Intrapartum rupture of the unscarred uterus

Determinants of stillbirths in katsina, Nigeria: a hospital-based study

Every year, about 3 million stillbirths occur globally, almost a third occurring during the intra-partum period. Almost all stillbirths (98%) occur in low and middle income countries, with Nigeria having the third largest burden. The aim of this study was to determine the stillbirth rate and its determinants in the Federal Medical Centre Katsina, located in north western Nigeria. This study was a retrospective review of all deliveries conducted between 1(st) March 2010 and 31(st) December 2012 in Federal Medical Centre Katsina. Data were extracted from labor room and theatre records, and patient folders. Cases were matched with controls by booking status. The privacy and confidentiality of information retrieved from cases and controls was also ensured by anonymizing the data retrieved. No conflict of interest was identified. The data was analyzed with SPSS 20. During the period under review, there were 6628 deliveries, out of which 331 of the products were stillborn. The stillbirth rate was 46.9±3.6 per 1000 deliveries. Determinants of stillbirths were antepartum hemorrhage, hypertensive disorders of pregnancy, uterine rupture, low birth weight and congenital fetal malformations. The study highlighted the poor perinatal health in the study population.

The conservative and interventional treatment of fibroids

BACKGROUND

Fibroids are the most common benign tumors in women. One-third of all women of reproductive age undergo treatment for symptomatic fibroids. In recent years, the spectrum of available treatments has been widened by the introduction of new drugs and interventional procedures.

METHODS

Selective literature review on the treatment of uterine fibroids, including consideration of several Cochrane Reviews.

RESULTS

Fibroids can be treated with drugs, interventional procedures (uterine artery embolization [UAE] and focused ultrasound treatment [FUS]), and surgery. The evidence regarding the various available treatments is mixed. All methods improve symptoms, but only a few comparative studies have been performed. A meta-analysis revealed that recovery within 15 days is more common after laparoscopic enucleation than after open surgery (odds ratio [OR], 3.2). A minimally invasive hysterectomy, or one performed by the vaginal route, is associated with a shorter hospital stay and a more rapid recovery than open transabdominal hysterectomy. UAE is an alternative to hysterectomy for selected patients. The re-intervention rates after fibroid enucleation, hysterectomy, and UAE are 8.9-9%, 1.8-10.7%, and 7-34.6%, respectively. The main drugs used to treat fibroids are gonadotropin-releasing hormone analogs and selective progesterone receptor modulators.

CONCLUSION

Multiple treatment options are available and enable individualized therapy for symptomatic fibroids. The most important considerations in the choice of treatment are the question of family planning and, in some cases, the technical limitations of the treatments themselves.

Signs, symptoms and complications of complete and partial uterine ruptures during pregnancy and delivery

OBJECTIVES

Uterine rupture is a rare but potentially catastrophic complication of pregnancy that requires rapid diagnosis. Classically, its signs and symptoms combine pain, fetal heart rate (FHR) abnormalities, and vaginal bleeding. The purpose of this study is to identify these signs and symptoms as well as the immediate complications of complete and incomplete (partial) ruptures of the uterine wall, whether or not they follow a previous cesarean delivery.

STUDY DESIGN

Retrospective study of case records from two university hospital maternity units, from 1987 to 2008.

RESULTS

In a total of 97,028 births during the study period, we identified 52 uterine ruptures (0.05%): 25 complete and 27 partial. Most (89%) occurred in women with a previous cesarean delivery. In complete ruptures, FHR abnormalities were the most frequent sign (82%), while the complete triad of FHR abnormalities-pain-vaginal bleeding was present in only 9%. The signs and symptoms of partial ruptures were very different; these were asymptomatic in half the cases (48%). Neonatal mortality reached 13.6% among the complete ruptures; 27 and 40% of these newborns had pH<6.80 and pH<7.0, respectively. Among the incomplete ruptures, only 7.7% of the newborns had a pH<7.0 and there were no deaths.

CONCLUSION

Although complete rupture of the uterus has a severe neonatal prognosis, the complete set of standard symptoms is present in less than 10% of cases. FHR abnormalities are by far the most frequent sign.

Repair of Uterine Rupture during Second Trimester Leading to Successful Pregnancy Outcome: Case Study and Literature's Review

It was thought to be impossible to prolong the pregnancy in a case of uterine rupture in the second trimester. We encountered a case of rupture of the pregnant uterus in early mid-trimester, which we repaired with suture and overlapping of collagen fleece coated with fibrin glue, resulting in pregnancy prolongation until the 34th week. Our case and five previously reported cases were reviewed. Pregnant uterine rupture in mid-trimester could be repaired with suture and overlapping of collagen fleece in the absence of placenta percreta.

Rupture of an unscarred uterus in a quadruplet pregnancy

BACKGROUND

Uterine rupture of an unscarred uterus is a rare complication in a quadruplet pregnancy.

CASE

A 30-year-old woman, gravida 4 para 0030, with a quadruplet pregnancy and no previous uterine surgeries presented with moderate vaginal bleeding at 32 4/7 weeks of gestation. Fetal testing was reassuring, and the cervix showed no signs of preterm labor. A decision was made to proceed with cesarean delivery because of the amount of vaginal bleeding, with surgical findings of uterine rupture superior to the lower uterine segment.

CONCLUSION

High-order gestations may be an independent risk factor for uterine rupture.

Prelabor uterine rupture and extrusion of fetus with intact amniotic membranes: a case report

Introduction: The increasing rate of cesarean sections is an important issue globally, especially in developed countries. During the last decade, despite decreasing rates of vaginal delivery attempts after a previous cesarean section, the risk of uterine rupture has remained. Uterine rupture is a significant and catastrophic obstetric complication associated with maternal and fetal morbidity and mortality. We report here a very rare case of prelabor uterine rupture with intact membranes.

Case report: A 28-year-old, gravida 3, para 2 Turkish woman was referred to our emergency unit at 34 weeks’ gestation because of the absence of fetal movements and abdominal pain. She had had a vaginal birth in 2007 and a cesarean section in 2009. In the delivery room, the fetal extremities were palpated at the abdominal wall, and an ultrasonography revealed ruptured uterus and fetal death. A midline laparotomy was carried out to open the peritoneal cavity. An intact amniotic sac with fetus was observed in the abdominal cavity, and the uterus was also observed to be ruptured. The male fetus, weighing 2500 g, was dead. The rupture was extending from the left lateral side of cervix to the fundus. The tear was repaired by primarily suturing the uterus in two layers after ligation of the left uterine artery to control hemorrhage. The total estimated blood loss was about 1300 mL. The patient received two units of blood transfusion during the operation. In the 4th postoperative day, the patient was discharged.

Conclusion: Complete uterine rupture is a rare but catastrophic event, and if diagnosed late, can result in mortality. Uterine rupture is rare during a trial of vaginal labor in a patient with a history of cesarean section; it is much rarer to occur before any trial of vaginal labor in such a patient. If a patient with a history of cesarean section, especially with an unknown type of incision, presents with complaints of abdominal tenderness or vaginal bleeding in the 3rd trimester, the possibility of complete uterine rupture must be considered.

Prediction of scar integrity and vaginal birth after caesarean delivery

A statistically significant association with uterine rupture during a trial of labour after caesarean delivery was found in at least two studies for the following variables: inter-delivery interval (higher risk with short interval), birth weight (higher risk if 4000 g or over), induction of labour (higher risk), oxytocin dose (higher risk with higher doses), and previous vaginal delivery (lower risk). However, no clinically useful risk estimation model that includes clinical variables has been published. A thin lower uterine segment at 35-40 weeks, as measured by ultrasound in women with a caesarean hysterotomy scar, increases the risk of uterine rupture or dehiscence. No cut-off for lower uterine segment thickness, however, can be suggested because of study heterogeneity, and because prospective validation is lacking. Large caesarean hysterotomy scar defects in non-pregnant women seen at ultrasound examination increase the risk of uterine rupture or dehiscence in subsequent pregnancy, but the strength of the association is unknown. To sum up, we currently lack a method that can provide a reliable estimate of the risk of uterine rupture or dehiscence during a trial of labour in women with caesarean hysterotomy scar(s).

Maternal and newborn outcomes following uterine rupture among women without versus those with a prior cesarean

OBJECTIVE

To compare outcomes from uterine ruptures (UR) among women without versus with a prior cesarean.

METHOD

This case-control study matched on gestational age +/- 1 week and birth year +/- 2 years using a variable numbers of controls (maximum = 4) for each case. All URs in Massachusetts between 1990 and 1998 were identified using ICD-9 codes from linked hospital discharge and birth/fetal death certificate files and confirmed by medical record review. Complete hospitalization records were abstracted. Maternal outcomes were hysterectomy, transfusion, ICU admission, shock, assisted ventilation, and hospital length of stay. Infant outcomes were 5 min Apgar less than 3 or need for ventilation at birth, death, or poor prognosis at discharge.

RESULTS

The UR incidence in women without a prior cesarean was 7 per 100,000 births. Of the 49 women without a prior cesarean and a UR, 36 women met study criteria and were matched to 140 controls. Women without a prior cesarean had more severe maternal morbidity (50% vs. 16%) (adj OR 3.28, 95% CI: 1.70, 6.32) with 47% of cases requiring transfusion and 33% requiring ICU admission. Their hospital stays were nearly two days longer. Among their infants, 14% died or had a poor prognosis at discharge compared to 7% of control infants (OR = 2.42, 95% CI 0.94, 6.28).

CONCLUSION

Although UR in a woman without a prior cesarean is uncommon, providers should be prepared for more severe maternal morbidity which may be mitigated by prompt surgical intervention and heightened hemodynamic surveillance.

Safety of labor induction with prostaglandin E2 in grandmultiparous women

OBJECTIVE

The aim of this study was to assess the safety of labor induction with vaginal prostaglandin E2 (PGE2) in grandmultiparous women.

METHODS

We conducted a retrospective cohort study of 1376 grandmultiparous women who underwent induction of labor with low dose PGE2. The primary outcome was uterine rupture and secondary outcomes included mode of delivery, postpartum hemorrhage and five minutes Apgar score.

RESULTS

One case was diagnosed with uterine rupture (0.07%). Vaginal delivery was achieved in 1329 (96.6%) patients, whereas 47 (3.4%) patients had emergent cesarean delivery. Five minutes Apgar score ≤7 was recorded in three cases (0.2%). There was no correlation between parity and cesarean delivery rate or low Apgar score. There were no significant differences between the grandmultiparous and great-grandmultiparous patients regarding cesarean delivery rate (3.1 vs. 5%, P = 0.12), operative vaginal delivery rate (2 vs. 2.3%, P = 0.74) or postpartum hemorrhage rate (0.8 vs. 1.1%, P = 0.6).

CONCLUSIONS

Low dose PGE2 is a safe and efficient method for induction of labor in grandmultiparous and great-grandmultiparous women.

Uterine rupture by intended mode of delivery in the UK: a national case-control study

BACKGROUND

Recent reports of the risk of morbidity due to uterine rupture are thought to have contributed in some countries to a decrease in the number of women attempting a vaginal birth after caesarean section. The aims of this study were to estimate the incidence of true uterine rupture in the UK and to investigate and quantify the associated risk factors and outcomes, on the basis of intended mode of delivery.

METHODS AND FINDINGS

A UK national case-control study was undertaken between April 2009 and April 2010. The participants comprised 159 women with uterine rupture and 448 control women with a previous caesarean delivery. The estimated incidence of uterine rupture was 0.2 per 1,000 maternities overall; 2.1 and 0.3 per 1,000 maternities in women with a previous caesarean delivery planning vaginal or elective caesarean delivery, respectively. Amongst women with a previous caesarean delivery, odds of rupture were also increased in women who had ≥ two previous caesarean deliveries (adjusted odds ratio [aOR] 3.02, 95% CI 1.16-7.85) and <12 months since their last caesarean delivery (aOR 3.12, 95% CI 1.62-6.02). A higher risk of rupture with labour induction and oxytocin use was apparent (aOR 3.92, 95% CI 1.00-15.33). Two women with uterine rupture died (case fatality 1.3%, 95% CI 0.2-4.5%). There were 18 perinatal deaths associated with uterine rupture among 145 infants (perinatal mortality 124 per 1,000 total births, 95% CI 75-189).

CONCLUSIONS

Although uterine rupture is associated with significant mortality and morbidity, even amongst women with a previous caesarean section planning a vaginal delivery, it is a rare occurrence. For women with a previous caesarean section, risk of uterine rupture increases with number of previous caesarean deliveries, a short interval since the last caesarean section, and labour induction and/or augmentation. These factors should be considered when counselling and managing the labour of women with a previous caesarean section.

Rupture of a pregnant unscarred uterus in an early secondary trimester: a case report and brief review

Rupture of a pregnant uterus in early pregnancy and an unscarred uterus are extremely rare, and some non-specific symptoms might appear before this occurrence. We report the case of a multiparous woman (gravida 3, para 2) with uterine fundal rupture in her early second trimester (17+ weeks of gestational age), who presented upper abdominal discomfort and vomiting for 3 days, and progressed into sudden acute abdomen and shock. During emergent laparotomy, the entire amniotic sac was found in the peritoneal cavity with a rupture of the uterine fundus. Although we could not confirm that the appearance of upper gastrointestinal symptoms and severe vomiting was associated with uterine rupture in this pregnant woman, abdominal symptoms or signs might be a hint or cause of severe catastrophic pregnancy-related complications.

A large amniocele with protruded umbilical cord diagnosed by 3D ultrasound

An amniocele is a herniation of the amniotic sac through a uterine defect. Uterine rupture during pregnancy may develop as a result of a pre-existing injury, uterine anomaly, or unscarred uterus. A 30-year-old patient, with a history of 2 vaginal deliveries, presented an amniocele complicated by left fundal perforation and was evaluated with 3-dimensional ultrasound at 23 weeks. Because of worsening lower abdominal pain and vaginal bleeding, she underwent exploratory laparotomy. Herein, we report a uterine rupture with amniocele.

A ruptured uterus in a pregnant woman not in labor

Reducing maternal mortality constitutes one of the eight Millennium Development Goals. While significant progress has been made, system issues and professional training continue to affect maternal survival, especially when unusual, but deadly, complications arise. This rare case of survival after the rupture of an unscarred uterus in a grand multiparous woman from a remote village in Ghana illustrates how systemic transportation issues and limited access to advanced medical care put women with obstetric complications at risk. The usual clinical presentation of ruptured uteri and methods to prevent this catastrophic event are discussed. This case illustrates the systemic transportation issue that often limits access to prenatal and emergency care throughout much of the developing world and demonstrates how advanced training for emergency nurses and the use of ultrasound diagnosis can expedite difficult diagnoses and lead to maternal survival, even in the most adverse circumstances.

A Description of the Management and Outcomes of Vaginal Birth After Cesarean Birth in the Homebirth Setting

Our objective was to describe the outcomes of intended home birth among 57 women with a previous cesarean birth. Data were drawn from a larger prospective study of intended homebirth in nurse-midwifery practice. Available data included demographics, perinatal risk information, and outcomes of prenatal, intrapartum, postpartum, and neonatal care. The hospital course was reviewed for those transferred to the hospital setting. Fifty-three of 57 women (93%) had a spontaneous vaginal birth, 1 had a vacuum-assisted birth, and 3 (5.3%) had a repeat cesarean birth. Thirty-one of 32 (97%) women who had a previous vaginal birth after cesarean birth (VBAC) had a successful VBAC; 22 of 25 (88%) women without a history of VBAC successfully delivered vaginally. Fifty (87.7%) of these women delivered in the home setting, whereas 7 (12.3%) delivered in the hospital setting. None of the women experienced uterine rupture or dehiscence. One infant was stillborn. This event was attributed to a postdates pregnancy with meconium. Certified nurse-midwives with homebirth practices must be knowledgeable about the risks for mother and baby, screen clientele appropriately, and be able to counsel patients with regard to potential adverse outcomes. Given what is presently known, VBAC is not recommended in the homebirth setting. It is imperative in the light of current evidence and practice climate to advocate for the availability of certified nurse-midwife services and woman-centered care in the hospital setting.

[Obstetric bleeding: an update]

Massive bleeding in obstetrics still ranks among the most frequent causes of maternal morbidity and mortality worldwide. The most frequent type is primary postpartum hemorrhage, which is usually the result of an atonic uterus. The clinical priorities are to assure hemodynamic stability and to correct coagulation abnormalities. If pharmacologic treatment cannot achieve these goals, invasive methods such as interventional vascular radiology or artery ligation must be used. Hysterectomy is the last resort when the previous methods fail. For the best prognosis, in terms of preventing death, maintaining maternal fertility and minimizing morbidity, every maternity ward should have a well-defined multidisciplinary protocol that facilitates diagnosis and immediate treatment.

Repair of uterine rupture in twin gestation after laparoscopic cornual resection

Spontaneous uterine rupture in the course of pregnancy is a rare event that usually occurs in a scarred uterus. The event occurs mostly during the intrapartum period and is potentially catastrophic for both mother and fetus. We report a case of 2-cm cornual rupture in a pregnant woman at 13 weeks twin gestation with previous history of cornual pregnancy successfully managed via laparoscopy. Sudden onset of abdominal pain and vaginal bleeding was noted first. Physical examination revealed stable vital signs, lower abdominal tenderness, and mild rebounding pain. Pelvic ultrasonography revealed twin pregnancy at 13 weeks with extrauterine saccular structure 6 cm in diameter located on the left fundus and contiguous with an intrauterine oligohydramnics twin. Exploratory laparotomy was promptly performed, and a small rupture about 2 cm in diameter was observed on the upper portion of the left fundus, the site of a previous laparoscopic cornual resection scar. A protruding amniotic sac of about 6 cm diameter and containing some part of the umbilical cord was seen. The uterine rupture site was repaired directly after aspiration of amniotic fluid from the protruding sac. After surgery, the patient received antibiotics, 17-OH-progesterone for potential rupture of membranes and prematurity. Tocolysis with Ritodrine for irregular uterine contractions was given at 22 weeks gestation. Steroids were given at 24 weeks gestation. The pregnancy ended with a successful delivery by cesarean section because of uncontrollable uterine contractions at 30 5/7 weeks gestation. In conclusion, although termination of pregnancy would normally be recommended when uterine rupture occurs, a different approach to management may now be accepted.

Uterine rupture in The Netherlands: a nationwide population-based cohort study

OBJECTIVE

To assess incidence of uterine rupture in scarred and unscarred uteri and its maternal and fetal complications in a nationwide design.

DESIGN

Population-based cohort study.

SETTING

All 98 maternity units in The Netherlands.

POPULATION

All women delivering in The Netherlands between August 2004 and August 2006 (n = 371,021).

METHODS

Women with uterine rupture were prospectively collected using a web-based notification system. Data from all pregnant women in The Netherlands during the study period were obtained from Dutch population-based registers. Results were stratified by uterine scar.

MAIN OUTCOME MEASURES

Population-based incidences, severe maternal and neonatal morbidity and mortality, relative and absolute risk estimates.

RESULTS

There were 210 cases of uterine rupture (5.9 per 10,000 pregnancies). Of these women, 183 (87.1%) had a uterine scar, incidences being 5.1 and 0.8 per 10,000 in women with and without uterine scar. No maternal deaths and 18 cases of perinatal death (8.7%) occurred. The overall absolute risk of uterine rupture was 1 in 1709. In univariate analysis, women with a prior caesarean, epidural anaesthesia, induction of labour (irrespective of agents used), pre- or post-term pregnancy, overweight, non-Western ethnic background and advanced age had an elevated risk of uterine rupture. The overall relative risk of induction of labour was 3.6 (95% confidence interval 2.7-4.8).

CONCLUSION

The population-based incidence of uterine rupture in The Netherlands is comparable with other Western countries. Although much attention is paid to scar rupture associated with uterotonic agents, 13% of ruptures occurred in unscarred uteri and 72% occurred during spontaneous labour.

The changing specter of uterine rupture

OBJECTIVE

The objective of the study was to review all patient records discharged with codes for uterine rupture in 2006 in Hospital Corporation of America hospitals.

STUDY DESIGN

All patient charts were distributed to a committee of perinatologists and general obstetricians. Case report forms were analyzed for variables of interest to determine validity of coding and quality of care.

RESULTS

Of 69 cases identified, only 41 were true ruptures. Twenty patients had previous cesareans, and in 9 of these patients, concurrent use of oxytocics was documented. Among the 21 patients without previous cesareans, 7 had previous uterine surgery, and oxytocics were documented in 12 of the remaining 14 patients. Standard of care violations were identified in 10 of 41 true rupture cases.

CONCLUSION

Epidemiological data on uterine rupture based on hospital discharge codes without concurrent chart review may be invalid. Patients with previous cesareans represent only half of true uterine ruptures in contemporary practice.

Intrapartal posterior cervicoisthmic uterine rupture

A case is presented of complete intrapartal rupture of an intact, nonscarred uterus in the cervicoisthmic region in a quadripara without a history of cesarean section or other uterine operation, with dorsoposterior high longitudinal fetal head position.

Uterine rupture in a primigravida with adenomyosis recently subjected to laparoscopic resection of rectovaginal endometriosis: case report

A case of intrapartum, complete, low-posterior wall, transverse uterine rupture, complicated by uterine atony and treated by emergency hysterectomy in a primigravida with uterine adenomyosis who delivered vaginally at 37 weeks plus 5 days of gestation, 9 months after undergoing laparoscopic resection of rectovaginal septum endometriosis.

Uterine rupture during pregnancy and delivery among women attending the Al-Tthawra Hospital in Sana'a City Yemen Republic

BACKGROUND

About 20 percent of the population in developing countries is composed of women of reproductive age. These women face one of the catastrophic risks of pregnancy "uterine rupture". Studies conducted in the developing world give strong evidence that uterine rupture is a major health problem in these countries with the rate being high in rural areas.

AIM

The purpose of the study was to estimate the incidence and determine the risk factors and outcome of uterine rupture among women using the referral hospital Al-thawra in Sana'a City, Yemen republic and to extrapolate the data to the whole of Yemen.

METHODS

The data was collected retrospectively; by interviewing, examining and following up all the cases of uterine rupture coming to the hospital during a period of 9 months between September 1996 and May 1997. A descriptive analysis and distribution frequency of the commonest causes of uterine rupture in 37 cases are presented taking into account medical, reproductive, health services provided and sociodemographic factors.

RESULTS

Incidence of uterine rupture in Yemen was found to be (0.63), obstructed labor 83 %, contracted pelvis 19 %, previous surgery in 48 %, Oxytocine infusion in 42 %. Grand-multiparty was in 65 % and maternal age over 35 years in 50 %. Antenatal care was only in 34 %.

CONCLUSION

The high percentage of malpresentation, cephalopelvic disproportion, previous uterine surgery accompanied by the high percentage of use of Oxytocin in this study highlights very clearly the role of this medication in increasing the risk of uterine rupture in Yemen.

Identifying risk factors for uterine rupture

Uterine rupture, whether in the setting of a prior uterine incision or in an unscarred uterus, is an obstetric emergency with potentially catastrophic consequences for both mother and child. Numerous studies have been published regarding various risk factors associated with uterine rupture. Despite the mounting data regarding both antepartum and intrapartum factors, it currently is impossible to predict in whom a uterine rupture will occur. This article reviews the data regarding these antepartum and intrapartum predictors for uterine rupture. The author hopes that the information presented in this article will help clinicians assess an individual's risk for uterine rupture.

Major obstetric hemorrhage

Major obstetric hemorrhage remains the leading cause of maternal mortality and morbidity worldwide, and is associated with a high rate of substandard care. A well-defined and multidisciplinary approach that aims to act quickly and avoid omissions or conflicting strategies is key. The most common etiologies of hemorrhage are abruptio placenta, placenta previa/accreta, uterine rupture in the antepartum period and retained placenta, uterine atony, and genital-tract trauma in the postpartum period. Basic treatment of postpartum hemorrhage relies on manual removal of the placenta or manual exploration of the uterus plus bladder emptying and oxytocin administration. If this does not arrest bleeding, or if there is any suspicion of genital-tract trauma, examination of the vagina and cervix with appropriate valves and analgesia/anesthesia must follow quickly. Postpartum uterine atony resistant to oxytocin must be treated with prostaglandin within 15 to 30 minutes; uterine balloon tamponade can be also useful at this stage. Aggressive transfusion therapy and resuscitation are mandatory in major obstetric hemorrhage. Specific invasive treatment must be considered within no more than 30 to 60 minutes, if previous measures have failed -- and even earlier in some particular etiologies. The two main options are radiologic embolization and surgical artery ligations. Recombinant factor VIIa may also be considered, but should not delay the performance of a life-saving procedure such as embolization or surgery. Hysterectomy must be implemented when all other interventions have failed.

Imaging features of postpartum uterine rupture: a case report

We present a case report on a postpartum uterine rupture with the history of a previous cesarean section. During the diagnosis of rupture, ultrasound, computerized tomography (CT) and magnetic resonance imaging of the uterus were obtained. Ultrasound examination did not result in substantial information. CT and magnetic resonance imaging established the correct diagnosis. The patient underwent exploratory laparotomy, and the diagnosis was confirmed. Diagnostic qualifications of these three instruments were compared.

Placenta Percreta Leading to Spontaneous Complete Uterine Rupture in the Second Trimester

A 30-year-old gravida 2 para 1 was admitted to hospital 2 years after cesarean section at 20 weeks' gestation with acute onset of abdominal pain and hypovolaemic shock. Emergency laparotomy revealed a uterine rupture located in the anterior uterine wall caused by a placenta percreta and supracervical hysterectomy was performed. This site of invasion and finally rupture was in projection of the previous lower-segment cesarean section. This report illustrates the dramatic consequences of abnormal placentation after prior uterine surgery, which can already occur early during pregnancy and prior to the onset of labour.