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.

Ruptured uterus in Ibadan--a twelve year review

Maternal mortality and morbidity have remained very high in the developing countries. A common cause is ruptured uterus. In this report of 227 cases of ruptured uterus, the incidence was found to be rising. About 71.4% of the cases lacked prenatal care while 48.4% had a previously scarred uterus with many of them laboring for more than 12 h. The most common etiological factor was prolonged labor. Maternal mortality was 7.5% while perinatal mortality was 62.0%. Labor in high risk patients outside hospital because of declining economy and the rising influence of religion were some of the predisposing factors implicated. Methods to reduce this obstetric catastrophe are discussed.

Vaginal delivery in Nigerian women after a previous cesarean section

A total of 154 consecutive Nigerian women at term pregnancy who had undergone one previous cesarean delivery were prospectively studied during the year March 1987 to February 1988. A repeat elective cesarean section was performed in 52 (33.8%) patients. Vaginal delivery was achieved in 73 (71.6%) of the 102 subjects who were allowed into labor, and in over 90% of the comparison group. High vaginal delivery rates occurred among the women within the selection criteria irrespective of the indication for the previous cesarean section. A repeat emergency cesarean section was performed in 29 (24.5%) women. Rupture of the uterine scar occurred in 5 (4.9%) instances with the loss of 2 babies; there was no maternal loss. Excluding the high incidence of fetal asphyxia and uterine rupture which occurred among women in the study group, maternal morbidity and perinatal mortality and morbidity were similar to those of the comparison group. There was a statistically significant difference between the study and comparison group. There was a statistically significant difference between the study and comparison groups with regard to the mode of delivery. Among the study group, a significant correlation existed between the vaginal delivery rate of the patients and the indication for the primary cesarean section. There was however, no significant difference between the mean parities of the women who were delivered by cesarean section and those who delivered vaginally. Similarly, no significant difference existed in the mean birthweights of the babies delivered vaginally and those who were delivered abdominally during labor.(ABSTRACT TRUNCATED AT 250 WORDS)

[Utero-vesical perforation caused by an IUD]

A rare complication of positioning of an IUD represented by utero-vesical puncture is reported in a woman of 37 who was using this contraceptive technique for the first time. The IUD was removed endoscopically, about 2 years after its positioning. The observation was an almost chance event by echography performed for vague pains in the suprapubic region.

Perforation of the uterus following IUD insertion in the puerperium

Perforation of the uterus by an IUD is very rare. However, during the puerperium when the uterus is small and the uterine wall is thin the risk of perforation increases. We present three patients treated within a rather short period of time at our institution for perforation of the uterus caused by IUD insertion 3-4 months after delivery. Although perforation is by no means always associated with pain, our patients did present with abdominal pain caused by this rare IUD-associated complication. One patient underwent laparotomy, and in two, laparoscopy sufficed to treat this complication.

Uterine perforation during second-trimester abortion by cervical dilation and instrumental extraction: a review of 15 cases

Review of the records of 15 women who had uterine perforations at the time of second-trimester abortion by dilation and evacuation showed that unexpected pain (but not excessive bleeding) was the most prominent sign. All patients required laparotomy, but in no case was laparotomy necessary as an emergency procedure. Laparoscopy was not helpful. Two-thirds had bowel injuries and two required hysterectomy. Errors in estimating gestational duration, inadequate cervical dilation, and failure to use sonography characterized these complicated cases.

True rupture/scar dehiscence in delivery following prior section

Fear of uterine rupture has led to the widespread practice of 'Once a section, always a section'. Between 1972 and 1982, 1498 patients with one or more previous cesarean sections were delivered at University College Hospital, Galway. Trial of labor was undertaken in 844 patients, while the remaining 654 patients underwent repeat elective section because they had two or more prior sections. Eight true ruptures and 22 scar dehiscences were found. Regional analgesia and oxytocin did not significantly affect the rate of true rupture. The mean parity with uterine rupture was five, and it occurred most frequently in the initial trial of labor. There were four perinatal deaths associated with true rupture. Failure to detect the already compromised fetus before labor and delivery, rather than the method of delivery, was responsible for fetal demise in some instances. Five true ruptures were found in the trial of labor group (i.e. a ratio of 1:169), with the loss of three babies. A further baby was stillborn in a mother who ruptured a classical scar before labor. There were no maternal deaths in trial-of-labor patients and one in the elective section group. Two patients with true rupture had their uterus repaired, and were subsequently delivered by section. Another two patients with bloodless dehiscence and no repair, had two subsequent elective repeat sections each, and the unrepaired scar dehiscence was not evident.

Early spontaneous rupture of the post myomectomy gravid uterus

Rupture of a pregnant uterus is a serious threat to the mother's life and her fetus. Most of these cases have predisposing factors of which a post myomectomy scar is rare. Rupture of a post myomectomy gravid uterus usually occurs in the third trimester of pregnancy or during labor. We present a case of a very early spontaneous rupture which occurred at the 20th week of gestation in a post myomectomy uterus. To the best of our knowledge no previous report of a ruptured myomectomy scarred uterus has been described at such an early stage.

[Rupture of the pregnant uterus]

A case of intrapartum rupture of the uterus in an unscarred uterus uterus is reported. The patient was stimulated with oxytocin infusion at 42 weeks of gestation because of mild preeclampsia. Labour was uneventful for four hours, when the patient suddenly complained of abdominal pain during contractions. The fetus was found in transverse lie and no fetal heart rate could be registered. An acute cesarean section was performed and both the placenta and the child were delivered through a complete rupture extending from the right uterine horn to the vagina. Intrapartum uterine rupture is a rare but serious complication carrying high mortality rates for both mother and child. It is usually considered to be related to a weakness in the uterine wall, e.g. a previous cesarean section.

Multiple uterine rupture and crushing injury of the fetal skull after blunt maternal trauma. A case report

Multiple pelvic fractures and explosive-type uterine lacerations occurred in a previously healthy 17-year-old primigravida involved in a motor vehicle accident. The fetus suffered a crushed skull and was completely extruded with the placenta from the uterus. Treatment was complicated by severe disseminated intravascular coagulation with secondary fibrinolysis. Thrombelastography enabled us to rapidly evaluate the patient's coagulation status and to monitor her response to goal-directed therapeutic interventions (surgery, specific blood product therapy and epsilon-aminocaproic acid).

Successful outcome after antepartum expulsion of placenta and fetus into the abdominal cavity; a case report

Spontaneous rupture of the uterus before labour is a rare event associated with a high incidence of maternal and fetal death. We report a case of spontaneous uterine rupture at 34 weeks' gestation in a patient's second pregnancy. The case is unusual because both the mother and baby survived despite the expulsion of the placenta with the fetus into the abdominal cavity prior to laparotomy.

Uterine rupture complicating midtrimester abortion. A report of two cases

Uterine rupture occurring during a midtrimester abortion is rare. This complication may lead to profound shock and death as well as to interference with the patient's future fertility. Two patients sustained a uterine rupture during midtrimester abortion. This complication seems to be preventable. The risk of uterine rupture due to overstimulation is higher when amnioinfusion with prostaglandin or hypertonic saline is combined with the use of other oxytocic drugs. Grand multiparas undergoing amnioinfusion should not be given oxytocin; in the rare cases in which oxytocin is needed, it should be administered cautiously and monitored continuously. When a supplemental agent, such as an oxytocic, is needed, it should not be started until several hours after the amnioinfusion.

Choriocarcinoma following term pregnancy--a case report

A patient, with two previous term deliveries, presented with post-partum haemorrhage and spontaneous uterine perforation due to choriocarcinoma, requiring emergency laparotomy. Choriocarcinoma following term pregnancy is a rare form of gestational trophoblastic disease. Such tumour appears to follow a more aggressive course with a more extensive metastatic spread and is less responsive to chemotherapy resulting in a poorer prognosis. Choriocarcinoma presenting as postpartum haemorrhage, and spontaneous tumour perforation with intra-abdominal haemorrhage is even rarer. Early diagnosis is an important factor for the patient's survival. A high index of suspicion is required as the tumour may be overlooked. An aggressive chemotherapeutic regime has improved the overall survival.

Placenta percreta induced uterine rupture and resulted in intraabdominal abortion

Acute abdomen and shock are diagnosed in a 21-year-old primigravid patient at 23 weeks' gestation. Laparotomy revealed a 7 to 8 cm rupture on the fundus of the uterus and a 450 gm dead fetus in the abdominal cavity.

[Rupture of the uterus in the ninth week due to an angular pregnancy. Clinical case]

A clinical case of ruptured uterus in the ninth week of an angular intrauterine pregnancy is presented.

[Management of labor following cesarean section]

Of 451 deliveries between 1 July 1981 and 30 June 1987, in patients having previously undergone a cesarean section, 279 (62%) were vaginal births, 80 (18%) were primary and 92 (20%) secondary repeat cesareans. The highest frequency of vaginal deliveries was in cases with prior abnormal presentation (87%). History continues to play an important role: vaginal deliveries were achieved in 59% of the cases in which the cesarean section was the only previous delivery. This rate increased to 89% if the subsequent birth was vaginal. Uterine rupture occurred in 10 cases (2.2%). The mode of delivery had no significant influence on the incidence of acidosis; in the repeat cesarean cases the newborns had poorer one-minute Apgar scores.

Vaginal birth after cesarean delivery in the twin gestation

The pregnancy outcomes of 56 women with a twin gestation and a prior cesarean birth were analyzed to determine whether a trial of labor was a reasonable consideration. Of these patients, 31 (55%) underwent an elective repeat cesarean delivery and 25 (45%) attempted vaginal delivery. Of those who attempted vaginal delivery, 18 (72%) were vaginally delivered of both infants. The dehiscence rate among women with twin pregnancies who attempted a trial of labor was 4% compared with 2% in women with singleton pregnancies. There were no significant differences in maternal or neonatal morbidity or mortality rates in trial of labor versus no trial of labor groups. We conclude in this limited population that a trial of labor in a twin gestation after a previous cesarean delivery appears to be a reasonable consideration. The usual safeguards for attempted vaginal delivery in the twin gestation should be followed.

Spontaneous uterine rupture during pregnancy after treatment of Asherman's syndrome

The treatment of Asherman's syndrome is often complicated by uterine perforation during hysteroscopic correction. We describe the first reported case of spontaneous uterine rupture with resultant hemorrhage during pregnancy after surgical treatment of Asherman's syndrome. This complication mandates close monitoring of these patients during pregnancy.