Spontaneous prelabor uterine rupture in a primigravida: a case report and review of the literature

Spontaneous uterine rupture complicated by bilateral pulmonary emboli: A case report

Spontaneous uterine rupture in unscarred uteri complicated by pulmonary emboli is a rare event with major maternal morbidity and mortality. This is a case of a 32-year-old woman, G1P0, at term, with no pertinent past medical/surgical history, who underwent an emergency cesarean delivery for failed induction of labor complicated by uterine rupture. Post-operatively, the patient was tachycardic and hypoxic. CT arteriogram revealed massive bilateral pulmonary emboli, and she was transferred for specialist care. An emergency pulmonary embolectomy and implantation of an extracorporeal right ventricular assist device were performed. Once the patient was clinically stable, an evaluation for thrombophilias and collagen disorders was done, and was positive for a variant of unknown significance in the ELN gene (c.205G > C). This case report highlights a potential connection between uterine ruptures, hemorrhage, and multiple, large pulmonary emboli. The authors propose a multidisciplinary discussion and evaluation to identify risk factors and biologic causes for these rare but life-threatening complications.

Labisia pumila as a Culprit of Primary Uterine Rupture Alongside Abruptio Placentae: A Case Report

Purpose

Uterine rupture is a rare obstetrical and surgical emergency but is often associated with a catastrophic obstetric complication. Traditionally, unscarred uteri without risk factors are considered immune to rupture and information about its risk factors is only few due to its rarity. Complementary and alternative medicine is commonly used in pregnant woman in southeast Asian countries such as Indonesia, however information regarding its toxicity due to irrational use is few. This case report presents a G2P1A0 35-year-old woman with acute abdomen with spontaneous unscarred uterine rupture >15 cm after continuously consuming herbal water made of Kacip Fatimah leaves in boiling water.

Case Description

A 35-year-old pregnant woman was referred to hospital due to abdominal discomfort 3 hours before admission due to suspicion of intrauterine fetal death. She drank the extracted herbal water to help her when the labor comes, which was made from boiled water with rumput Fatimah from her neighbor's house. Then, she was diagnosed with G2P1A0 parturient aterm latent phase; acute abdomen due to suspicion of placentae abruption dd/ ruptur uteri; and Intrauterine Fetal Death. Exploratory laparotomy was decided due to acute abdominal pain, and during the procedure the operator decided to do subtotal hysterectomy on the patient. The operator found her uterine was already ruptured, approximately 15-18 cm and the placentae was located outside of the uterus.

Conclusion

This case suggest that rational usage of herbal medicine must be implemented to avoid unwanted complication.

Antepartum Rupture of the Posterior Uterine Wall in a Woman With Two Previous Cesarean Deliveries

Uterine rupture is a rare pregnancy complication. In patients with a previous cesarean delivery, it usually involves the scarred area. Uterine rupture of the posterior wall is even rarer and mostly described during labor. Conditions that confer fragility to the posterior uterine wall have been associated with an increased risk of uterine rupture. There are very few cases of spontaneous posterior uterine wall rupture in a non-labor setting in pregnant women without risk factors. We report the case of a pregnant woman admitted to the hospital due to placental abruption at 26 weeks' gestation. Once fetal and maternal stability were assured, expectant management was maintained. At 29 weeks, an emergent cesarean delivery due to fetal bradycardia was performed, and a large rupture of the posterior uterine wall was diagnosed. Subsequently, a hysterectomy was performed. The patient was discharged nine days after the procedure and the newborn on the 64th day of life.

Diagnosis and Methods of Repair for a Uteroperitoneal Fistula (UPF) Formed After Gynecological Surgeries

A uteroperitoneal fistula (UPF) is a rare disorder that can lead to infertility and has never been reported. UPFs can cause infertility and perinatal complications. A 34-year-old woman (gravida 0) with a history of three gynecological surgeries using a uterine manipulator was diagnosed with a UPF using hysteroscopy and hysterosalpingography. She underwent laparoscopic uterine repair as an infertility treatment. The uterine perforation may have been caused by uterine manipulator insertion or suture failure in the myometrium during her previous laparoscopic myomectomy and cystectomy procedures. The UPF disappeared after the current surgical treatment. The complications of UPFs include infection, infertility, ectopic pregnancy, and uterine rupture. We expected that the presence of a fistula would increase the risk of impaired fertilization, implantation failure, and ectopic pregnancy. This case report contributes valuable insights into the diagnosis of UPFs and their laparoscopic repair.

Unscarred uterine rupture with catastrophic hemorrhage immediately after vaginal delivery: diagnosis and management of six consecutive cases

BACKGROUND

To describe and explore the risk factors, clinical presentations, timely diagnostic approaches, and management in patients experiencing unscarred uterine rupture with catastrophic hemorrhage.

METHODS

We retrospectively analyzed clinical and imaging data from women who encountered postpartum hemorrhage (PPH) and were diagnosed with unscarred uterine rupture within a three-year timeframe (2018-2020). The data were extracted from medical records obtained from a multi-hospital 24-hour emergency PPH transfer system.

RESULTS

Six patients were identified as having unscarred uterine rupture after vaginal delivery. All six women were para 2, with four of them undergoing vacuum-assisted delivery. One patient experienced out-of-hospital cardiac arrest (OHCA), while five patients presented with hypovolemic shock. Abdominopelvic ultrasound revealed a boggy lower uterine segment. Initially, five patients underwent transarterial embolization (TAE) of the internal iliac arteries in an attempt to achieve hemostasis, but this approach proved unsuccessful. Abdominopelvic computed tomography (CT) confirmed the diagnosis of ruptured uterus by demonstrating disrupted myometrium and hemoperitoneum. Immediate exploratory laparotomy followed by life-saving hysterectomy was performed in all cases. The median estimated total blood loss was 2725 mL ± 900 mL (ranging from 1600 mL to 7100 mL). Lower segment lacerations were observed in all patients, with more extensive uterine damage noted in those who underwent vacuum extraction. The length of hospital stay varied between 9 and 38 days.

CONCLUSION

Instrument-assisted obstetric delivery is a possible contributing factor to unscarred uterine rupture in our study. In specific cases, the use of abdominopelvic CT prior to initiating transarterial embolization (TAE) offers valuable information to complement ultrasound findings. This comprehensive approach helps in accurately identifying the underlying cause of intractable postpartum hemorrhage (PPH). Immediate conversion to laparotomy is essential to explore the intra-abdominal factors causing PPH that cannot be controlled by TAE. The rational etiologies of uterine rupture must be clarified while generating practical guideline in the future.

Uterine rupture due to adenomyosis in an adolescent: A case report and review of literature

BACKGROUND

Uterine rupture is a fatal medical complication with a high mortality rate. Most cases of uterine rupture occur in late pregnancy or during labor and are mainly related to uterine scarring due to previous surgical procedures. Adenomyosis is a possible risk factor for uterine rupture. However, spontaneous uterine rupture due to severe adenomyosis in a non-gravida-teenaged female has not been reported in the literature to date.

CASE SUMMARY

A 16-year-old girl was referred to our hospital for acute abdominal pain and hypovolemic shock with a blood pressure of 90/50 mmHg. Radiologic studies revealed a huge endometrial mass with multiple nodules in the lung, suggesting lung metastasis. The patient underwent an emergency total hysterectomy and wedge resection of the lung nodules. Histologically, the uterus showed diffuse adenomyosis with glandular and stromal dissociation. Lung nodules were endometrioma with massive hemorrhage. Immunohistochemistry demonstrated that the tumor cells were positive for PAX8, ER, and PR expression, leading to a final diagnosis of pulmonary endometriosis and uterine adenomyosis. Following surgery, the patient remains in good condition without recurrence.

CONCLUSION

This is the first case of spontaneous uterine rupture due to adenomyosis in a non-gravida adolescent.

Incidence and outcomes of uterine rupture in women with unscarred, preterm or prelabour uteri: data from the international network of obstetric survey systems

OBJECTIVE

Analysis of atypical cases of uterine rupture, namely, uterine rupture occurring in unscarred, preterm or prelabour uteri.

DESIGN

Descriptive multi-country population-based study.

SETTING

Ten high-income countries within the International Network of Obstetric Survey Systems.

POPULATION

Women with unscarred, preterm or prelabour ruptured uteri.

METHODS

We merged prospectively collected individual patient data in ten population-based studies of women with complete uterine rupture. In this analysis, we focused on women with uterine rupture of unscarred, preterm or prelabour ruptured uteri.

MAIN OUTCOME MEASURES

Incidence, women's characteristics, presentation and maternal and perinatal outcome.

RESULTS

We identified 357 atypical uterine ruptures in 3 064 923 women giving birth. Estimated incidence was 0.2 per 10 000 women (95% CI 0.2-0.3) in the unscarred uteri, 0.5 (95% CI 0.5-0.6) in the preterm uteri, 0.7 (95% CI 0.6-0.8) in the prelabour uteri, and 0.5 (95% CI 0.4-0.5) in the group with no previous caesarean. Atypical uterine rupture resulted in peripartum hysterectomy in 66 women (18.5%, 95% CI 14.3-23.5%), three maternal deaths (0.84%, 95% CI 0.17-2.5%) and perinatal death in 62 infants (19.7%, 95% CI 15.1-25.3%).

CONCLUSIONS

Uterine rupture in preterm, prelabour or unscarred uteri are extremely uncommon but were associated with severe maternal and perinatal outcome. We found a mix of risk factors in unscarred uteri, most preterm uterine ruptures occurred in caesarean-scarred uteri and most prelabour uterine ruptures in 'otherwise' scarred uteri. This study may increase awareness among clinicians and raise suspicion of the possibility of uterine rupture under these less expected conditions.

Management of heterotopic pregnancy: clinical analysis of sixty-five cases from a single institution

Objective

This retrospective study aims to analyze the influence of different treatment modalities on viable intrauterine pregnancy and to summarize the clinical features of heterotopic pregnancy (HP) patients.

Material and methods

All patients diagnosed with HP between January 2012 and December 2022 in Tianjin Central Obstetrics and Gynecology Hospital were reviewed retrospectively.

Results

This study diagnosed 65 patients using transvaginal ultrasound (TVS), including two cases of natural pregnancy, seven cases of ovulation induction pregnancy, and 56 cases after in vitro fertilization and embryo transfer (IVF-ET). The gestational age was 50.2 ± 13.0 days at the time of diagnosis. The most frequent manifestations were abdominal pain (61.5%) and vaginal bleeding (55.4%), while 11 patients (16.9%) had no symptoms before the diagnosis. The primary treatment was expectant and surgical management, including laparotomy and laparoscopic surgery. In the expectant management group, four patients were transferred to surgery due to rupture of ectopic pregnancy or ectopic pregnancy mass gradually enlarged. In the surgical management group, 53 patients underwent laparoscopic surgery, and six underwent laparotomy. The laparoscopic group's mean operation time was 51.3 ± 14.2 min (range: 15-140 min), and the median intraoperative blood loss was 20 mL (range 5-200 mL). In contrast, the laparotomy group's mean operation time was 80.0 ± 25.3 min (range 50-120 min), and the median intraoperative blood loss was 22.5 mL (range 20-50 mL). Four patients had postoperative abortions. Sixty-one newborns had no birth abnormalities, and no developmental malformations were discovered after a median follow-up of 32 months.

Conclusion

Expectant treatment has a high failure rate in HP, and laparoscopic surgery is a safe and effective treatment for removing ectopic pregnancy without increasing the risk of abortion or newborn birth defects.

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.

Obstetric Outcomes after Perforation of Uterine Cavity

We aimed to evaluate the pregnancy characteristics and obstetric outcomes in patients after perforation of the uterus. Study design: A retrospective cohort study was conducted and included all patients who were diagnosed with uterine perforation and treated in a tertiary referral medical center between the years 1996 and 2018. Up to two deliveries after perforations were investigated. Results: During the study period, 51 women were diagnosed with uterine perforation during gynecological procedures, including intrauterine device (IUD) insertion. The mean age of patients at the time of diagnosis was 27.9 (±4.7) years. The majority, 76.5% (n = 39), experienced perforation during IUD insertion, and 23.5% (n = 12) of the patients experienced perforation during surgical procedures. Most of the patients were multiparous or grand multiparous, 45.8. % (n = 22) and 39.6% (n = 19) respectively. Anteflexed uterus was found in 86.4% of the patients (n = 38). Five patients (9.8%) had pelvic abscesses after the IUD insertion. A total of 50 patients had 71 deliveries subsequent to uterine perforation. One patient experienced intrauterine fetal death due to fetal malformations. One patient experienced uterine rupture. No other major obstetric complications were noted. Conclusions: Uterine perforation may be associated with adverse obstetric outcomes. The possibility of uterine rupture must be considered while managing the deliveries of patients after uterine perforation. Moreover, a larger cohort and further studies are needed to establish an association between uterine perforation and adverse outcomes of the subsequent deliveries.

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.

Spontaneous unscarred uterine rupture in a twin pregnancy complicated by adenomyosis: A case report

INTRODUCTION

Uterine rupture during pregnancy is a serious obstetric complication accompanied by a high incidence of maternal morbidity and mortality, and the presence of uterine scars is the main risk factor. In the present case, uterine rupture occurred in an unscarred uterus in a nonlaboring primigravida woman with adenomyosis and twin pregnancy in the third trimester.

PATIENT CONCERNS

In this case, the patient suspected to have a history of endometriosis have got twin pregnancies following intracytoplasmic sperm injection, and complained of recurrent lower abdominal pain from 16 weeks to 29 weeks of gestation.

DIAGNOSIS

After exploratory laparotomy, the patient was diagnosed with uterine rupture and adenomyosis.

INTERVENTIONS

The patient was first administered expectant treatment such as antibiotics, tocolytics, and fluid replacement therapy. Symptoms then appeared repeatedly and worsened, followed by eventual peritoneal irritation, and exploratory laparotomy was performed.

OUTCOMES

Two live female fetuses were extracted by cesarean section, and the uterine laceration was repaired. The mother recovered without any postoperative complications, and the babies were discharged after receiving one month of prematurity care without any postnatal complications.

CONCLUSION

Adenomyosis and the conception of twins may lead to uterine rupture. For pregnant women with a history of adenomyosis with multiple gestations, close monitoring for signs of uterine rupture is necessary. Single-embryo transfer and multifetal pregnancy reduction should be recommended for infertile patients with adenomyosis.

Symptomatic Uterine Rupture: A Fifteen Year Review

Background and objectives: To assess the incidence of complete and partial uterine rupture during childbirth in a single tertiary referral centre as well as the significant risk factors, symptoms and peripartum complications. Materials and Methods: A retrospective single-centre study involved all cases of uterine rupture at the Kaunas Perinatal Centre in 2004–2019. Data were from a local medical database complemented with written information from medical records. We included 45,893 women with an intact uterus and 5630 with uterine scars. Women (n = 5626) with scarred uterus’ after previous cesarean delivery. The diagnosis was defined by clinical symptoms, leading to an emergency cesarean delivery, when complete or partial uterine rupture (n = 35) was confirmed. Asymptomatic cases, when uterine rupture was found at elective cesarean section (n = 3), were excluded. The control group is represented by all births delivered in our department during the study period (n = 51,525). The outcome was complete (tearing of all uterine wall layers, including serosa and membranes) and partial uterine rupture (uterine muscle defect but intact serosa), common uterine rupture symptoms. Risk factors were parameters related to pregnancy and labour. Results: 51,525 deliveries occurred in Kaunas Perinatal Centre during the 15 years of the study period. A total number of 35 (0.06%) symptomatic uterine ruptures were recorded: 22 complete and 13 partial, leading to an incidence rate of 6.8 per 10,000 deliveries. The uterine rupture incidence rate after a single previous cesarean delivery is 44.4 per 10,000 births. 29 (83%) cases had a uterine scar after previous cesarean, 4 (11%) had a previous laparoscopic myomectomy, 2 (6%) had an unscarred uterus. The most significant risk factors of uterine rupture include uterine scarring and augmentation or epidural anaesthesia in patients with a uterine scar after cesarean delivery. The most common clinical sign was acute abdominal pain in labour 18 (51%). No maternal, six intrapartum perinatal deaths (17%) occurred, and one hysterectomy (2.8%) was performed due to uterine rupture. Neonatal mortality reached 22% among the complete ruptures. Average blood loss was 1415 mL, 4 (11%) patients required blood transfusion. Conclusions: The incidence rate of uterine rupture (complete and incomplete) at Kaunas Perinatal Centre is 6.8 per 10,000 deliveries. In cases with a scar of the uterus after a single cesarean, the incidence of uterine rupture is higher, exceeding 44 cases per 10,000 births. The most significant risk factors were uterine scar and augmentation or epidural anaesthesia in a previous cesarean delivery. Acute abdominal pain in labour is the most frequent symptom for uterine rupture.

Prelabour uterine rupture: characteristics and outcomes

OBJECTIVE

To describe the characteristics and outcomes of prelabour uterine ruptures.

DESIGN

Descriptive study based on population data from the Medical Birth Registry of Norway, the Patient Administration System and medical records.

SAMPLE

Maternities with uterine rupture before start of labour in Norway during the period 1967-2008 (8 complete ruptures among 2 334 712 women with unscarred uteri, and 22 complete and 45 partial ruptures among 121 085 women with scarred uteri).

METHOD

We measured the rate of perinatal deaths and peripartum hysterectomy following ruptures. In addition, we studied the characteristics of ruptures.

RESULTS

The eight complete ruptures in women with unscarred uteri were associated with trauma from traffic accidents (n = 3; 37.5%), previous curettage (n = 3; 37.5%) and congenital uterine malformations (n = 2; 25%), resulting in seven perinatal deaths and two hysterectomies. The 22 complete ruptures in scarred uteri were mostly outside the lower uterine segment (n = 17; 72.7%). Abnormally invasive placenta (AIP) and previous rupture were present in four (18.2%) and three women (13.6%), respectively. They resulted in nine perinatal deaths (39.1%) and two hysterectomies (9.1%). The 45 partial ruptures involved mostly scars in the lower uterine segment (n = 39; 86.7%). None of them resulted in perinatal death or hysterectomy. Perinatal deaths have decreased dramatically in recent years, despite increasing prelabour rupture rates.

CONCLUSION

Although complete uterine ruptures before labour start were rare, they often resulted in catastrophic outcomes, such as perinatal death. Scars outside the lower segment were associated with a higher percentage of catastrophic prelabour ruptures compared with scars in the lower segment (Video S1).

TWEETABLE ABSTRACT

Complete prelabour uterine ruptures were rare, but resulted in high perinatal deaths, especially if they were in scars outside the lower segment.

Spontaneous Uterine Rupture Secondary to Morbidly Adherent Placenta in an Unscarred Uterus

We report a case of spontaneous uterine rupture in a primigravida with an unscarred uterus, which was secondary to morbidly adherent placenta proven on surgery and histology. Although rare, uterine rupture should be considered as a differential diagnosis of acute abdominal pain in pregnancies, especially when associated with free fluid, even with the absence of vaginal bleeding. Abnormal placentation is associated with spontaneous antepartum uterine rupture even in early pregnancy. Most cases in the literature have advocated emergency hysterectomy to arrest life-threatening hemorrhage.

Spontaneous Uterine Rupture in the Second Trimester in a Patient With Previous Pelvic Radiotherapy in Childhood: A Case Report

BACKGROUND

Pelvic irradiation in childhood may result in abnormal uterine function. Poor obstetric outcomes have been reported in these patients.

CASE

A 30-year-old woman with a previous midtrimester miscarriage, G2, P0, presented at 23⁴ weeks gestation with acute abdominal pain and signs of hemodynamic instability. The patient was treated in childhood for Ewing sarcoma of the pelvis. Spontaneous uterine rupture was diagnosed. A supracervical hysterectomy with intrauterine fetus was performed.

CONCLUSION

A high index of suspicion is needed in primigravidas with risk factors for uterine rupture. Pelvic radiotherapy in childhood may be a risk factor.

Silent spontaneous posterior uterine rupture of a prior caesarean delivery at 36 weeks of gestation

Background

In caesarean section patients, the spontaneous rupture of the posterior wall of the uterus is extremely rare, with nonspecific signs and symptoms being present. Perinatal and maternal morbidity and mortality are high.

Case presentation

A 28-year-old woman at 36 + 6 weeks of gestation presented with mild uterine contractions and developed a sudden abdominal distension. An emergency laparotomy was performed, and the posterior wall of the uterus had ruptured. A baby boy was born.

Conclusion

Silent uterine rupture is very rare and easy to ignore due to nonspecific clinical symptoms, unexplained haemoglobin reduction and haemoperitoneum, but these features caution us to more closely consider uterine rupture in patients.

Uterine rupture in pregnancy after an intervention complicated by uterine perforation: Case report and systematic review of literature

OBJECTIVES

The present study is a descriptive study of characteristics of women who had a uterine rupture during pregnancy with a history of uterine perforation and no previous caesarean section.

STUDY DESIGN

We present a case report of a woman with a uterine rupture in pregnancy subsequent to a perforation made by uterine sounding and we performed a systematic review including all case-reports of uterine ruptures after perforation during dilatation and curettage or due to uterine sounding.

RESULTS

14 case-reports were included in this review. 12 out of 14 women presented with abdominal pain prior to the uterine rupture. In eight out of 14 cases an abdominal ultrasound was performed and in five ultrasounds a uterine wall defect was detected, in two other cases free fluid was visible and in one case fetal bradycardia was seen. Neonatal outcome was uneventful in six cases, there where two immature fetuses born and in two cases there was fetal demise.

CONCLUSION

Uterine rupture in a (supposed) unscarred uterus is a relatively unknown complication. We recommend clinicians to be aware of uterine rupture in pregnant women with abdominal pain and a history of uterine manipulation. When a uterine rupture is suspected and mother and fetus are in suspected good condition, an ultrasound examination could be an easy and fast next step.

Uterine rupture in a primigravid patient, an uncommon but severe obstetrical event: a case report

BACKGROUND

A spontaneous rupture of the unscarred uterus in a primigravid patient is extremely rare and is associated with high perinatal and maternal morbidity and mortality.

CASE PRESENTATION

A 34-year-old white primigravid woman, 31 + 3 weeks of gestation, presented with pre-eclampsia and developed a sudden acute abdomen. An emergency laparotomy was performed and a uterine rupture was found as the cause of the event. A stillborn girl was born.

CONCLUSION

A rupture of the pregnant uterus should always be considered in a pregnant woman presenting with abdominal pain, even in a primigravid patient.

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

OBJECTIVE

We sought to report obstetric and neonatal characteristics and outcomes following primary uterine rupture in a large contemporary obstetric cohort and to compare outcomes between those with primary uterine rupture vs those with uterine rupture of a scarred uterus.

STUDY DESIGN

This was a retrospective case-control study. Cases were defined as women with uterine rupture of an unscarred uterus. Controls were women with uterine rupture of a scarred uterus. Demographics, labor characteristics, and obstetric, maternal, and neonatal outcomes were compared. Primary rupture case outcomes were also compared by mode of delivery.

RESULTS

There were 126 controls and 20 primary uterine rupture cases. Primary uterine rupture cases had more previous live births than controls (3.6 vs 1.9; P < .001). Cases were more likely to have received oxytocin augmentation (80% vs 37%; P < .001). Vaginal delivery was more common among cases (45% vs 9%; P < .001). Composite maternal morbidity was higher among primary uterine rupture mothers (65% vs 20%; P < .001). Cases had a higher mean estimated blood loss (2644 vs 981 mL; P < .001) and higher rate of blood transfusion (68% vs 17%; P < .001). Women with primary uterine rupture were more likely to undergo hysterectomy (35% vs 2.4%; P < .001). Rates of major composite adverse neonatal neurologic outcomes including intraventricular hemorrhage, periventricular leukomalacia, seizures, and death were higher in cases (40% vs 12%; P = .001). Primary uterine rupture cases delivering vaginally were more likely to ultimately undergo hysterectomy than those delivering by cesarean (63% vs 9%; P = .017).

CONCLUSION

Although rare, primary uterine rupture is particularly morbid. Clinicians must remain vigilant, particularly in the setting of heavy vaginal bleeding and severe pain.

Spontaneous rupture of unscarred uterus in a primigravida with preterm prelabour rupture of membranes

Intrapartum uterine rupture is a true obstetrical emergency. Uterine rupture is associated with severe maternal and fetal morbidity and mortality. It is rare in the unscarred uterus of a primigravida. A 23-year-old primigravida with an unscarred uterus was admitted with preterm prelabour rupture of membranes at 36(+4) weeks of gestation. Abnormal fetal heart monitoring, associated with acute onset of severe abdominopelvic pain, developed on admission. Rupture occurred prior to onset of regular uterine contractions and in the absence of any interventional oxytocin. The neonate had evidence of severe acidosis despite emergency caesarean delivery. This case highlights the importance of maintaining a high index of suspicion for uterine rupture, even in the unlikely setting of a primigravida with an unscarred uterus.

Spontaneous rupture of uterine leiomyoma during labour

Uterine rupture in labour requires an emergency caesarean section. In women with a uterine scar, either from gynaecological surgery or from a previous caesarean section, it is well documented that the risk of rupture is higher than in those without. Spontaneous uterine rupture in a uterus with fibroids during pregnancy or labour is extremely rare. We present a case of a 33-year-old, unbooked pregnant woman from Nigeria who had a uterine rupture secondary to fibroids. She required an emergency caesarean section in labour. The fibroids were not removed. Her baby was born alive and in good condition and she made an uneventful recovery.

Hysteroscopy: guidelines for clinical practice from the French College of Gynaecologists and Obstetricians

The objective of this study was to provide guidelines for clinical practice from the French College of Obstetrics and Gynecology (CNGOF), based on the best evidence available, concerning hysteroscopy. Vaginoscopy should be the standard technique for diagnostic hysteroscopy (Grade A) using a miniature (≤3.5mm sheath) (Grade A) rigid hysteroscope (Grade C), using normal saline solution distension medium (Grade C), without any anaesthesia (conscious sedation should not be routinely used), without cervical preparation (Grade B), without vaginal disinfection and without antibiotic prophylaxy (Grade B). Misoprostol (Grade A), vaginal oestrogens (Grade C), or GnRH agonist routine administration is not recommended before operative hysteroscopy. Before performing hysteroscopy, it is important to purge the air out of the system (Grade A). The uterine cavity distention pressure should be maintained below the mean arterial pressure and below 120mm Hg. The maximum fluid deficit of 2000ml is suggested when using normal saline solution and 1000ml is suggested when using hypotonic solution. When uterine perforation is recognized during operative hysteroscopy using monopolar or bipolar loop, the procedure should be stopped and a laparoscopy should be performed in order to eliminate a bowel injury. Diagnostic or operative hysteroscopy is allowed when an endometrial cancer is suspected (Grade B). Implementation of this guideline should decrease the prevalence of complications related to hysteroscopy.

An unusual cause for epigastric pain in pregnancy. Spontaneous uterine rupture with herniation of the amniotic sac in a 33-week primigravida

A 29-year-old in vitro fertilisation patient presented at 33 weeks of gestation with abdominal pain. An abdominal ultrasound revealed a cystic lesion adjacent to the fundus. During caesarean section, a defect at the fundus was identified with herniation of the amniotic sac through this defect. There were no complications postoperatively and the patient made an unremarkable recovery. With at least one maternal death reported in the most recent confidential enquiry into maternal death, uterine rupture is an obstetric emergency and can have catastrophic outcomes. The incidence of uterine rupture as a result of previous perforation is unclear with little published data and few case reports. Cases of uterine rupture after perforation following hysteroscopic resection of fibroids, uterine septum are well published but the authors found no known previous cases related to laparoscopy. Counselling patients post perforation should include discussion regarding the management of future pregnancies and the risk of uterine rupture.

[Prevention of the complications related to hysteroscopy: guidelines for clinical practice]

OBJECTIVE

To provide clinical practice guidelines (CPGs) from the French college of obstetrics and gynecology (CNGOF), based on the best evidence available, concerning the adverse events related to hysteroscopy.

MATERIALS AND METHODS

Review of literature using following Keywords: hysteroscopy; vaginoscopy; infection; perforation; intrauterine adhesions

RESULTS

Vaginoscopy should be the standard technique for outpatient hysteroscopy (grade A) using a miniature (≤ 3.5mm sheath) (grade A) rigid hysteroscope (grade C), using normal saline solution distension medium (grade C), without any anesthesia (conscious sedation should not be routinely used), without cervical preparation (grade B), without vaginal disinfection and without antibiotic prophylaxy (grade B). Misoprostol (grade A), vaginal estrogens (grade C), or GnRH agonist routine administration is not recommended before operative hysteroscopy. Before performing hysteroscopy, it is important to purge the air out of the system (grade A). The uterine cavity distention pressure should be maintained below the mean arterial pressure and below 120 mmHg. The maximum fluid deficit of 2000 mL is suggested when using normal saline solution and 1000 mL is suggested when using hypotonic solution. When uterine perforation is recognized during operative hysteroscopy using monopolar or bipolar loop, the procedure should be stopped and a laparoscopy should be performed in order to eliminate a bowel injury. Diagnostic or operative hysteroscopy is allowed when an endometrial cancer is suspected (grade B).

CONCLUSION

Implementation of this guideline should decrease the prevalence of complications related to office and operative hysteroscopy.