Spontaneous rupture of an unscarred uterus during pregnancy: A rare but life-threatening emergency: Case series

RATIONALE

In most cases, uterine rupture occurs during the third trimester of pregnancy or during labor. Even fewer reports have been published about the occurrence of this condition without a gynecologic history of any surgical procedure. Due to their scarcity and variable clinical presentation, early diagnosis of uterine rupture may be difficult, and if the diagnosis is not timely, the condition may be life-threatening.

PATIENT CONCERNS

Herein, 3 cases of uterine rupture from a single institution are described. Three patients are at different gestational weeks and all have no history of uterine surgery. They came to the hospital due to acute abdominal pain, which is characterized by severe and persistent pain in the abdomen, with no apparent vaginal bleeding.

DIAGNOSES

All 3 patients were diagnosed with uterine rupture during the operation.

INTERVENTIONS

One patient underwent uterine repair surgery; while the other 2 underwent subtotal hysterectomy due to persistent bleeding and pathological examination after surgery confirmed placenta implantation.

OUTCOMES

The patients recovered well after the operation, and no discomfort occurred in the follow-up.

LESSONS

Acute abdominal pain during pregnancy can pose both diagnostic and therapeutic challenges. It is important to consider the possibility of uterine rupture, even in cases where there is no history of prior uterine surgery. The key to the treatment of uterine rupture is to shorten the diagnosis time as much as possible, this potential complication should be carefully monitored for and promptly addressed to ensure the best possible outcomes for both the mother and the developing fetus.

[Uterine rupture during medical termination of pregnancy or intrauterine death: A risk management study]

OBJECTIVE

To describe and analyze a series of uterine ruptures (UR) that occurred in the context of medical termination of pregnancy (MTP) or intrauterine death (IUD) from a risk management perspective.

METHODS

French retrospective descriptive observational study of all cases of UR occurring during induction for IUD or MTP, reported between 2011 and 2021 by Gynerisq. Cases were recorded on a basis of voluntary reports using targeted questionnaires.

RESULTS

Between November 27, 2011, and August 22, 2021, 12 cases of UR occurring during an induction for IUD or MTP were recorded. 50 % of the patients had never given birth by cesarean section. The term of delivery varied from 17+3 days to 41+2 days. The clinical signs found were pain (n=6), ascending fetal presentation (n=5) and bleeding (n=4). All patients were managed by laparotomy, 5 were transfused. One vascular ligation and one hysterectomy were required.

CONCLUSION

Knowledge of surgical history is involved in the prevention of UR. The signs of detection are pain, ascending presentation and bleeding. The speed of management and good teamwork allow a reduction of maternal complications. The findings of the morbidity and mortality reviews show that prevention and mitigation barriers can be established.

New ultrasonographic risk assessment of uterine scar dehiscence in pregnancy after cesarean section

PURPOSE

We performed a new ultrasonographic risk assessment of uterine scar dehiscence, which is a potential risk factor for uterine rupture, in pregnancy after cesarean section. We attempted to shed light on the natural course of the change in the lower uterine segment by means of a longitudinal investigation through quantitative and qualitative evaluations.

METHODS

This retrospective single-center study involved 31 women with a normal singleton pregnancy delivered by elective cesarean section between 2020 and 2021, with all women showing a "niche" in the lower uterine segments. The lower uterine segments were assessed qualitatively and quantitatively using transvaginal ultrasonography at 16-21, 22-27, and 28-33 weeks of gestation, and subjects were divided into two groups: those with uterine dehiscence (12 women) and those without uterine dehiscence (19 women), depending on the gross findings of the lower uterine segments at cesarean section. Analyses were performed using Wilcoxon's rank-sum and Mann-Whitney U test with a significance level of P < 0.05.

RESULTS

The lower uterine segments changed from V-shaped to U-shaped to thin as gestation progressed and was more prominent in the uterine dehiscence group, occurring mostly at 22-27 weeks. At 22-27 weeks, the median myometrial thickness in the uterine dehiscence group was lower than in the group without uterine dehiscence (P = 0.0030). Thinning of the lower uterine segments had moved the cephalad at 22-27 and 28-33 weeks in cases with and without uterine dehiscence.

CONCLUSION

A model of morphological changes in the niche was constructed based on qualitative and quantitative assessments. The morphological changes and actual thinning of the lower uterine segments were prominent in the second trimester in women considered to have uterine scar dehiscence.

Rupture-mediated large uterine defect at 30th gestational week with protruded amniotic sac and fetal head without fetal compromise after laparoscopic electromyolysis: Case report and literature review

BACKGROUND

We describe a case of a rupture-mediated large uterine defect, which occurred on the 30th gestation week presenting a protruding amniotic sac sac without fetal compromise after a laparoscopic electromyolysis.

CASE PRESENTATION

A 28-year-old woman in her 30th week of gestation (gravida 2, para 0) presented with whole abdominal and right lower quadrant pain at Sanggye Paik Hospital. Ultrasound examination showed normal amniotic fluid and placentation but with breech presentation. She had undergone laparoscopic right ovarian cystectomy due to endometriosis 5 years earlier. Cardiotocography revealed an intermittent variable deceleration and no uterine contraction. Magnetic resonance imaging ruled out acute appendicitis. Four hours later, we observed a protrusion of the amniotic sac with the fetal head through a large uterine defect on magnetic resonance imaging, and performed emergency cesarean section. A boy was delivered without fetal compromise. During the cesarean section, multiple myometric wall defects and thinning were identified. After reconstruction of the uterine wall, the flaccid uterus bled persistently; thus, a cesarean hysterectomy was performed. Packed red cells and frozen plasma were transfused. The mother and neonate had uneventful puerperal and neonatal courses, respectively. After cesarean hysterectomy, we were informed that the mother had undergone a combined laparoscopic electromyolysis during the laparoscopic right ovarian cystectomy. Three years later, the child showed normal neural development.

CONCLUSIONS

Before myomectomy or electromyolysis, patients should be informed of the possibility of uterine rupture during subsequent pregnancies. If a pregnant woman has abdominal pain, clinicians should take a detailed history of uterine surgery and consider uterine rupture. Although, fortunately, the outcomes in this case were uneventful, urgent delivery is required when uterine rupture is diagnosed.

Trial of labor after cesarean in twin gestation with no prior vaginal delivery - evidence from largest cohort reported

OBJECTIVE

To investigate trial of labor after cesarean (TOLAC) success rates in twin gestations with no prior vaginal delivery.

METHODS

A retrospective study of women with twin gestations who underwent a TOLAC and had no prior vaginal delivery during 2011-2020. TOLAC success and failure groups were compared.

RESULTS

Of 675 twin gestations with a history of cesarean delivery and no prior vaginal delivery, 83 (12.3%) elected to undergo a TOLAC and 26 (31.3%) succeeded. Two (7.7%) women delivered by cesarean for the second twin after vaginal delivery of the first twin. Epidural analgesia was positively associated with TOLAC success (odds ratio [OR] 4.31, 95% confidence interval [CI] 1.56-11.94, P = 0.004). Uterine rupture occurred in two patients (3.5%) of the TOLAC failure group. The proportion of cases with low Apgar score (<7) at 5 min was higher in the TOLAC success group (4 [15.4%] versus 1 [1.8%]; OR 10.1, 95% CI 1.07-96.22, P = 0.032) and the neonatal composite adverse outcome rate was lower in this group (OR 0.22, 95% CI 0.07-0.69, P = 0.009).

CONCLUSION

TOLAC in women with twins with no prior vaginal delivery is associated with a low success rate. No independent predictors of successful TOLAC were identified.

Uterine rupture after previous caesarean section with hysterotomy above the lower uterine segment

Background Spontaneous uterine rupture is a severe pregnancy complication. Several risk factors have been described, especially for women with a previous caesarean section. Method We reported two cases of uterine rupture (UR) occurring outside of labour in patients with a history of caesarean section (CS) due to placenta previa. Results: The current study evaluates how a higher hysterotomy, combined with some risk factors, can increase the prevalence of UR in the subsequent pregnancy. Conclusion This study supports that a careful evaluation of risk factors can identify patients who need a specific follow up to early diagnose and treat UR and thus improve the maternal-fetal outcome.

[Traumatic uterine rupture in gemelli pregnant woman causing emergency hysterectomy]

This is a case report of a 30-year-old gemelli pregnant woman in gestation week 15 and 6 days, who was admitted to a local hospital after being involved in a high impact motor vehicle accident. Traumatic uterine rupture was suspected and the patient was immediately operated with exploratory laparotomy. Emergency hysterectomy was performed, hence the pregnancy was terminated. This case is a rare obstetric trauma situation, and prompt diagnosis is life-saving.

[Prediction and analysis of adverse pregnancy outcomes in pregnant women with cesarean scar diverticulum]

Objective: To investigate the pregnancy outcomes of pregnant women with cesarean scar diverticulum (CSD) and to find the relevant factors that predict the occurrence of adverse pregnancy outcomes. Methods: From January 2015 to March 2019, 501 singleton pregnant women with a history of cesarean section who underwent regular prenatal examination in early pregnancy and eventually delivered in Peking University First Hospital were prospectively collected. According to the presence or absence of CSD in the first trimester of pregnancy, the pregnant women were divided into the CSD group (n=127, 25.3%) and the non-CSD group (n=374, 74.7%). According to the mode of delivery and the classification of the lower uterine segment seen during cesarean section, the CSD group was further divided into the non-rupture group (including spontaneous delivery and lower uterine segment grade Ⅰ;n=108, 85.0%) and rupture group (including lower uterine segment grade Ⅱ-Ⅳ;n=19, 15.0%). The general clinical data, pregnancy outcomes, diverticulum-related indexes [including length, width, depth (D), average diameter, volume, and residual myometrial thickness (RMT)] were compared. The predictive values of D/adjacent myometrial thickness≥50%, RMT≤2.2 mm and D/RMT>1.3 for uterine rupture in CSD pregnant women were verified. Results: (1) Comparison between CSD group and non-CSD group: the lower uterine segment thickness in the third trimester of pregnancy in the CSD group was lower than that in the non-CSD group [(1.2±0.5) vs (1.4±0.6) mm, respectively], and the incidence of uterine rupture was higher than that in the non-CSD group [15.0% (19/127) vs 8.0% (30/374), respectively], and the differences were statistically significant (both P<0.05). There were no significant differences in other clinical data and pregnancy outcomes between the two groups (all P>0.05). (2) Comparison of rupture group and non-rupture group: the lower uterine segment thickness in the third trimester of pregnancy in rupture group [(0.6±0.5) mm] was lower than that in non-rupture group [(1.2±0.6) mm], and the difference was statistically significant (t=3.486, P=0.001). There were no significant differences in diverticulum-related indexes between the two groups (all P>0.05). (3) Relationship between high risk predictors of uterine rupture and actual uterine rupture: the sensitivity of D/adjacent muscle thickness ≥50%, RMT≤2.2 mm and D/RMT>1.3 in predicting the high risk of uterine rupture were 94.7%, 57.9% and 73.6%, the specificity were 12.0%, 40.7% and 24.1%, the positive predictive value were 15.9%, 14.7%, 14.6%, and the negative predictive value were 92.8%, 84.6%, 83.9%, respectively. Conclusions: The risk of uterine rupture in pregnant women with CSD is higher than that in those without CSD. There is no significant correlation between CSD related indexes and uterine rupture in the first trimester. Monitoring the lower uterine segment thickness in the third trimester might be helpful to predict the occurrence of adverse pregnancy outcomes.

Surgical uterus-preserving therapy after uterine rupture and haemorrhage due to placenta percreta in the first trimester following embolisation of the uterine arteries and B-Lynch suture in a previous pregnancy

A woman in her early 30s in the 11 2/7 week of pregnancy was admitted with severe abdominal pain and emesis. One year prior, the patient had undergone hysteroscopic adhesiolysis to treat Asherman syndrome resulting from a prior pregnancy. Examination of the patient revealed a haemoperitoneum and an intact intrauterine pregnancy. Laparoscopic adhesiolysis and haemostasis was performed and the patient was transferred to the intensive care unit. Subsequent examination due to persistent abdominal pain revealed an occult iatrogenic perforation of the uterus and placenta percreta with spontaneous uterine rupture. Although treatment for placenta percreta has generally been hysterectomy, in this case, the rupture and perforation sites were resected, representing successful fertility preserving management for this oft-overlooked pregnancy complication.

[Establish and application of scoring scale for trial of labor after cesarean section]

Objective: To establish a scoring scale for trial of labor after cesarean section (TOLAC), to explore the evaluation ability of this scoring scale for vaginal delivery after cesarean section (VBAC), and to improve the success rate of TOLAC. Methods: The delivery information of 661 TOLAC pregnant women admitted to Zhengzhou Central Hospital Affiliated to Zhengzhou University from 2014 to 2017 was retrospectively analyzed, and the TOLAC scoring scale was established by referring to relevant literatures. A prospective cohort study of pregnant women with TOLAC from January 2018 to December 2019 in Zhengzhou Central Hospital was conducted, including 440 pregnant women who were excluded from contraindications in trial labor. According to TOLAC scoring scale, pregnant women were divided into 3 groups, 0-6 group (94 cases), 7-9 group (234 cases) and 10-15 group (112 cases). The success rate of trial labor, failure reasons and incidence of maternal and neonatal complications were compared among the three groups. Results: (1) The overall success rate of TOLAC in 440 pregnant women was 75.0% (330/440). The success rates of 0-6, 7-9 and 10-15 groups were 53.2% (50/94), 76.9% (180/234) and 89.3% (100/112), respectively. The success rate of 10-15 group were significantly higher than those of 0-6 and 7-9 groups (all P<0.05). (2) Among the causes of trial labor failure, there were statistically significant differences between the three groups in terms of threatened uterine rupture and maternal abandonment (all P<0.05). Pairings showed that the incidences of threatened uterine rupture and maternal abandonment in 0-6 group was lower than those in 7-9 and 10-15 groups, and the differences were statistically significant (all P<0.05). (3) Maternal and neonatal complications mainly included postpartum hemorrhage and neonatal asphyxia, but there were no significant difference in the incidence of TOLAC success or failure among the three groups (all P>0.05). There was no uterine rupture in all groups. (4) The main factors affecting TOLAC score of pregnant women in the three groups included natural labor, estimated weight of the fetus at this time, Bishop score of the cervix at admission and gestational age, and the scores of the above indexes in 10-15 group were significantly higher than those in 0-6 group and 7-9 group (all P<0.05). Conclusions: TOLAC scoring scale has more accurate evaluation ability for VBAC, which could improve the success rate of TOLAC and maternal and child safety. The score of 0-6 is not recommended for vaginal trial labor, the score of 7-9 is recommended for vaginal trial labor, and the score of 10-15 is strongly recommended for vaginal trial labor.

Scar Rupture in Early Puerperium: A Case Report

Uterine scar dehiscence or rupture is a rare but potentially life-threatening complication of caesarean delivery. It is the opening of the uterine incision line that can lead to postpartum haemorrhage, pelvic hematoma, pelvic abscess, endomyometritis, generalised or localised peritonitis and sepsis. Here we report a case of a 25 years old female who presented with puerperal pyrexia. Investigations revealed uterine scar rupture with a uterovesical collection. The case was managed conservatively with intravenous antibiotics, an intracervical Foley's catheter and a gonadotropin-releasing hormone agonist.

Ruptured uterus: Frequency, risk factors and feto-maternal outcome: Current scenario in a low-resource setup

Introduction

Pakistan is among the countries with the highest maternal death rates. Obstetric hemorrhage accounts for 41% of these deaths. Uterine rupture is a grave obstetric emergency with high maternal and neonatal morbidity and mortality. It is important to identify its frequency and associated risk factors to formulate programs for its prevention and management. This study aimed to assess the frequency, associated risk factors, fetomaternal outcomes, and management of women with the ruptured uterus at our hospital.

Material and methods

It was a retrospective study of 206 women to review data collected from cases of uterine rupture managed at the WCTH Bannu, Pakistan from October 2016 to October 2018. A structured proforma was designed and used to extract data from operating theatre registers and the hospital medical records. In our hospital, there is a strong system of maintaining all information of the patients related to demographics, obstetric information, operative notes, and postoperative course during their hospital stay in the patient’s charts. Detailed information on operative procedures is further maintained in the operation theater register and all these registers are checked in the weekly statistical meetings to ensure proper documentation. Data was entered and analyzed in SPSS package version 21 (IBM Corp.; Armonk, NY, USA). Frequency and percentages were calculated for the categorical variables. For inferential statistics, chi-square or Fischer exact tests were used. A p-value of < 0.05 was considered statistically significant.

Results

The overall incidence of the ruptured uterus was 1.71%. The important etiological factors were grand multiparity 62 (35.2%), obstructed/neglected labour 58 (32.9%), injudicious use of Oxytocin 56 (31.8%) and prostaglandins 26 (14.7%), previous cesarean section 35 (19.8%) and previous pelvic surgery (0.5%). Hysterectomy was done in 80.6% of cases, 34 (19.2%) patients underwent uterine repair and 4.5% had bladder repair. The mortality rate was 21%, mainly due to irreversible shock or disseminated intravascular coagulation. Perinatal mortality was 91.4%. Duration of surgery more than two hours and presentation to the hospital at night time was significantly associated with poor maternal outcome (p = 0.00).

Conclusion

Uterine rupture is a preventable obstetric emergency associated with high fetomaternal morbidity and mortality. The main causes were grand multigravidity, obstructed labour, previous C-sections and injudicious use of oxytocin and prostaglandins. Women with prolonged surgery and admission at night time had a poor maternal outcome.

[Uterine rupture in a patient with a cesarean scar pregnancy]

Caesarean scar pregnancy is a rare form of ectopic pregnancy, but it is increasingly common due to the increasing number of caesarean sections and advances in medical imaging. There are two types of cesarean scar pregnancy depending on the depth of the implantation : endogenous type I and exogenous type II. In the case of a pregnancy resulting from a type II caesarean scar, the main complication is uterine rupture, which could be life-threatening for the patient. Early diagnosis and treatment are therefore essential for the woman. We report the case of a patient in early pregnancy with a history of cesarean section who presented with severe pelvic pain due to uterine rupture.

Risk factors and outcomes associated with type of uterine rupture

PURPOSE

To identify risk factors associated with the occurrence of complete uterine rupture (CUR) in comparison to partial uterine rupture (PUR) to further investigate to what extent a standardized definition is needed and what clinical implications can be drawn.

METHODS

Between 2005 and 2017 cases with CUR and PUR at Charité University Berlin, Germany were retrospectively identified. Demographic, obstetric and outcome variables were analyzed regarding the type of rupture. Binary multivariate regression analysis was conducted to identify risk factors associated with CUR. In addition, the intended route of delivery (trial of labor after cesarean delivery (TOLAC) and elective repeat cesarean delivery (ERCD)), divided according to the type of rupture, was compared.

RESULTS

92 cases with uterine rupture were identified out of a total of 64.063 births (0.14%). Puerperal complications were more frequent in CUR (67.9 versus 41.1%, p = 0.021). Multiparity ≥ 3 was more frequent in CUR (31 versus 10.7%, p = 0.020). Factors increasing the risk for CUR were parity ≥ 3 (OR = 3.8, p = 0.025), previous vaginal birth (OR = 4.4, p = 0.011), TOLAC (OR = 6.5, p < 0.001) and the use of oxytocin (OR = 2.9, p = 0.036). After multivariate analysis, the only independent risk factor associated with CUR was TOLAC (OR = 7.4, p = 0.017).

CONCLUSION

TOLAC is the only independent risk factor for CUR. After optimized antenatal counselling TOLAC and ERCD had comparable short-term maternal and fetal outcomes in a high resource setting. A high number of previous vaginal births does not eliminate the risk of uterine rupture. A clear distinction between CUR and PUR is essential to ensure comparability among studies.

Subsequent Pregnancy Outcome in Women with Prior Complete Uterine Rupture: A Single Tertiary Care Centre Experience

Limited data is available to assess the burden of maternal morbidity, mortality, and perinatal outcome after subsequent pregnancy in women with prior uterine rupture. Therefore, this retrospective descriptive study was conducted to determine subsequent pregnancy outcomes in a larger series of women with prior complete uterine rupture. All pregnant women who had complete uterine rupture were managed according to the standard Institute protocol. The women who conceived following a uterine repair from July 2011 to June 2020 were recruited into the study. Outcome measures included severe maternal morbidities and perinatal outcomes. Fifty-three women with prior complete uterine rupture were conceived subsequently. Two women had an abortion in the first and second trimester, respectively. None of the women developed recurrence of uterine rupture. However, three women developed uterine dehiscence in a total of 16 women who went into spontaneous labour before elective cesarean delivery at 32, 36, and 37 weeks, respectively. None of the women had placenta previa, placenta accreta, bowel injury, bladder injury and none required a hysterectomy. However, 16.7% of women needed a blood transfusion. None of the women required mechanical ventilation, inotropic support, and intensive care unit stay. Seventeen babies required neonatal intensive care admission, and prematurity (90%) was the most common reason, followed by low APGAR scores. In conclusion, subsequent pregnancy outcomes in women with prior uterine rupture appear acceptable in institutionalized care. Timing of cesarean delivery may have to be weighed against the risk of prematurity-associated neonatal morbidity and mortality.

Spontaneous complete uterine rupture with protrusion of foetal limbs at the third trimester following laparoscopic cornuostomy: A case report

RATIONALE

Spontaneous complete uterine rupture during gestation is rare and has no specific symptoms; however, it is a life-threatening event for both the fetus and mother. The rupture typically happens in labor and is uncommon before labor. Herein, we present the case of a woman, encountering complete rupture at third trimester followed by laparoscopic cornuostomy.

PATIENT CONCERNS

A 26-year-old woman presented with acute right lower abdominal pain at 33 weeks and 5 days of gestation.

DIAGNOSES

We made a diagnosis of threatened uterine rupture.

INTERVENTION

Urgent cesarean section performed. Exploration of the uterine dehiscence wound demonstrated that the myometrium was completely ruptured at the primary laparoscopic surgical scar with a defect of 40 mm, and live birth and preservation of the uterus was achieved.

OUTCOME

On the third day of operation, she had a good recovery and was discharged. After a 6-week postpartum follow-up, she displayed a good level of rehabilitation.

LESSONS

Pregnancy after laparoscopic cornuostomy should be treated as high-risk gestation and the rupture during gestation of the uterine scar should be suspected once lower abdominal pain occurred. Swift diagnosis and prompt intervention play a crucial role in saving the lives of the fetus and the mother.

Posterior uterine rupture in early first trimester

Uterine rupture can be associated with severe maternal and neonatal morbidity and mortality. It should be considered as a differential diagnosis in all pregnant women who present with acute abdomen, haemoperitoneum and have specific risk factors, even during the first trimester. This is a case report of a 25-year-old woman who presented to emergency department with abdominal pain and vaginal bleeding at approximately 6-8 weeks gestation. She developed an acute surgical abdomen and required urgent surgical management. Despite intervention, she had massive haemorrhage, disseminate intravascular coagulation, admission to intensive care unit and prolonged hospital stay as complications. Posterior uterine wall rupture while rare, must be considered as a differential diagnosis as early intervention is crucial to prevent bad outcomes.

Epidemiology of uterine rupture among pregnant women in China and development of a risk prediction model: analysis of data from a multicentre, cross-sectional study

OBJECTIVES

To describe the epidemiology of uterine rupture in China from 2015 to 2016 and to build a prediction model for uterine rupture in women with a scarred uterus.

SETTING

A multicentre cross-sectional survey conducted in 96 hospitals across China in 2015-2016.

PARTICIPANTS

Our survey initially included 77 789 birth records from hospitals with 1000 or more deliveries per year. We excluded 2567 births less than 24 gestational weeks or unknown and 1042 births with unknown status of uterine rupture, leaving 74 180 births for the final analysis.

PRIMARY AND SECONDARY OUTCOME MEASURES

Complete and incomplete uterine rupture and the risk factors, and a prediction model for uterine rupture in women with scarred uterus (assigned each birth a weight based on the sampling frame).

RESULTS

The weighted incidence of uterine rupture was 0.18% (95% CI 0.05% to 0.23%) in our study population during 2015 and 2016. The weighted incidence of uterine rupture in women with scarred and intact uterus was 0.79% (95% CI 0.63% to 0.91%) and 0.05% (95% CI 0.02% to 0.13%), respectively. Younger or older maternal age, prepregnancy diabetes, overweight or obesity, complications during pregnancy (hypertensive disorders in pregnancy and gestational diabetes), low education, repeat caesarean section (≥2), multiple abortions (≥2), assisted reproductive technology, placenta previa, induce labour, fetal malpresentation, multiple pregnancy, anaemia, high parity and antepartum stillbirth were associated with an increased risk of uterine rupture. The prediction model including eight variables (OR >1.5) yielded an area under the curve (AUC) of 0.812 (95% CI 0.793 to 0.836) in predicting uterine rupture in women with scarred uterus with sensitivity and specificity of 77.2% and 69.8%, respectively.

CONCLUSIONS

The incidence of uterine rupture was 0.18% in this population in 2015-2016. The predictive model based on eight easily available variables had a moderate predictive value in predicting uterine rupture in women with scarred uterus. Strategies based on predictions may be considered to further reduce the burden of uterine rupture in China.

Maternal and Fetal Outcomes after Prior Mid-Trimester Uterine Rupture: A Systematic Review with Our Experience

Background and Objectives: Since spontaneous uterine rupture in the mid-trimester is rare, maternal and fetal outcomes in subsequent pregnancies remain unclear. Therefore, this study aimed to examine the maternal and fetal outcomes of subsequent pregnancies after prior mid-trimester uterine rupture. Materials and Methods: A systematic review using PubMed, the Cochrane Central Register of Controlled Trials, and Scopus until 30 September 2021, was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The studies that clarified the maternal and fetal outcomes after prior mid-trimester uterine rupture and our case (n = 1) were included in the analysis. Results: Among the eligible cases, there were five women with eight subsequent pregnancies after prior mid-trimester uterine rupture. The timing of prior mid-trimester uterine rupture ranged from 15 to 26 weeks of gestation. The gestational age at delivery in subsequent pregnancies was 23–38 gestational weeks. Among the included cases (n = 8), those involving prior mid-trimester uterine rupture appeared to be associated with an increased prevalence of placenta accreta spectrum (PAS) (n = 3, 37.5%) compared with those involving term uterine rupture published in the literature; moreover, one case exhibited recurrent uterine rupture at 23 weeks of gestation (12.5%). No maternal deaths have been reported in subsequent pregnancies following prior mid-trimester uterine rupture. Fetal outcomes were feasible, except for one pregnancy with recurrent mid-trimester uterine rupture at 23 weeks of gestation, whose fetus was alive complicated by cerebral palsy. Conclusions: Our findings suggest that clinicians should be aware of the possibility of PAS and possible uterine rupture in pregnancies after prior mid-trimester uterine rupture. Further case studies are warranted to assess maternal and fetal outcomes in pregnancies following prior mid-trimester prior uterine rupture.

Surgical complications after caesarean section: A population-based cohort study

BACKGROUND

The rate of caesarean section without medical indication is rising but the risk for surgical complications has not been fully explored.

METHODS

Altogether 79 052 women from the Swedish Medical Birth Register who delivered by caesarean section only from 2005 through 2016 were identified and compared with a control group of women delivering vaginally only from the same register and the same period of time. By cross-linking data with the National Patient Register the risks for bowel obstruction, incisional hernia and abdominal pain were analysed, as well as risk factors for these complications. We also analysed acute complications, uterine rupture, and placenta praevia.

FINDINGS

Caesarean section is associated with an increased risk for bowel obstruction (OR 2.92; CI 2.55-3.34), surgery for bowel obstruction (OR 2.12; CI 1.70-2.65), incisional hernia (OR 2.71; CI 2.46-3.00), surgery for incisional hernia (OR 3.35; CI 2.68-4.18), and abdominal pain (OR 1.41; CI 1.38-1.44). Smoking, obesity, and more than one section delivery added significantly to the risk for these complications.

INTERPRETATION

Caesarean section is considered a safe procedure, but awareness of the risk for serious complications is important when deciding on mode of delivery. In this study, more than one section, obesity and smoking significantly increased the risk for complications after caesarean section. Prevention of smoking and obesity among fertile women worldwide must continue to be a high priority.