Fatal spontaneous rupture of a gravid uterus: case report and literature review of uterine rupture

Idiopathic spontaneous rupture of unscarred uterus in a primigravida in active labour

Introduction

Rupture of unscarred pregnant uterus is a rare occurrence and its incidence is higher in developing countries. Rupture of unscarred uterus is associated higher likelihood of adverse maternal and fetal outcomes. Occurrence of rupture of an unscarred uterus lays foundation for the importance of supervised labour and to maintain a high index of suspicion even in a prim gravida.

Case report

We present a case of spontaneous rupture of unscarred uterus in a primigravida with no known risk factors. Rupture was diagnosed in second stage of labour when there was cessation of contractions and loss of station. On exploratory laparotomy, hemoperitoneum of 100 ml and a 10 cm tear was found in left posterolateral aspect of uterus. The tear was repaired successfully and patient had a normal post- operative course.

Discussion

Presence of a uterine scar is the key factor leading to rupture. Spontaneous rupture of unscarred uterus is a rare entity and is associated with multiple factors. In our case, all these factors were ruled out. In literature search we could find 15 cases of spontaneous rupture in unscarred uterus. According to our best knowledge this is the 7th case of rupture in unscarred uterus, reported in a prim gravida without any obvious risk factors.

Conclusion

Rupture uterus should be kept in mind in all patients, even in primigravida if there is high index of suspicion. Quick diagnosis and immediate laparotomy is the cornerstone of treatment in such cases.

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Rupture of unscarred uterus is rare but is associated with significant morbidity.

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High index of suspicion is needed even in absence of risk factors.

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Immediate laparotomy is the gold standard management.

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Delay in diagnosis and management can lead foeto-maternal morbidity.

Spontaneous Rupture of Unscarred Uterus in a Term Primagravida with Lethal Skeletal Dysplasia Fetus (Thanatophoric dysplasia). A Case Report and Review of the Literature

Background and Importance

 Spontaneous uterine rupture, especially in an unscarred uterus, is a rare pregnancy complication that can cause severe morbidity and mortality in both the mother and the fetus. The vast majority of uterine ruptures occur in the presence of a previous uterine scar, most commonly from a previous cesarean delivery. To our knowledge, here we reported the first case of spontaneous rupture of unscarred uterus in a term primigravida secondary to lethal skeletal dysplasia fetus (Type 1 Thanatophoric dysplasia) faced by a practicing clinician in an underdeveloped country (Somalia) with a successful outcome.

Case Presentation

 The patient was 24 yrs. Old Primagravida, at 40 weeks gestation by LMP, presented with abdominal pain and active vaginal bleeding; she did not receive antenatal care during pregnancy; after initial abdominal ultrasonography and vaginal examination, laparotomy was performed due to high suspicion of uterine rupture. After dead fresh fetal extraction, the uterine defect was repaired successfully, and the patient was discharged home in good condition after several days.

Conclusion

 Through this case, we would like to highlight the urgent need to focus on and recognize the importance of receiving antenatal care in the community so that the burden of thousands of lives lost each year can be reduced.

Placenta Percreta and Uterine Rupture in the First Trimester of Pregnancy

Spontaneous uterine rupture in the first trimester of pregnancy is uncommon and difficult to diagnose. Although extremely rare, it is important to consider the occurrence of placenta percreta as differential diagnosis of acute hemorrhagic abdomen at the beginning of pregnancy. We describe below a case of uterine rupture in the first trimester of pregnancy related to placenta percreta.

Spontaneous Rupture of an Unscarred Uterus Diagnosed Postpartum: A Case Report

BACKGROUND

Uterine rupture is a tear in the uterine wall involving its full thickness, resulting in the formation of a defect in the uterine wall. The major risk factor is the presence of uterine scarring (specifically from Caesarean section), but it can also occur in an unscarred uterus. Although rare, this has been shown to result in more severe complications.

CASE

A 31-year-old woman, gravida 6 para 6, without prior uterine incision or manipulation developed significant postpartum bleeding. She was found to have a uterine rupture with retroperitoneal extension, and surgical management was required.

CONCLUSION

Early diagnosis of uterine rupture with rapid initiation of supportive and surgical care may significantly improve prognosis. It is imperative to consider uterine rupture in any obstetrical patient with hemodynamic instability or hemorrhage, regardless of whether risk factors (including a previous uterine scar) are present.

Spontaneous Uterine Rupture of an Unscarred Uterus before Labour

Uterine rupture is a public health problem in developing countries. When it is spontaneous, it occurs most often during labor in a context of scarred uterus. Uterine rupture during pregnancy is a rare situation. The diagnosis is not always obvious and morbidity and maternal and fetal mortality is still high. We report a case of spontaneous uterine rupture during pregnancy at 35 weeks of an unscarred uterus before labour. This is an exceptional case that we observe for the first time in our unit.

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.

Placenta increta causing hemoperitoneum in the 26th week of pregnancy: a case report

INTRODUCTION

Placenta increta is a serious complication of pregnancy. We describe a case leading to uterine rupture associated with massive intra-abdominal hemorrhage.

CASE PRESENTATION

A 34-year-old Caucasian Albanian woman, gravida 2, para 1, was admitted to the emergency department of our hospital for acute abdominal pain associated with profound secondary anemia. An anatomopathological diagnosis of placenta increta destruens was made. An urgent hysterectomy was performed after resuscitation procedures, applied due to the severe anemia and the abdominal drama accompanying the case. Intra-operatively, a uterus-saving procedure was found to be impossible, and hysterectomy remained the only surgical option. The uterine structures were sent for further microscopic evaluation. On histological examination, deep trophoblastic infiltration of the uterine wall was observed, justifying the surgeon's decision. Our patient received blood transfusions and antibiotics. Her sutures were removed on the eighth postoperative day and she was discharged the following day in a stable condition.

CONCLUSION

This case, describing a patient with uterine rupture and massive hemorrhage, illustrates a serious and potentially fatal complication of placenta previa. In such cases, surgery is essential, and hysterectomy may be the only viable option.

Preterm spontaneous uterine rupture in a non-labouring grand multipara: a case report

BACKGROUND

Uterine rupture can be a catastrophic obstetrical emergency. Many risk factors for uterine rupture have been identified, as well as a wide range of clinical presentations. In this case report, we describe the occurrence of fetal death and uterine rupture in a non-labouring, preterm patient.

CASE

A 32-year-old woman, gravida 10, para 7, who had three previous lower segment Caesarean sections, presented with minor abdominal pain and vaginal bleeding. Fetal demise was confirmed on ultrasound examination. Delivery of the fetus by lower segment Caesarean section was planned, but at laparotomy a complete uterine rupture was found, with the amniotic sac intact in the mother's abdomen.

CONCLUSION

Uterine rupture can be a fatal event for the fetus, with the mother experiencing only minor symptoms. In managing patients with risk factors for uterine rupture, clinicians must always keep the possibility of rupture in mind. Abdominal trauma and intercourse may be added risk factors for uterine rupture.

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.

Spontaneous uterine rupture in the first trimester: a case report

Uterine rupture is one of the most feared obstetric complications affecting the pregnant woman and fetus. Most of the cases have various risk factors and mainly occur during the second or third trimester. However, spontaneous uterine rupture during the first trimester is extremely rare. We experienced a case of spontaneous uterine rupture in a 36-yr-old multiparous woman without definite risk factors. The initial impression was a hemoperitoneum of an unknown origin with normal early pregnancy. Intensive surgical method would be needed for accurate diagnosis and immediate management in bad situation by hemoperitoneum even though a patient was early pregnancy.

Perimortem cesarean delivery: were our assumptions correct?

OBJECTIVE

The recommendation to perform a perimortem cesarean delivery within 4 minutes of maternal cardiac arrest was introduced in 1986. This recommendation was based on the assumptions that cardiopulmonary resuscitation is ineffective in the third trimester because of aortocaval compression, and that fetal and perhaps maternal outcomes would be optimized by timely delivery. Our objective was to review the outcomes of perimortem cesarean deliveries to attempt to validate those assumptions.

STUDY DESIGN

Ovid MEDLINE searches using maternal mortality, cardiopulmonary resuscitation, perimortem cesarean delivery, heart attack, and cardiac arrest from 1985 until 2004. Citations from bibliographies of identified publications were perused and cross-referenced for other potential articles. Case reports were included for analysis when mothers had complete cardiopulmonary arrest, and cardiopulmonary resuscitation had been initiated before cesarean delivery.

RESULTS

There were 38 cases of perimortem cesarean delivery identified; 34 infants survived (3 sets of twins, 1 set of triplets); 4 other infants survived initially, but died several days after the deliveries from complications of prematurity and anoxia. Of the 34 infants (25-42 weeks' gestation), time of delivery after maternal cardiac arrest was available for 25. Eleven infants were delivered within 5 minutes, 4 were delivered from 6 to 10 minutes, 2 were delivered from 11 to 15 minutes, and 7 were delivered more than 15 minutes. Of 20 perimortem cesarean deliveries with potentially resuscitatable causes, 13 mothers were resuscitated and discharged from the hospital in good condition. One other mother was successfully resuscitated after the delivery, but died within 24 hours from complications related to her amniotic fluid embolism. In 12 of 18 reports that documented hemodynamic status, cesarean delivery preceded return of maternal pulse and blood pressure, often in a dramatic fashion. Eight other cases noted improvement in maternal status. Importantly, in no case was there deterioration of the maternal condition with the cesarean delivery. We wish to emphasize the large selection bias in this data.

CONCLUSION

Published reports from 20 years support, but fall far from proving, that perimortem cesarean delivery within 4 minutes of maternal cardiac arrest improves maternal and neonatal outcomes.

Subtotal hysterectomy for uterine rupture

OBJECTIVE

The aim of this paper was to stratify patients with uterine rupture in extremis (with hypotension, change in vital organ function, and altered mental status) and evaluate outcome for patients undergoing subtotal hysterectomy (STH) vs. uterine repair (UR).

METHODS

Of 39667 hospital deliveries between 1993 and 1998 at a university hospital, 367 presented with uterine rupture. Of these, 96 presented in extremis and had an irregularly torn uterus found at operation. Charts were retrospectively reviewed to stratify patient population with uterine rupture and their outcome. Results were analyzed using Fisher's exact test.

RESULTS

Patients with uterine rupture were 31-35 years old, para> or =3, had received no antenatal care, and presented with rupture in the lower uterine segment. Sixty-one patients underwent STH while 35 underwent UR. The groups were similar with respect to patient age, parity, cause of rupture, and clinical condition at the time of evaluation (P=0.2). The operative time for STH was significantly less than UR, 35 min vs. 75 min (P<0.01). Maternal mortality was significantly higher in patients undergoing UR vs. STH, 46% vs. 20% (P=0.01). Maternal morbidity occurred in 30% of patients undergoing STH vs. 50% in patients undergoing UR (P=0.01). The time to discharge was significantly less in patients undergoing STH compared to UR, 14.5 days vs. 27 days (P<0.01).

CONCLUSIONS

Patients with uterine rupture in extremis tend to be young, multiparous, receive no antenatal care, and have uterine rupture of the lower segment. STH significantly lowered operative time, morbidity, time to discharge, and mortality than UR in patients in extremis with uterine rupture.

Uterine emergencies. Atony, inversion, and rupture

Uterine atony, inversion, and rupture are potentially fatal events that may occur in pregnancy. They are obstetric emergencies that require immediate attention. Although all women may experience these complications, identification or known risk factors allow the obstetric team to prepare for rapid diagnosis and intervention. This article includes management options to help prepare for these uncommon events.