Maternal and fetal morbidity associated with uterine rupture of the unscarred uterus

[Uterine rupture of the unscarred uterus: A report of 10 cases]

INTRODUCTION

Uterine rupture in the healthy uterus is a rare obstetrical complication, not much suspected and with badly identified risk factors. Thus, there exists frequent delay for treatment and therefore fetal-maternal important morbidity and mortality. This article describes clinical signs and symptoms, management, and maternal and neonatal prognosis of uterine rupture.

METHODS

Descriptive retrospective study within 13 maternity hospitals, reporting 10 series of cases of uterine rupture on gravid healthy uterus during the third trimester of pregnancy.

RESULT

The incidence was 2.8/100,000 births. Surgical treatment was conservative in 9 out of 10 cases, the maternal prognosis was good with no maternal deaths and 6 out of 7 patients had at least one subsequent pregnancy. The fetal prognosis was more reserved, with 2 fetal or neonatal deaths and 1 with motor disability. 6/6 patients (100%) had at least one iterative Caesarean section during the following pregnancies with healthy fetuses.

CONCLUSION

In this series of 10 cases over 25years, maternal-fetal morbidity and mortality were significant, in agreement with the literature. Maternal prognosis remained favorable. When surgical treatment is conservative a subsequent pregnancy is possible and an iterative cesarean section must be performed.

Rupture of the scarred and unscarred gravid uterus: Outcomes and risk factors analysis

OBJECTIVE

To study the maternal and fetal outcomes and assess the risk factors in patients with rupture at the lower-segment or non-lower-segment scarred, or unscarred gravid uterus.

MATERIALS AND METHODS

Gravid patients with uterine rupture were retrospectively collected in Chang-Gung Memorial Hospital from November 2004 to July 2017. The rupture timing and location in association with maternal and fetal outcomes were collected as well as the possible risk factors including surgical history and interval prior to conception were analyzed.

RESULTS

Thirty patients were included [mean age (±SEM), 34.4 ± 0.7 years; mean body mass index, 25.0 ± 0.6 kg/m²] with mean onset of rupture at 34.2 ± 0.9 weeks, in which, 12 occurred at term and 18 at preterm (range 20-34 weeks). Four fetal demises, 22 transferals to neonatal intensive care unit, and 17 maternal blood transfusions without maternal mortality were noted. Twenty-two patients presented with acute abdominal pain and/or abnormal fetal heart rate tracing were managed with emergent cesarean delivery. Four ruptures were found in postpartum of vaginal delivery, in which 3 were after trials of labor after cesarean delivery and 1 was unscarred uterus, and two of the four eventually underwent hysterectomy. Unscarred uterus (n = 6) without identifiable risk factor ruptured in significantly later gestation associated with higher fetal birthweights than those of the scarred uterus (n = 24) (both p < 0.05), both of which yielded morbidity. The rupture timing between patients of non-lower-segment scar (n = 14) and lower-segment scar (n = 10) were not significantly different.

CONCLUSION

Rupture of gravid uterus prevalently occurred after 30 weeks of gestation with remarkable morbidity. Unscarred uterus could rupture in later gestation than the scarred ones without identifiable risk factor. Alertness to the acute abdominal pain, atypical from uterine contraction or the suspicious fetal heart rate tracing is the key to the timely rescue and successful management.

Concurrent intraoperative uterine rupture and placenta accreta. Do preoperative chronic hypertension, preterm premature rupture of membranes, chorioamnionitis, and placental abruption provide warning to this rare occurrence?

Uterine and placental pathology can be a major cause of morbidity and mortality in the parturient and infant. When presenting alone, placental abruption, uterine rupture, or placenta accreta can result in significant peripartum hemorrhage, requiring aggressive surgical and anesthetic management; however, the presence of multiple concurrent uterine and placental pathologies can result in significant morbidity and mortality. We present the anesthetic management of a parturient who underwent an urgent cesarean delivery for non-reassuring fetal tracing in the setting of chronic hypertension, preterm premature rupture of membranes, and chorioamnionitis who was subsequently found to have placental abruption, uterine rupture, and placenta accreta.

Diagnosis of a defect in the uterine wall using 3D ultrasound in the 16th week of gestation

The 3D volumetric transabdominal study with rendering mode is a very useful tool to perform a detailed study of the uterine wall, and it allows us to create a safe and early strategy during pregnancy in uterine dehiscences, as we show in this case in the 16th week of gestation.

Spontaneous Rupture of Pyometra in a Nonpregnant Young Woman

A 40-year-old woman presented with severe vaginal bleeding. Initial workup with an abdominal sonography revealed endometrium for about 3 mm and free fluid in the abdomen. Hemodynamic instability with abdominal pain and free fluid in the abdomen prompted blood transfusion and laparotomy. There were about 1000 cc blood and clots in the abdomen at laparotomy. There was a longitudinal rupture from fundus up to cervix at the left side of the uterus. Tearing was in full thickness from serosa to endometrium. Scar of previous cesarean was transvers and not associated with this tearing. There was not any myomectomy scar.

Spontaneous uterine laceration in labor: a type of intrapartum uterine injury different from the classical uterine rupture

Uterine rupture, a complete disruption of uterine wall, is synonymously used of intrapartum uterine corpus injuries. However, uterine laceration, partial and minor myometrial tear, is not well characterized. A 35-year-old Japanese woman with unscarred uterus was delivered of a baby at 38 gestational weeks. Shortly after delivering the placenta, she complained of severe lower abdominal pain with shock vitals. Exploratory laparotomy revealed a partial and shallow myometrial and serosal tear with massive hemoperitoneum. Despite its shallow and minor nature of the injury, uterine laceration can cause a catastrophic massive hemoperitoneum and should be noted as a type of intrapartum uterine injury in clinical practice.

Contemporary analysis of maternal and neonatal morbidity after uterine rupture: A nationwide population-based study

AIM

Uterine rupture is a rare but feared perinatal event. Despite abundant research and changes to guidelines implemented to reduce this complication, evaluation of whether uterine rupture still engenders significant maternal/neonatal morbidity has not been conducted. We analyzed recent cases of maternal/neonatal morbidity after uterine rupture.

METHODS

Deliveries complicated by uterine rupture from 2011 to 2012 in the United States were selected. Comparison cases without uterine rupture were used as controls. Measures of maternal/neonatal complications were compared with χ² test, and relative risks were calculated. Logistic regression was used to identify the most significant complications. P < 0.05 indicated statistical significance.

RESULTS

From 7 922 016 births, 1925 cases of uterine rupture and 3765 controls were identified. Regression models retained four maternal outcomes; blood transfusion was the most common (~15%) and unplanned hysterectomy had the highest odds (~97-fold). For newborns, the model retained three measures of morbidity; neonatal intensive care unit admission was the most common (~35%) and seizures had the highest odds (~20-fold).

CONCLUSIONS

Despite efforts to reduce complications, mothers remain at significant risk of unplanned hysterectomy and intensive care unit admission. Neonates are at sizeable risk for neonatal intensive care unit admission and seizures, recognized markers of long-term neurobehavioral abnormality. Uterine rupture remains a major risk for mothers and babies.

Risk factors for complete uterine rupture

BACKGROUND

Complete uterine rupture is a rare peripartum complication associated with a catastrophic outcome. Because of its rarity, knowledge about its risk factors is not very accurate. Most previous studies were small and over a limited time interval. Moreover, international diagnostic coding was used in most studies. These codes are not able to differentiate between the catastrophic complete type and less catastrophic partial type. Complete uterine rupture is expected to increase as the rate of cesarean delivery increases. Thus, we need more accurate knowledge about the risk factors for this complication.

OBJECTIVE

The objective of the study was to estimate the incidence and risk factors for complete uterine rupture during childbirth in Norway.

STUDY DESIGN

This population-based study included women that gave birth after starting labor in 1967-2008. Data were from the Medical Birth Registry of Norway and Patient Administration System, complemented with information from medical records. We included 1,317,967 women without previous cesarean delivery and 57,859 with previous cesarean delivery. The outcome was complete uterine rupture (tearing of all uterine wall layers, including serosa and membranes). Risk factors were parameters related to demographics, pregnancy, and labor. Odds ratios for complete uterine rupture were computed with crude logistic regressions for each risk factor. Separate multivariable logistic regressions were performed to calculate the adjusted odds ratios and 95% confidence intervals.

RESULTS

Complete uterine rupture occurred in 51 cases without previous cesarean delivery (0.38 per 10,000) and 122 with previous cesarean delivery (21.1 per 10,000). The strongest risk factor was sequential labor induction with prostaglandins and oxytocin, compared with spontaneous labor, in those without previous cesarean delivery (adjusted odds ratio, 48.0, 95% confidence interval, 20.5-112.3) and those with previous cesarean delivery (adjusted odds ratio, 16.1, 95% confidence interval, 8.6-29.9). Other significant risk factors for those without and with previous cesarean delivery, respectively, included labor augmentation with oxytocin (adjusted odds ratio, 22.5, 95% confidence interval, 10.9-41.2; adjusted odds ratio, 4.4, 95% confidence interval, 2.9-6.6), antepartum fetal death (adjusted odds ratio, 15.0, 95% confidence interval, 6.2-36.6; adjusted odds ratio, 4.0, 95% confidence interval, 1.1-14.2), and previous first-trimester miscarriages (adjusted odds ratio, 9.6, 95% confidence interval, 5.7-17.4; adjusted odds ratio, 5.00, 95% confidence interval, 3.4-7.3). After a previous cesarean delivery, the risk of rupture was increased by an interdelivery interval <16 months (adjusted odds ratio, 2.3; 95% confidence interval, 1.1-5.4) and a previous cesarean delivery with severe postpartum hemorrhage (adjusted odds ratio, 5.6; 95% confidence interval, 2.4-13.2).

CONCLUSION

Sequential labor induction with prostaglandins and oxytocin and augmentation of labor with oxytocin are important risk factors for complete uterine rupture in intact and scarred uteri.

Successful delivery after surgical repair of uterine rupture at 15 weeks of gestation: case report and brief review

OBJECTIVE

Second-trimester uterine rupture is a rare disorder and it is unclear if it should be managed with caesarean section, repair or hysterectomy. This article provides a case report of second-trimester uterine rupture repair, and reviews the risk factors, signs and symptoms, suturing technique and newborn outcome.

METHODS

PubMed was searched using the terms 'uterine rupture', 'second trimester' and 'repair' Only cases of second-trimester uterine rupture repair that led to successful prolongation of pregnancy were included.

RESULTS

The main risk factor of uterine rupture is previous caesarean section (5/10, 50%). Eight of 10 cases presented with abdominal pain and three cases presented in shock. Haemoperitoneum was present in five cases. The mean and median gestational age at delivery were 33.4 and 33.5 weeks, respectively (range 28-37 weeks), with mean and median delayed interval delivery of 95.5 and 91 days, respectively (range 14-147 days). Neonatal outcome was good for 10 of 11 newborns. Despite the early onset of uterine rupture, there were no cases of extremely preterm delivery. One early preterm infant, seven moderate-to-late preterm infants and one term infant were delivered.

CONCLUSIONS

The lack of extremely preterm deliveries and good neonatal outcomes encourage attempts to repair the uterus after second-trimester rupture.