Uterine rupture: risk factors and pregnancy outcome

Prospective evaluation for the feasibility and safety of vaginal birth after laparoscopic myomectomy

STUDY OBJECTIVE

To estimate the feasibility and safety of vaginal birth after laparoscopic myomectomy (LM).

DESIGN

Prospective clinical study (Canadian Task Force classification II-2).

SETTING

University hospital.

PATIENTS

The study was performed on 1334 patients who underwent LM at our hospital from January 2000 through December 2005.

INTERVENTIONS

Laparoscopic myomectomy.

MEASUREMENTS AND MAIN RESULTS

The potential of a safe vaginal birth after LM was discussed with all 1334 patients before and after their LM. A strict protocol for a vaginal birth after LM was prepared using the criteria for a vaginal birth after cesarean section (CS). Of the 221 women who became pregnant after LM by December 2006, 111 were scheduled to deliver at our hospital. The findings at LM in these patients were as follows: mean diameter of the largest myoma (mean +/- SD, 95% CI), 66.1 +/- 18.8 (62.6-69.6) mm; and mean number of enucleated myomas, 3.5 +/- 3.6 (2.8-4.2). The endometrium was opened in 13 patients. Of the 111 patients, 82 patients opted for a vaginal delivery and 29 patients requested a CS. Of the 82 patients, 8 underwent an elective CS because of complications of pregnancy. Vaginal delivery was completed in 59 (79.7%) of the remaining 74 patients. The 15 patients who failed vaginal delivery underwent a CS: eleven because of failure to progress in labor or absence of spontaneous labor by 42 weeks of gestation; and 4 because of a nonreassuring fetal status during labor. No significant differences in delivery outcomes existed between the successful and failed group. None of the patients had a uterine rupture.

CONCLUSION

Uterine rupture during pregnancy after LM is rare, and vaginal birth after LM appears to be safe in selected patients who meet our criteria.

Risk factors for uterine rupture and neonatal consequences of uterine rupture: a population-based study of successive pregnancies in Sweden

OBJECTIVE

Uterine rupture is a rare but a catastrophic event. The aim of the present study was to explore the risk factors for uterine rupture and associated neonatal morbidity and mortality among a cohort of Swedish women attempting vaginal birth in their second delivery.

DESIGN

Population-based cohort study.

SETTING

Sweden.

POPULATION

A total of 300,200 Swedish women delivering two single consecutive births between 1983 and 2001.

METHODS

Swedish population-based registers were used to obtain information concerning demographics, pregnancy and birth characteristics, and neonatal outcomes. Logistic regression was used to analyse potential risk factors for uterine rupture and risk of neonatal mortality associated with uterine rupture. Odds ratios were used to estimate relative risks using 95% CI.

MAIN OUTCOME MEASURE

Uterine rupture and neonatal mortality in the second pregnancy.

RESULTS

Compared with women who delivered vaginally in their first birth, women who underwent a caesarean delivery were, during their second delivery, at increased risk of uterine rupture (adjusted OR 41.79; 95% CI 29.73-57.00). Induction of labour, high (> or = 4000 g) birthweight, postterm (> or = 42 weeks) births, high (> or = 35 years) maternal age, and short (< or = 164 cm) maternal stature were also associated with increased risk of uterine rupture. Uterine rupture was associated with a substantially increased risk in neonatal mortality (adjusted OR 65.62; 95% CI 32.60-132.08).

CONCLUSION

The risk of uterine rupture in subsequent deliveries is not only markedly increased among women with a previous caesarean delivery but also influenced by induction of labour, birthweight, gestational age, and maternal characteristics.

Vaginal birth after cesarean section: X-ray pelvimetry at term is informative

OBJECTIVE

To examine whether X-ray pelvimetry data to evaluate the likelihood of vaginal birth after previous cesarean section.

DESIGN

Retrospective study.

SETTING

University hospital.

POPULATION

Patients with a previous cesarean delivery who underwent X-ray pelvimetry and gave birth at gestational age 37 weeks during a seven-year period.

METHODS

1190 patients with a scarred uterus were compared with 15,189 patients without a scarred uterus. In the scarred uterus group, 760 patients with a transverse pelvic diameter > or =12 cm were compared with 430 patients with a transverse pelvic diameter <12 cm.

MAIN OUTCOME MEASURES

The obstetrical outcomes were spontaneous or induced labor, and mode of delivery. The maternal morbidity outcomes were hemorrhage requiring transfusion of packed red cells, uterine rupture, bladder injury, and hysterectomy due to hemorrhage. The neonatal morbidity outcomes were the 5-min Apgar score, transfer to intensive care, and intubation.

RESULTS

Patients with a scarred uterus had a significantly higher rate of cesarean section (35.5%) than those with no prior cesarean section (9%). Among patients with a scarred uterus who were selected for vaginal delivery, 81% delivered vaginally when the transverse diameter (TD) of the pelvic inlet was greater than 12 cm, 68% when the TD was between 11.5 and 12 cm, and 58% when the TD was less than 11.5 cm. Maternal morbidity was significantly higher in the patients with a scarred uterus. The neonatal results were comparable in the different groups.

CONCLUSION

X-ray pelvimetry tailors the information given to each patient about the likelihood of having a vaginal delivery. It can also be used to optimize the selection of patients allowed to enter labor.

Litigation in Obstetrics: a Lesson Learnt and a Lesson to Share

A perfect baby is the expectation of all parents, and a perfect outcome is the mission of obstetrics. Every obstetrician dreads to hear that there is an unexpected maternal mortality and/or severe fetal injury at the hospital. The role of a perceived public expectation of perfection in obstetric medicine reflects a belief that bad outcomes in obstetrics should not be tolerated and that every maternal-fetal injury merits financial compensation and punishment. What has brought these troubling times to obstetric medicine? The drivers behind malpractice crises are the four leading interest groups in the medical-legal debate: pregnant patients and their environment (husband, parents, relatives, friends, legislators, and the media), health-care providers, insurance companies, and trial attorneys. Litigation in obstetrics is the result of a complex of events when malpractice (presumed or real) impacts on the attitude of pregnant women and their environment. In such complexity, information is mandatory but may often be misinterpreted. If messages are not tailored to the receiver's capacity, communicating well with the pregnant patient becomes crucial. Therefore, to reduce medical-legal issues in obstetrics, increasing attention and an applicable standard of obstetric care to avoid negligence and medical errors should go along with better communication with pregnant women. Communication should be clear, targeted, effective, flexible, and empathic to share a common language and decisions. This review briefly presents and discusses some of the most frequently encountered medical-legal claim cases in obstetric practice. In-depth review of pregnancy-related deaths and major morbidities can help determine strategies needed to continue making pregnancy safer.

Uterine dehiscence in term pregnant patients with one previous cesarean delivery: growth factor immunoexpression and collagen content in the scarred lower uterine segment

OBJECTIVE

This study aimed at investigating the relationship between the occurrence of uterine dehiscence in term pregnant scarred uteri and the presence of altered biochemical behavior of the scarring process.

STUDY DESIGN

Collagen content and the expression of transforming growth factor-beta and its isoforms transforming growth factor-beta1 and transforming growth factor-beta3, connective tissue growth factor, basic fibroblast growth factor, vascular endothelial growth factor, platelet-derived growth factor, and tumor necrosis factor-alpha in myometrium of lower uterine segment were assessed in 19 otherwise healthy term patients with one previous cesarean delivery who were not in labor. We were searching for differences between patients who showed uterine dehiscence (9 cases) and patients who showed a normal-appearing scarred lower uterine segment (10 cases). We also evaluated all these features in lower uterine segment from unscarred uteri of 10 otherwise healthy patients who were not in labor.

RESULTS

In the case of uterine dehiscence, the scarred lower uterine segment showed a higher collagen content, a reduction of pan transforming growth factor-beta expression because of a marked decrease or absence of transforming growth factor-beta3, a reduction of connective tissue growth factor, an increase in basic fibroblast growth factor and a slight enhancement in vascular endothelial growth factor, platelet-derived growth factor, and tumor necrosis factor-alpha expression.

CONCLUSION

These findings contribute to meliorate our knowledge about uterine scar healing and allow us to hypothesize that uterine dehiscence of a scarred uterus may be related to altered biochemical behavior of the scarring process.

“Silent” rupture of unscarred gravid uterus with subsequent pelvic abscess: Successful laparoscopic management

Intrapartum rupture of an unscarred uterus is rare in current times. However, it is still associated with significant maternal and fetal mortality and morbidity. Unlike rupture or dehiscence of a previous cesarean scar, which is occasionally bloodless, complete rupture of a gravid unscarred uterus frequently results in fetal jeopardy and significant maternal intraperitoneal bleeding, causes acute abdomen, and demands emergency surgical (laparotomy) intervention. Laparoscopy generally has no role in such circumstances due to the generally unstable maternal hemodynamic condition and the necessity of prompt fetal delivery with an abdominal approach. We present a rare case of intrapartum rupture of an unscarred gravid uterus with an atypical insidious clinical course. The diagnosis of complete uterine rupture was made 20 days after the patient's successful vaginal delivery, at which time a large pelvic abscess formed. The condition was successfully managed laparoscopically. Successful vaginal delivery, even with normal lochia, good uterine contraction, and stable vital signs, does not preclude the possibility of uterine rupture. For patients with unusual postpartum pelvic pain, uterine rupture should be considered as one of the possible etiologic factors, and prompt survey should be performed. Laparoscopic intervention may be valuable in such situations.

Laparoscopic and vaginal repair of uterine scar dehiscence following cesarean section as detected by ultrasound

INTRODUCTION AND OBJECTIVE

Cesarean section (CS) is the most common operation in obstetrics, with rising incidence in most countries. As a result of this operation late scar dehiscence may occur, which may lead to uterine rupture in a subsequent pregnancy. In this case series we have described sonographic detection of scar dehiscence after CS and feasibility of vaginal or combined laparoscopic and vaginal scar excision and uterine repair.

METHODS

Five consecutive patients underwent vaginal or laparoscopic assisted vaginal approach for repair of suspected scar dehiscence following CS, during a 5 year period. In all cases, transvaginal sonography detected suspicious features of scar dehiscence over the anterior uterine wall. Except of one, all patients had reported recurrent pelvic pain and/or irregular menstrual bleedings. Furthermore all patients planned for a further pregnancy.

RESULTS

Resection of the uterine defect and re-constitution of the uterine wall was successfully achieved in all five patients. There were no intra-operative complications and none of the patients required blood transfusion. The mean operation time was 117 min (27-192). Presence of scar tissue was confirmed on histology in all specimens. Four patients remained free of symptoms with no evidence of recurrent scar dehiscence on sonography over a median follow up of 30 months (3-46). One patient had an uneventful pregnancy 24 months after scar removal and was delivered by repeat CS at 39 weeks' gestation.

CONCLUSION

Patients with a history of CS should undergo transvaginal sonography of the scar region in order to detect latent scar dehiscence in combination with uterine wall thinning prior to planning further pregnancy. In suspected cases, a combined laparoscopic - vaginal or vaginal approach can be employed to repair the defect.

Iatrogenic uterine rupture caused by overinflation of RUMI manipulator balloon

The RUMI uterine manipulator is a useful device for uterine mobilization and chromopertubation during laparoscopic surgery. We report two cases of iatrogenic uterine rupture caused by overinflation of the intrauterine balloon of the RUMI manipulator during chromopertubation. One rupture, which occurred on the uterine fundus, simply was sutured during surgery. The other rupture, which occurred into the uterine lateral wall, caused retroperitoneal hematoma. A second operation was required to treat this complication. Overinflation of the tip balloon of the RUMI manipulator during chromopertubation can cause uterine rupture that can result in massive hematoma.

Reproductive outcomes after pregnancy complicated by maternal-fetal surgery

OBJECTIVE

The reproductive outcomes for women after the pregnancy complicated by maternal-fetal surgery were evaluated to obtain evidence-based information for prenatal risk counseling.

STUDY DESIGN

The retrospective review identified 83 women with maternal-fetal surgery from a single institution (1996-2002). These women were sent a consent form and a questionnaire to document postoperative problems, fertility, obstetric outcomes, and psychosocial concerns in pregnancy after the index fetal therapy. Institutional Review Board approval was obtained from Committee for Protection of Human Subjects.

RESULTS

The total return rate was 55 (66%). The pregnancy rate was 62% (18% spontaneous abortion, 24% preterm delivery, and 58% term delivery). Complications were reported in 12 of 34 pregnancies (35%), including uterine dehiscence/rupture (12%/6%), cesarean hysterectomy (3%), and antepartum hemorrhage requiring transfusion (9%).

CONCLUSION

The reproductive outcome of uterine dehiscence, rupture, and hysterectomy was 12%, 6%, and 3%, respectively, after a pregnancy complicated by maternal-fetal surgery. The uterine rupture rate is similar to the rupture rate after "classical" cesarean section (4%-9%).

Uterine rupture: differences between a scarred and an unscarred uterus

OBJECTIVES

This study aimed to compare risk factors, site of rupture, and outcome of uterine rupture among patients with a scarred versus an unscarred uterus. Study design We conducted a comparison between all cases of uterine rupture (n=53) in women with a scarred versus an unscarred uterus, occurring between January 1988 and July 2002.

RESULTS

During the study period, there were ruptures among 26 patients with a scarred uterus and 27 patients without a uterine scar. No significant differences were noted between the scarred and unscarred groups while comparing risk factors such as birth order, birth weight, hydramnios, oxytocin induction, diabetes, and malpresentation. The main site of involvement in both groups was the lower uterine segment representing 92.6% of the ruptures in the unscarred group and 92.3% of the ruptures in the scarred uterus group. Cervical involvement was significantly more common among patients without a previous uterine scar (33.3% vs 7.7%; odds ratio [OR]=6.0, 95% CI, 1.16-31.23, P=.04). Conversely, uterus corpus involvement did not differ between the groups. Perinatal mortality did not differ between the groups. In addition, no significant differences were noted regarding maternal morbidity such as the need for hysterectomy, blood transfusion, or length of hospitalization.

CONCLUSION

Although cervical involvement was significantly more prevalent in the rupture of an unscarred uterus, no significant differences in maternal or perinatal morbidity were noted between rupture of a scarred versus an unscarred uterus.