early diagnosis of uterine rupture. Mortality rates for the mother and fetus can be decreased with a high index of suspicion, early diagnosis, and immediate surgical intervention.

Prerupture ultrasound diagnosis of interstitial and rudimentary uterine horn pregnancy in the second trimester. A report of two cases

Pregnancies in an interstitial and rudimentary uterine horn are rare and often fatal varieties of ectopic gestation. Ruptures tend to occur in the second trimester, resulting in maternal morbidity and mortality. Only a few cases of the ultrasonographic diagnosis of unruptured second-trimester interstitial and rudimentary uterine horn pregnancy have been reported. In two such cases second-trimester ultrasonographic examination revealed an unusual pregnancy location, thin uterine wall, incomplete myometrial layer and empty uterus.

[A twin pregnancy in a bicornuate uterus]

A case of twin pregnancy in bicornuate uterus with a fetus in each horn is presented. During the second trimester, the rudimentary horn ruptured. This horn was extirpated and two non viable fetus were delivered by cesarean section. Later on, the patient had another pregnancy in the unicornuate uterus. She was delivered at 36th week of pregnancy by cesarean section. The baby was in good condition.

Uterine rupture during trial of labor after previous cesarean section

This study was undertaken to determine the incidence and associations of uterine rupture and dehiscence with an attempted vaginal birth after cesarean section. The charts from 137 patients who had uterine scar separation after a previous cesarean section from 1983 to 1989 were examined. Approximately 9.3% of the 119,395 women who were delivered in that interval had a prior cesarean section. Of those, 68.8% underwent a trial of labor with a 79.2% success rate. The uterine rupture rate in this latter group was 0.8%, while an additional 0.7% had a bloodless dehiscence. Bleeding and pain were unlikely findings with a uterine scar separation (3.4% and 7.6%, respectively). The most common manifestation of a scar separation was a prolonged fetal heart rate deceleration leading to operative intervention (70.3%). We conclude that, although the incidence of uterine rupture was low, the event is most often seen as an acute emergency. Prevention should be directed toward timely diagnosis and prompt management of labor dystocias. Staff and facilities for safe management of a uterine scar separation are a requisite for the conduct of a vaginal birth after previous cesarean section.

[Pregnancy in a non-communicating rudimentary uterine cavity. Presentation of a case in a multipara]

A case of pregnancy in a rudimentary uterine horn is presented. The pregnancy developed asymptomatically until the 14th week when spontaneous rupture of the uterine horn occurred. The diagnosis was made at laparotomy indicated for hypovolemic shock due to intraperitoneal hemorrhage. The pathologic study of uterine horn showed a normally developed fetus and the placental tissues protruding at the rupture site of horn. The purpose of this paper is analysis of fecundation, implantation and the type of endometrium of the rudimentary uterine horn.

[Echographic and morphological parallels in the evaluation of the condition of the uterine scar]

Examinations of 86 women included echography, examination of the lower segment of the uterus during surgery, control manual examination of the postpartum uterus, and histologic examination of the tissues collected from the so-called cicatrix site. The authors claim that the criteria of the myometrial adequacy are the V-shaped lower segment of the uterus, at least 3-4 mm thick, continuous anterior contour of the uterus, the presence of a homogenous echostructure or a structure with small sites of elevated echogenicity. A balloon-shaped lower segment of the uterus and its thinness (less than 3 mm), no continuity in the uterine contour, predominance of elevated echogenicity incorporations in the echostructure of the cicatrix site indicate the inadequacy of the myometrium at the site of the transverse cicatrix in the lower segment of the uterus. The findings evidence that echography is a highly informative method for the diagnosis of the uterine cicatrix status and that echographic examinations should be widely used to choose the delivery mode for pregnant women with a history of abdominal delivery.

Rupture uterus: changing trends in etiology and management

Sixty-four cases of rupture uterus which occurred during the period 1980-89 were studied and compared with 70 cases in the preceding decade (1970-79). The changing trends in etiological factors and management of this condition have been demonstrated. While spontaneous rupture continued to account for about two-thirds of the cases (70.3%), the incidence of traumatic rupture uterus has become less than half, from 17.1 to 7.8%, and that of scar rupture has increased to more than double (from 11.4 to 23.4%). As regards management, there are improved results seen with conservative repair of the uterus. It was also seen that a subtotal hysterectomy was more commonly resorted to than total hysterectomy in the later decade. There was a decrease in the overall morbidity from 42.8 to 35.9% and also in the mortality rate from 24.3 to 18.7%.

Mandatory trial of labor after cesarean delivery: an alternative viewpoint

Twelve women experienced major rupture of the uterus during a trial of labor after previous cesarean (low transverse cervical incision in 11, low vertical in one). Two women required hysterectomy and a third had serious postoperative complications. There were three perinatal deaths, and two infants suffered significant long-term neurologic impairment. Although vaginal birth after cesarean delivery is considered safe in most instances, these cases serve as a reminder that catastrophic events can occur. Potential complications have important implications for clinicians when counseling patients about the route of delivery and for the management of any trial of labor after cesarean delivery.

Rupture of low transverse cesarean scars during trial of labor

We report eight cases of rupture of low transverse cesarean scars occurring during trials of labor. The cases occurred in five hospitals in the Denver metropolitan area during a 13-month period. The estimated incidence was 0.7% of planned trials of labor. Complications of rupture included one neonatal death, two cases of severe neonatal asphyxia, three maternal bladder lacerations, and one hysterectomy.

Trial of labor: a study of 110 patients

STUDY OBJECTIVE

The purpose of the study was to determine whether epidural analgesia is unsafe for trial of labor (TOL).

DESIGN

Retrospective chart review.

SETTING

Inpatient obstetric department at a university medical center.

PATIENTS

One hundred ten ASA physical status I and II term parturients who attempted a TOL between December 1987 and June 1988.

INTERVENTIONS

All the parturients previously had low transverse uterine incisions and received continuous electronic fetal and uterine pressure monitoring throughout labor. All the parturients were offered epidural analgesia during labor with bupivacaine 0.25%.

MEASUREMENTS AND MAIN RESULTS

Sixty-seven percent of the parturients had successful vaginal delivery. Fifty-one of the 110 parturients had epidural analgesia for labor. There were two complete uterine ruptures; neither had epidural catheters. Both of the complete ruptures presented with monitored fetal distress rather than abdominal pain. Both mothers and their infants recovered uneventfully.

CONCLUSIONS

Uterine rupture presents as monitored fetal distress rather than abdominal pain. Thus, epidural analgesia can be used in patients attempting a TOL.

Vaginal birth after cesarean section in rural Tanzania

Eighty-seven of 134 women with a history of previous cesarean section in two rural hospitals in Tanzania had a vaginal delivery after a trial of labor. The incidence of scar-rupture was high: in 9 of 134 cases (6.7%). Maternal death, however, did not occur. It is concluded that a trial of labor is justified, and that the risk of scar-rupture should be balanced with the risk of repeat operations.

Rupture of the pregnant uterus--a 21-year review

Uterine rupture is still a common problem in developing countries although even here the incidence varies from urban to rural settings. This article is a review of uterine rupture in an urban referral hospital in Malaysia. It examines aetiology, clinical presentation, complications and management of the problem. Meticulous screening of patients together with optimal antenatal and intrapartum care will markedly reduce the incidence of uterine rupture. Early diagnosis and prompt treatment will further help reduce morbidity and mortality to both mother and fetus.

[Dystocia in a Grevy's zebra]

Dystocia in a Grevy zebra, caused by faulty position of the fetus, resulted in complete prolapse of the uterus and rupture of the uterus wall. Suturing, reposition and vaginal obstruction led to the total recovery of the Grevy zebra mare.

Intrapartum uterine rupture and inflammatory bowel disease

The incidence of uterine rupture in pregnant women ranges from 0% to 1.1% in large series. This case report describes a woman with a history of obstetric complications, uterine rupture, and active inflammatory bowel disease that was treated with high-dose prednisone.

[Uterine rupture in modern obstetrics]

The paper reports 18 cases of womb rupture observed in the Institute of Gynecology and Obstetrics at the University of Turin from April 1978 to June 1988. Following an analysis of the data relating to the above cases, the paper concludes that in order to reduce the incidence of womb rupture it is important to hospitalize high-risk patients preferably before the start of labour so as to intervent using caesarian section.

Uterine rupture

Uterine rupture is a sudden, unforeseeable event that carries a high rate of maternal and perinatal mortality. When the diagnosis of uterine rupture is suspected, prompt surgical intervention with an experienced pelvic surgeon and blood product replacement should be considered. At the time of uterine rupture, the patient should be evaluated for possible repair or hysterectomy. It appears, based on the aforementioned information, that repair is a reasonable consideration. In those patients who have undergone a repair, early delivery by elective cesarean after assessment of fetal lung maturity at or around 36 weeks gestation would appear prudent. In those patients with a prior cesarean, continuous electronic fetal monitoring to detect intrapartum fetal distress would appear prudent. In these patients fetal distress is the most common sign or symptom of uterine rupture and frequently precedes any other clinical manifestations of this complication.