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

Risk factors for maternal complications following uterine rupture: a 12-year single-center experience

PURPOSE

To determine maternal outcomes and risk factors for composite maternal morbidity following uterine rupture during pregnancy.

METHODS

A retrospective cohort study including all women diagnosed with uterine rupture during pregnancy, between 2011 and 2023, at a single-center. Patients with partial uterine rupture or dehiscence were excluded. We compared women who had composite maternal morbidity following uterine rupture to those without. Composite maternal morbidity was defined as any of the following: maternal death; hysterectomy; severe postpartum hemorrhage; disseminated intravascular coagulation; injury to adjacent organs; admission to the intensive care unit; or the need for relaparotomy. The primary outcome was risk factors associated with composite maternal morbidity following uterine rupture. The secondary outcome was the incidence of maternal and neonatal complications following uterine rupture.

RESULTS

During the study period, 147,037 women delivered. Of them, 120 were diagnosed with uterine rupture. Among these, 44 (36.7%) had composite maternal morbidity. There were no cases of maternal death and two cases of neonatal death (1.7%); packed cell transfusion was the major contributor to maternal morbidity [occurring in 36 patients (30%)]. Patients with composite maternal morbidity, compared to those without, were characterized by: increased maternal age (34.7 vs. 32.8 years, p = 0.03); lower gestational age at delivery (35 + 5 vs. 38 + 1 weeks, p = 0.01); a higher rate of unscarred uteri (22.7% vs. 2.6%, p < 0.01); and rupture occurring outside the lower uterine segment (52.3% vs. 10.5%, p < 0.01).

CONCLUSION

Uterine rupture entails increased risk for several adverse maternal outcomes, though possibly more favorable than previously described. Numerous risk factors for composite maternal morbidity following rupture exist and should be carefully assessed in these patients.

[Maternal mortality due to obstetric haemorrhage in France 2016-2018]

Between 2016 and 2018, 20 maternal deaths were related to obstetric haemorrhage, excluding haemorrhage in the first trimester of pregnancy, representing a mortality ratio of 0.87 per 100,000 live births (95% CI 0.5 -1.3). Obstetric haemorrhage is the cause of 7.4% of all maternal deaths up to 1 year, 10% of maternal deaths within 42days, and 21% of deaths directly related to pregnancy (direct causes). Between 2001 and 2018, maternal mortality from obstetric haemorrhage has been considerably reduced, from 2.2deaths per 100,000 live births in 2001-2003 to 0.87 in the period presented here. Nevertheless, obstetric haemorrhage is still one of the main direct causes of maternal death, and remains the cause with the highest proportion of deaths considered probably (53%) or possibly (42%) preventable according to the CNEMM's collegial assessment (see chapter 3). The preventable factors reported are related to inadequate content of care in 94% of cases and/or organisation of care in 44% of cases. In this triennium, maternal death due to haemorrhage occurred mainly in the context of caesarean delivery (65% of cases, i.e. 13/20), and mostly in the context of emergency care (12/13). The main causes of obstetric haemorrhage were uterine rupture (6/20) in unscarred uterus or in association with placenta accreta, and surgical injury during the caesarean delivery (5/20). Every maternity hospital, whatever its resources and/or technical facilities, must be able to plan any obstetric haemorrhage situation that threatens the mother's vital prognosis. Intraperitoneal occult haemorrhage following caesarean section and uterine rupture require immediate surgery with the help of skilled surgeon resources with early and appropriate administration of blood products.

Oxytocin augmentation and neurotransmitters in prolonged delivery: An experimental appraisal

The uterus is a highly innervated organ, and during labor, this innervation is at its highest level. Oxytocinergic fibers play an important role in labor and delivery and, in particular, the Lower Uterine Segment, cervix, and fundus are all controlled by motor neurofibers. Oxytocin is a neurohormone that acts on receptors located on the membrane of the smooth cells of the myometrium. During the stages of labor and delivery, its binding causes myofibers to contract, which enables the fundus of the uterus to act as a mediator. The aim of this study was to investigate the presence of oxytocinergic fibers in prolonged and non-prolonged dystocic delivery in a cohort of 90 patients, evaluated during the first and second stages of labor. Myometrial tissue samples were collected and evaluated by electron microscopy, in order to quantify differences in neurofibers concentrations between the investigated and control cohorts of patients. The authors of this experiment showed that the concentration of oxytocinergic fibers differs between non-prolonged and prolonged dystocic delivery. In particular, in prolonged dystocic delivery, compared to non-prolonged dystocic delivery, there is a lower amount of oxytocin fiber. The increase in oxytocin appeared to be ineffective in patients who experienced prolonged dystocic delivery, since the dystocic labor ended as a result of the altered presence of oxytocinergic fibers detected in this group of patients.

A rare case of massive intrapartum hemorrhage followed by inner myometrial laceration during a vaginal delivery: A case report

Key Clinical Message

Considering the laceration of the inner layer of the myometrium as an important and controllable cause of bleeding during childbirth can lead to saving the mother's life.

Abstract

Laceration of the inner layer of the myometrium can cause massive bleeding during and after childbirth, which can lead to the death of the mother if it is not diagnosed in time.we presented a rare case of massive intrapartum bleeding following myometrial laceration that diagnosed correctly and the patient survived with in-time treatments. The patient was a 26-year-old woman who was under observation for term pregnancy and complaint of rupture of membranes (ROM) and vaginal bleeding. Following the spontaneous course of labor and without receiving oxytocin, during the normal course of labor, she was with an estimated total blood loss of 750 mL bleeding, which despite the normal fetal heart rate and with the mother's indication for cesarean section, was transferred to the operating room and underwent cesarean section. During the cesarean section, the amniotic fluid was clear, after the removal of the placenta, severe and clear bleeding was flowing from the posterior wall of the uterus, which was caused by the laceration of the inner layer of the myometrium in the posterior wall of the lower segment of the uterus. The myometrial laceration was repaired with absorbable continuous locked sutures and hemostasis was established, and then the patient used uterotonic drugs, and after monitoring, the patient was discharged from the hospital in good condition.

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.

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.

Fetomaternal outcome of scarred uterine rupture compared with primary uterine rupture: a retrospective cohort study

OBJECTIVES

Literature comparing maternal and perinatal outcomes among women with scarred and primary uterine rupture are limited. Therefore, the study aimed to compare maternal and perinatal outcomes and associated risk factors of uterine rupture among scarred and unscarred uterus.

METHODS

This retrospective cohort study was performed at a large tertiary care of India between July 1, 2011 and June 30, 2020. We analysed all the cases of complete uterine rupture beyond the 20th week of gestation. The outcome measures were live birth rate, perinatal mortality, maternal mortality and morbidity.

RESULTS

A total of 115 complete uterine ruptures were noted in 148,102 pregnancies. Of those 115 uterine ruptures, 89 (77.3 %) uterine ruptures occurred in women with a history of caesarean delivery, and 26 (22.6 %) uterine ruptures occurred in primary uterine rupture. The primary uterine rupture group had a significantly higher incidence of lower parity, breech presentation and mean birth weight. The live birth rate (68.18% vs. 42.85 %; p=0.04) was significantly higher in the scarred group, and the stillbirth rate (57.14% vs. 31.86 %; p=0.009) was significantly higher in the primary uterine rupture group. Hypoxic ischemic encephalopathy, APGAR score, and neonatal intensive care unit admission were comparable. Postpartum haemorrhage, blood transfusion, severe acute maternal morbidity and intensive care unit stay were more frequently reported in the primary uterine rupture group.

CONCLUSIONS

The maternal and perinatal outcomes appear less favourable among women with primary uterine rupture than scarred uterine rupture.

Uterine rupture and factors associated with adverse outcomes

PURPOSE

To review cases of uterine rupture and identify risk factors associated with adverse outcomes.

METHODS

This study is a retrospective cohort of complete uterine ruptures diagnosed in a large hospital system in Massachusetts between 2004 and 2018. Baseline demographics, labor characteristics and outcomes of uterine rupture were collected from medical records.

RESULTS

A total of 173 cases of uterine rupture were identified. There were 30 (17.3%) women with an unscarred uterus, while 142 (82.1%) had a scarred uterus. Adverse outcomes (n = 89, 51.4% of cases) included 26 (15.0%) hysterectomies, 55 (31.8%) blood transfusions, 18 (10.4%) bladder/ureteral injuries, 5 (2.9%) reoperations, 25 (14.5%) Apgar scores lower than 5 at 5 min and 9 (5.2%) perinatal deaths. Uterine rupture of a scarred uterus was associated with decreased risk of hemorrhage (OR 0.40, 95% CI 0.17-0.93), blood transfusion (OR 0.27, 95% CI 0.11-0.69), hysterectomy (OR 0.23, 95% CI 0.08-0.69) and any adverse outcome (OR 0.34, 95% CI 0.13-0.91) compared with unscarred rupture. Uterine rupture during vaginal delivery was associated with increased risk of transfusion (OR 6.55, 95% CI 1.53-28.05) and hysterectomy (OR 8.95, 95% CI 2.12-37.72) compared with emergent C-section.

CONCLUSIONS

Although rare, uterine rupture is associated with adverse outcomes in over half of cases. Unscarred rupture and vaginal delivery demonstrate increased risk of adverse outcomes, highlighting the need for early diagnosis and operative intervention.

Antepartum unscarred uterine rupture caused by placenta percreta: a case report and literature review

The main risk for uterine rupture is the presence of a uterine scar due to prior cesarean delivery or other uterine surgery. However, rupture in an unscarred uterus is extremely rare, and risk factors include multiple gestations, trauma, congenital anomalies, use of uterotonics and placenta accreta spectrum.

Placenta accreta spectrum, also known as morbidly adherent placenta, is becoming increasingly common and is associated with significant maternal and neonatal morbidity and mortality.

We report a case of unscarred uterine rupture due to placenta percreta in a multiparous woman that required emergency peripartum hysterectomy.

Spontaneous rupture of an unscarred uterus during pregnancy: A rare but life-threatening emergency: Case series

RATIONALE

In most cases, uterine rupture occurs during the third trimester of pregnancy or during labor. Even fewer reports have been published about the occurrence of this condition without a gynecologic history of any surgical procedure. Due to their scarcity and variable clinical presentation, early diagnosis of uterine rupture may be difficult, and if the diagnosis is not timely, the condition may be life-threatening.

PATIENT CONCERNS

Herein, 3 cases of uterine rupture from a single institution are described. Three patients are at different gestational weeks and all have no history of uterine surgery. They came to the hospital due to acute abdominal pain, which is characterized by severe and persistent pain in the abdomen, with no apparent vaginal bleeding.

DIAGNOSES

All 3 patients were diagnosed with uterine rupture during the operation.

INTERVENTIONS

One patient underwent uterine repair surgery; while the other 2 underwent subtotal hysterectomy due to persistent bleeding and pathological examination after surgery confirmed placenta implantation.

OUTCOMES

The patients recovered well after the operation, and no discomfort occurred in the follow-up.

LESSONS

Acute abdominal pain during pregnancy can pose both diagnostic and therapeutic challenges. It is important to consider the possibility of uterine rupture, even in cases where there is no history of prior uterine surgery. The key to the treatment of uterine rupture is to shorten the diagnosis time as much as possible, this potential complication should be carefully monitored for and promptly addressed to ensure the best possible outcomes for both the mother and the developing fetus.

Outcomes of Uterine Rupture in the Setting of the Unscarred Compared With the Scarred Uterus

Uterine rupture is a rare obstetric complication that is associated with maternal and neonatal morbidity and mortality. The aim of this study was to examine uterine rupture and its outcomes in the setting of the unscarred compared with the scarred uterus. A retrospective observational cohort study was performed examining all cases of uterine rupture in three tertiary care hospitals in Dublin, Ireland, over a 20-year period. The primary outcome was perinatal mortality rate with uterine rupture, which was 11.02% (95% CI 6.5-17.3). There was no significant difference in perinatal mortality between cases of scarred and unscarred uterine rupture. Unscarred uterine rupture was associated with higher maternal morbidity , defined as major obstetric hemorrhage or hysterectomy.

Rupture-mediated large uterine defect at 30th gestational week with protruded amniotic sac and fetal head without fetal compromise after laparoscopic electromyolysis: Case report and literature review

BACKGROUND

We describe a case of a rupture-mediated large uterine defect, which occurred on the 30th gestation week presenting a protruding amniotic sac sac without fetal compromise after a laparoscopic electromyolysis.

CASE PRESENTATION

A 28-year-old woman in her 30th week of gestation (gravida 2, para 0) presented with whole abdominal and right lower quadrant pain at Sanggye Paik Hospital. Ultrasound examination showed normal amniotic fluid and placentation but with breech presentation. She had undergone laparoscopic right ovarian cystectomy due to endometriosis 5 years earlier. Cardiotocography revealed an intermittent variable deceleration and no uterine contraction. Magnetic resonance imaging ruled out acute appendicitis. Four hours later, we observed a protrusion of the amniotic sac with the fetal head through a large uterine defect on magnetic resonance imaging, and performed emergency cesarean section. A boy was delivered without fetal compromise. During the cesarean section, multiple myometric wall defects and thinning were identified. After reconstruction of the uterine wall, the flaccid uterus bled persistently; thus, a cesarean hysterectomy was performed. Packed red cells and frozen plasma were transfused. The mother and neonate had uneventful puerperal and neonatal courses, respectively. After cesarean hysterectomy, we were informed that the mother had undergone a combined laparoscopic electromyolysis during the laparoscopic right ovarian cystectomy. Three years later, the child showed normal neural development.

CONCLUSIONS

Before myomectomy or electromyolysis, patients should be informed of the possibility of uterine rupture during subsequent pregnancies. If a pregnant woman has abdominal pain, clinicians should take a detailed history of uterine surgery and consider uterine rupture. Although, fortunately, the outcomes in this case were uneventful, urgent delivery is required when uterine rupture is diagnosed.

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.

•

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

•

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

•

Immediate laparotomy is the gold standard management.

•

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.

Precipitous delivery complicated by uterine artery laceration and uterine rupture in an unscarred uterus: A case report

Precipitous delivery is associated with rapid cervical dilation and fetal descent. Complications of precipitous delivery can include vascular trauma, uterine rupture, and uterine artery laceration. Uterine artery laceration is a rare complication that can lead to significant postpartum hemorrhage and injury. Careful evaluation for trauma and aggressive resuscitation are critical to prevent maternal morbidity and mortality. This is a case report of a 39-year-old woman, gravida 2 para 1, at 39 weeks of gestation who delivered after induction of labor due to chronic hypertension. Her labor course was precipitous and complicated by uterine rupture and uterine artery laceration with postpartum hemorrhage that required massive transfusion, exploratory laparotomy with a supracervical hysterectomy, and interventional radiology for uterine and cervical artery embolization. This seems to be the first published case report of precipitous delivery associated with uterine artery laceration and uterine rupture. Thorough evaluation after precipitous delivery is critical to decrease maternal morbidity and mortality secondary to uterine artery injury.

•

Uterine artery laceration is a rare and serious complication of precipitous labor.

•

Uterine rupture and artery laceration increases the risk of postpartum hemorrhage.

•

Postpartum hemorrhage requires prompt and thorough evaluation and treatment.

Spontaneous rupture of the uterus in the third trimester after high-intensity ultrasound ablation in adenomyosis: A case report

Adenomyosis is a benign uterine disease. Due to the higher incidence of adenomyosis and patients' demands for fertility, high-intensity ultrasound ablation has been widely used in gynecological patients with uterine fibroids and adenomyosis. Ultrasound ablation of lesions can help alleviate symptoms in patients without increasing the incidence of obstetric complications in subsequent pregnancies. High-intensity ultrasound ablation is not considered a risk factor for uterine rupture. However, we describe a case of adenomyosis treated with high-intensity ultrasound ablation presenting with uterine rupture in the third trimester. The patient underwent an emergency cesarean section to deliver the baby successfully and underwent uterine repair surgery. When treating patients with adenomyosis, care should be taken to protect the myometrium, endometrium, and serous layer to reduce the risk of uterine rupture.

Risk factors and outcomes associated with type of uterine rupture

PURPOSE

To identify risk factors associated with the occurrence of complete uterine rupture (CUR) in comparison to partial uterine rupture (PUR) to further investigate to what extent a standardized definition is needed and what clinical implications can be drawn.

METHODS

Between 2005 and 2017 cases with CUR and PUR at Charité University Berlin, Germany were retrospectively identified. Demographic, obstetric and outcome variables were analyzed regarding the type of rupture. Binary multivariate regression analysis was conducted to identify risk factors associated with CUR. In addition, the intended route of delivery (trial of labor after cesarean delivery (TOLAC) and elective repeat cesarean delivery (ERCD)), divided according to the type of rupture, was compared.

RESULTS

92 cases with uterine rupture were identified out of a total of 64.063 births (0.14%). Puerperal complications were more frequent in CUR (67.9 versus 41.1%, p = 0.021). Multiparity ≥ 3 was more frequent in CUR (31 versus 10.7%, p = 0.020). Factors increasing the risk for CUR were parity ≥ 3 (OR = 3.8, p = 0.025), previous vaginal birth (OR = 4.4, p = 0.011), TOLAC (OR = 6.5, p < 0.001) and the use of oxytocin (OR = 2.9, p = 0.036). After multivariate analysis, the only independent risk factor associated with CUR was TOLAC (OR = 7.4, p = 0.017).

CONCLUSION

TOLAC is the only independent risk factor for CUR. After optimized antenatal counselling TOLAC and ERCD had comparable short-term maternal and fetal outcomes in a high resource setting. A high number of previous vaginal births does not eliminate the risk of uterine rupture. A clear distinction between CUR and PUR is essential to ensure comparability among studies.

Pregnancy outcomes and associated factors for uterine rupture: an 8 years population-based retrospective study

Background

Uterine rupture is an obstetrical emergency with serious undesired complications for laboring mothers resulting in fatal maternal and neonatal outcomes. The aim of this study was to assess the incidence of uterine rupture, its association with previous uterine surgery and vaginal birth after caesarean section (VBAC), and the maternal and perinatal implications.

Methods

This is a population-based retrospective study. All pregnant women treated for ruptured uterus in one center between 2013 and 2020 were included. Their information retrieved from the medical records department were reviewed retrospectively.

Results

A total of 209,112 deliveries were included and 41 cases of uterine rupture were identified. The incidence of uterine rupture was 1.96/10000 births. Among the 41 cases, 16 (39.0%) had maternal and fetal complications. There were no maternal deaths secondary to uterine rupture, while perinatal fatality related to uterine rupture was 7.3%. Among all cases, 38 (92.7%) were scarred uterus and 3 (7.3%) were unscarred uterus. The most common cause of uterine rupture was previous cesarean section, while cases with a history of laparoscopic myomectomy were more likely to have serious adverse outcomes, such as fetal death. 24 (59.0%) of the ruptures occurred in anterior lower uterine segment. Changes in Fetal heart rate monitoring were the most reliable signs for rupture.

Conclusions

Incidence of uterine rupture in the study area, Shanghai, China was consistent with developed countries. Further improvements in obstetric care and enhanced collaboration with referring health facilities were needed to ensure maternal and perinatal safety.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04415-6.

Risk Factors Associated with Uterine Rupture and Dehiscence: A Cross-Sectional Canadian Study

OBJECTIVE

 To compare maternal and perinatal risk factors associated with complete uterine rupture and uterine dehiscence.

METHODS

 Cross-sectional study of patients with uterine rupture/dehiscence from January 1998 to December 2017 (30 years) admitted at the Labor and Delivery Unit of a tertiary teaching hospital in Canada.

RESULTS

 There were 174 (0.1%) cases of uterine disruption (29 ruptures and 145 cases of dehiscence) out of 169,356 deliveries. There were associations between dehiscence and multiparity (odds ratio [OR]: 3.2; p = 0.02), elevated maternal body mass index (BMI; OR: 3.4; p = 0.02), attempt of vaginal birth after a cesarian section (OR: 2.9; p = 0.05) and 5-minute low Apgar score (OR: 5.9; p < 0.001). Uterine rupture was associated with preterm deliveries (36.5 ± 4.9 versus 38.2 ± 2.9; p = 0.006), postpartum hemorrhage (OR: 13.9; p < 0.001), hysterectomy (OR: 23.0; p = 0.002), and stillbirth (OR: 8.2; p < 0.001). There were no associations between uterine rupture and maternal age, gestational age, onset of labor, spontaneous or artificial rupture of membranes, use of oxytocin, type of uterine incision, and birthweight.

CONCLUSION

 This large cohort demonstrated that there are different risk factors associated with either uterine rupture or dehiscence. Uterine rupture still represents a great threat to fetal-maternal health and, differently from the common belief, uterine dehiscence can also compromise perinatal outcomes.

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.

Maternal and Fetal Outcomes after Prior Mid-Trimester Uterine Rupture: A Systematic Review with Our Experience

Background and Objectives: Since spontaneous uterine rupture in the mid-trimester is rare, maternal and fetal outcomes in subsequent pregnancies remain unclear. Therefore, this study aimed to examine the maternal and fetal outcomes of subsequent pregnancies after prior mid-trimester uterine rupture. Materials and Methods: A systematic review using PubMed, the Cochrane Central Register of Controlled Trials, and Scopus until 30 September 2021, was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The studies that clarified the maternal and fetal outcomes after prior mid-trimester uterine rupture and our case (n = 1) were included in the analysis. Results: Among the eligible cases, there were five women with eight subsequent pregnancies after prior mid-trimester uterine rupture. The timing of prior mid-trimester uterine rupture ranged from 15 to 26 weeks of gestation. The gestational age at delivery in subsequent pregnancies was 23–38 gestational weeks. Among the included cases (n = 8), those involving prior mid-trimester uterine rupture appeared to be associated with an increased prevalence of placenta accreta spectrum (PAS) (n = 3, 37.5%) compared with those involving term uterine rupture published in the literature; moreover, one case exhibited recurrent uterine rupture at 23 weeks of gestation (12.5%). No maternal deaths have been reported in subsequent pregnancies following prior mid-trimester uterine rupture. Fetal outcomes were feasible, except for one pregnancy with recurrent mid-trimester uterine rupture at 23 weeks of gestation, whose fetus was alive complicated by cerebral palsy. Conclusions: Our findings suggest that clinicians should be aware of the possibility of PAS and possible uterine rupture in pregnancies after prior mid-trimester uterine rupture. Further case studies are warranted to assess maternal and fetal outcomes in pregnancies following prior mid-trimester prior uterine rupture.

Spontaneous uterine rupture of an unscarred uterus revealed by a subocclusive syndrome: A case report and review of the literature

Spontaneous uterine rupture of an unscarred uterus is a complication that has dramatic results for both mother and fetus. The clinical presentation commonly comprises abdominal pain and metrorrhagia however we report a case of spontaneous uterine rupture revealed by a subocclusive syndrome. We report a case of a young woman who came to the ER with 3 days of progressive abdominal pain and subocclusive syndrome. The current pregnancy was estimated at 32 weeks of amenorrhea and the patient was hemodynamically stable. An obstetric ultrasound was performed showing a progressive monofoetal pregnancy and moderate peritoneal effusion. In view of the presence of effusion on ultrasound and the subocclusive syndrome, an abdominal and pelvic CT scan with contrast was carried out, showing a fundal uterine rupture defect with contrast media extravasation and intraperitoneal hemoperitoneum. The patient was immediately transferred to the operating room for a caesarean section. Although CT scans use radiation, their contribution was essential to avoid maternal death.

Vaginal birth after cesarean (VBAC): fear it or dare it? An evaluation of potential risk factors

OBJECTIVES

The consultation of women aspiring a vaginal birth after caesarean may be improved by integrating the individual evaluation of factors that predict their chance of success. Retrospective analysis of correlating factors for all trials of labor after caesarean that were conducted at the Department of Obstetrics of Charité-Universitätsmedizin Berlin, Campus Virchow Clinic from 2014 to October 2017.

METHODS

Of 2,151 pregnant women with previous caesarean, 408 (19%) attempted a vaginal birth after cesarean. A total of 348 women could be included in the evaluation of factors, 60 pregnant women were excluded because they had obstetric factors (for example preterm birth, intrauterine fetal death) that required a different management.

RESULTS

Spontaneous delivery occurred in 180 (51.7%) women and 64 (18.4%) had a vacuum extraction. 104 (29.9%) of the women had a repeated caesarean delivery. The three groups showed significant differences in body mass index, the number of prior vaginal deliveries and the child's birth weight at cesarean section. The indication for the previous cesarean section also represents a significant influencing factor. Other factors such as maternal age, gestational age, sex, birth weight and the head circumference of the child at trial of labor after caesarean showed no significant influence.

CONCLUSIONS

The clear majority (70.1%) of trials of labor after caesarean resulted in vaginal delivery. High body mass index, no previous spontaneous delivery, and fetal distress as a cesarean indication correlated negatively with a successful vaginal birth after cesarean. These factors should be used for the consultation of pregnant women.

Maternal death due to ruptured uterus consequent to abruptio placentae: 2 case reports

Background

Abruptio placentae is a complication of pregnancy that can lead to uterine rupture, increasing maternal and fetal mortality, especially when there is a lack of medical outreach in remote areas.

Case presentation

We present two maternal deaths due to uterine rupture in a term pregnancy consequent to abruptio placentae. In one case, the uterus ruptured at the previous lower segment Caesarean section (LSCS) scar site and in another over the lateral wall of Couvelaire uterus. In both cases, the fetus was partially lying outside the uterus in the peritoneal cavity, and there was a massive retro-placental clot.

Conclusions

Early identification of high-risk factors, followed by institutional delivery, may reduce maternal and fetal mortality due to abruption followed by uterine rupture.

European Guidelines on Perinatal Care - Oxytocin for induction and augmentation of labor[Formula: see text]

OF RECOMMENDATIONS1. Oxytocin for induction or augmentation of labor should not be started when there is a previous scar on the body of the uterus (such as previous classical cesarean section, uterine perforation or myomectomy when uterine cavity is reached) or in any other condition where labor or vaginal delivery are contraindicated. (Moderate quality evidence +++-; Strong recommendation).2. Oxytocin should not be started before at least 1 h has elapsed since amniotomy, 6 h since the use of dinoprostone (30 min if vaginal insert) and 4 h since the use of misoprostol (Low quality evidence ++- -; Moderate recommendation).3. Cardiotocography (CTG) should be performed and a normal pattern without tachysystole should be documented for at least 30 min before oxytocin is used. Continuous CTG, with adequate monitoring of both fetal heart rate and uterine contractions, should be maintained for as long as oxytocin is used, and thereafter until delivery (Low ++- - to moderate +++- quality evidence; Strong recommendation).4. For labor induction, at least 1-h should be allowed after amniotomy before oxytocin infusion is started, to evaluate whether adequate uterine contractility has meanwhile ensued. For augmentation of labor, if the membranes are intact and there are conditions for a safe amniotomy, the latter should be considered before oxytocin is started (Very low quality evidence +- --; Weak recommendation).5. Oxytocin should be administered intravenously using the following regimen: 5 IU oxytocin diluted in 500 mL of 0.9% normal saline (NaCl) (each mL contains 10 mIU of oxytocin), in an infusion pump at increasing rates, as shown in Table 1, until a frequency of 3-4 contractions per 10 min is reached, a non-reassuring CTG pattern ensues, or maximum rates are reached (Low quality evidence ++ - -; Strong recommendation). If the frequency of contractions exceeds 5 in 10 min, the infusion rate should be reduced, even if a normal CTG pattern is present. With a non-reassuring CTG pattern, urgent clinical assessment by an obstetrician is indicated, and strong consideration should be given to reducing or stopping the oxytocin infusion. The minimal effective dose of oxytocin should always be used. (Low ++- - to Moderate +++- - quality evidence; Strong recommendation).[Table: see text]6. Use of oxytocin for induction and augmentation of labor should be regularly audited (Low quality evidence ++--; Strong recommendation).

Delayed stillbirth by hysterectomy following early-term uterine rupture with fetal demise in secundigravida

Uterine rupture and postterm pregnancy pose a number of life-threatening complications to both mother and child, including severe intra-abdominal bleeding and peritonitis, birth injury, hypoxia, and fetal loss. This report presents a rare case of a 20-year-old female experiencing fetal demise at 60 weeks of pregnancy, with uterine rupture and bone tissue discharge from her vagina without severe intra-abdominal bleeding and peritonitis. The mild clinical course despite complete uterine rupture was due to the firm adhesion of the amniotic sac to the uterus caused by inflammation. The adhesion of the intestines to the rupture site prevented dehiscence of the ruptured wound. Suppuration and bone tissue discharge relieved the pressure on the patient's abdominal cavity and prevented subsequent occurrence of severe peritonitis. Radiologists mistakenly regarded the thick amniotic sac wall on the right side of the uterine wall as a right cornual pregnancy with uterine rupture caused by chronic inflammation. This report aims to bring awareness of this rare condition to medical students and radiologists.

Ten years of uterine rupture in an Australian tertiary hospital

AIMS

Complete uterine rupture is a rare and serious complication of pregnancy. Although most commonly associated with attempted vaginal birth after caesarean (VBAC), rupture also occurs in atypical/non-VBAC cases. This retrospective, single-tertiary-institution observational study aimed to assess the prevalence and morbidity of complete uterine rupture during 2010-2020.

METHODS

Hospital discharge codes and local maternity databases identified uterine rupture cases, with medical record reviews confirming the diagnosis, distinguishing complete rupture from dehiscence, and extracting additional data. VBAC attempt was defined as planned labour trial after one prior caesarean.

RESULTS

Over the decade, 27 complete ruptures occurred among 58 614 women, a rate of 4.6 per 10 000 births. One woman with three successive fundal ruptures had only the first included in further analysis, leaving 25 discrete women; 19 ruptures occurred in term planned VBAC attempts and six in preterm atypical/non-VBAC cases (two nulliparas and four women with multiple prior caesareans). The VBAC-attempt rupture rate was 0.74%, similar to published reports. All five perinatal deaths occurred in preterm atypical/non-VBAC cases. In the term VBAC-attempt group, rupture-related perinatal morbidity included four cases (21%) of hypoxic-ischaemic encephalopathy, with two cases (11%) of cerebral palsy at follow-up. Overall, perinatal morbidity was highest with total fetal extrusion. Maternal blood loss ≥1500 mL or transfusion was almost threefold higher, and postnatal length-of-stay was three days longer, after vaginal than caesarean birth, with delay in rupture recognition being a factor.

CONCLUSION

A high suspicion index for uterine rupture is imperative during any labour, particularly in the scarred uterus, with vigilance continuing after successful vaginal birth.

Postpartum unscarred uterine rupture caused by placenta accreta: A case report and literature review

Our case and the literature review suggest that placenta accreta spectrum, with use of uterotonics and manual removal of placenta, could be risk factors for postpartum unscarred uterine rupture.

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.

Computational medicine, present and the future: obstetrics and gynecology perspective

Medicine is, in its essence, decision making under uncertainty; the decisions are made about tests to be performed and treatments to be administered. Traditionally, the uncertainty in decision making was handled using expertise collected by individual providers and, more recently, systematic appraisal of research in the form of evidence-based medicine. The traditional approach has been used successfully in medicine for a very long time. However, it has substantial limitations because of the complexity of the system of the human body and healthcare. The complex systems are a network of highly coupled components intensely interacting with each other. These interactions give those systems redundancy and thus robustness to failure and, at the same time, equifinality, that is, many different causative pathways leading to the same outcome. The equifinality of the complex systems of the human body and healthcare system demand the individualization of medical care, medicine, and medical decision making. Computational models excel in modeling complex systems and, consequently, enabling individualization of medical decision making and medicine. Computational models are theory- or knowledge-based models, data-driven models, or models that combine both approaches. Data are essential, although to a different degree, for computational models to successfully represent complex systems. The individualized decision making, made possible by the computational modeling of complex systems, has the potential to revolutionize the entire spectrum of medicine from individual patient care to policymaking. This approach allows applying tests and treatments to individuals who receive a net benefit from them, for whom benefits outweigh the risk, rather than treating all individuals in a population because, on average, the population benefits. Thus, the computational modeling-enabled individualization of medical decision making has the potential to both improve health outcomes and decrease the costs of healthcare.

Case Report: Spontaneous perforation of a bicornuate uterus with concomitant sarcoma

A 47-year-old nulliparous, virginal woman presented to the emergency department with acute abdominal pain. Emergency pelvic ultrasound and abdominal CT were taken, which showed a significant amount of hemoperitoneum and a bicornuate uterus with about 18cm x 10cm mass on left uterus. Since the mass had increased vascularity and irregular margins, we thought that the mass could be a uterine sarcoma. MRI and PET/CT were taken additionally for oncologic evaluation before surgery. Intra operative findings showed a ruptured bicornuate uterus with a large mass within the left uterine horn. Total

abdominal hysterectomy with bilateral salpingo-oophorectomy was performed. Pathologic analysis confirmed an undifferentiated uterine sarcoma. She was treated with 6 cycles of chemotherapy(etoposide, ifosfamide, cisplatin) postoperatively. Chest and abdomen CT for follow up after chemotherapy showed no sign of cancer recurrence. We suggest a bicornuate uterus with concomitant sarcoma should be concerned as a possible cause of uterine rupture by reviewing this case.

Recurrence of a second-trimester uterine rupture in the fundus distant from old scars: A case report and review of the literature

Uterine rupture is a rare event which can have severe obstetric consequences and most often occurs on a scarred uterus at the site of the scar. However, a uterine rupture can appear at another location. We report the case of a woman with a previous emergency caesarean section for spontaneous posterior uterine rupture which recurred at another site during her second pregnancy. She was admitted to the emergency room with acute abdominal pain and development of a pre-shock hemorrhagic state. Abdominal ultrasound showed abundant peritoneal fluid and a fetus without cardiac activity in an intact bulging amniotic fluid membrane. We performed an emergency laparotomy, which confirmed an intact amniotic sac in the abdominal cavity and showed a 7 cm transverse fundal uterine rupture beginning at the right angle, distant from the old known scars. In view of the high maternal and fetal morbidity, obstetricians should have a high suspicion of an antepartum uterine rupture, even at an early gestational age, in the event of acute abdominal pain over a scarred uterus.

•

Exceptional case of a second uterine rupture in the second trimester distant from old scars.

•

Spontaneous uterine rupture in the second trimester is associated with a higher maternal-fetal morbidity.

•

The most common site of spontaneous uterine rupture which did not occur during labor is the fundus.

Spontaneous unscarred uterine rupture and surgical repair at 11 weeks of gestation in a twin pregnancy

A uterine rupture may result in a massive hemoperitoneum, which can be fatal to both the fetus and mother. Most uterine ruptures during pregnancy occur within a scarred uterus, rarely occurring in an unscarred uterus. Here, we report a very rare case of spontaneous rupture in an unscarred uterus at 11 weeks of gestation of a twin pregnancy and its surgical repair. A 37-year-old nulliparous infertile woman became pregnant with twins after artificial insemination and gonadotropin therapy. She underwent emergency surgery at 11 weeks of gestation due to an acute abdomen caused by massive hemoperitoneum. Upon laparotomy, one fetus with placenta was extruded into the abdominal cavity through a 3-cm myometrium rupture on the left posterior wall of the uterus. After surgical repair of the rupture site, the remaining fetus was alive and was successfully delivered by cesarean section at 34 weeks of gestation.

Laparoscopic repair of uterine rupture following successful second vaginal birth after caesarean delivery: A case report

BACKGROUND

With the increasing trend of vaginal birth after caesarean delivery (VBAC), evaluation of the feasibility and safety of a second VBAC with grand multiparity is worth considering. Intrapartum uterine rupture is diagnosed in approximately one-fifth of all VBAC cases following successful vaginal delivery. To our knowledge, no report is available on the application of laparoscopy to repair postpartum uterine rupture after a successful second VBAC in China.

CASE SUMMARY

A 31-year-old woman (gravida 5, para 2) at 39 wk and 5 d of gestation was admitted to the hospital in labour. After a successful VBAC and observation for approximately 13 h, the patient complained of progressive abdominal pain. Given the symptoms, signs, and auxiliary examination results, intraperitoneal bleeding was considered. Because the patient was stable and ultrasound imaging was the only method available to assess the possibility of rupture, we recommended laparoscopy to clarify the diagnosis and for prompt laparoscopic uterine repair or exploratory laparotomy if necessary. Operative findings included transverse uterine scar rupture at the lower uterine segment of approximately 5.0 cm in length and 800 mL of intraoperative pelvic haemoperitoneum. Finally, she successfully underwent laparoscopic repair of uterine rupture and recovered very well according to three-dimensional magnetic resonance imaging at 42 d postpartum.

CONCLUSION

Routine postpartum intrauterine exploration is not beneficial to the mother and may even increase the risk of rupture. This case highlights a laparoscopic approach for repairing uterine rupture in the immediate postpartum period.

Treatment strategy for failed repair of uterine rupture: Cleansing an abscess via the cervical Canal

We present a new, conservative treatment strategy for the cases in which an initial repair surgery of uterine rupture failed. In a case presented here, the patient underwent a repair surgery for the uterine rupture that became apparent 4 days after the cesarean delivery, but a part of the wound did not heal and an abscess formed in the surrounding area. The patient had purulent discharge from vagina, which led us to try to insert a Nelaton tube from vagina via cervical canal and to cleanse the abscess cavity. This procedure was successful and the abscess disappeared 38 days later, allowing the healing of the ruptured wound. The patient could deliver a baby 2 years later. Even if the initial repair treatment fails, a possibility of preserving the uterus should be considered for next pregnancy. One of the concrete treatment strategies for this purpose was presented.

Spontaneous Uterine Rupture in a Multigravid Pregnant Woman with Unscarred Uterus on Chronic Steroid Use: A Case Report

BACKGROUND

Uterine rupture in pregnancy is associated with severe maternal and fetal complications. Although it is a rare event, uterine rupture has been associated with certain risk factors. Glucocorticoids are known to weaken skeletal muscles; however, there have been no studies on the effects of chronic steroid use on the uterine myometrium.

CASE

We present the case of a 40-year-old multigravid woman who experienced a posterior uterine wall rupture on an unscarred uterus. She was on chronic glucocorticoids for the treatment of psoriatic arthritis. We hypothesize that the catabolic effects of glucocorticoids on skeletal muscles also weakened the uterine myometrium, leading to a higher risk of uterine rupture.

CONCLUSION

Uterine rupture may be associated with chronic use of corticosteroids. Identifying the different risk factors for uterine rupture can lead to more prompt diagnosis and management of uterine rupture, resulting in better maternal and fetal outcomes.

Uterine rupture and the risk for offspring long-term respiratory morbidity

Introduction: Uterine rupture during labor is a life-threatening event associated with high morbidity for both mother and fetus. While the immediate maternal and neonatal outcomes of uterine rupture are well established, less is known regarding the long-term respiratory morbidity of offspring which survived uterine rupture.Aim: To assess whether a history of uterine rupture at birth, is associated with an increased risk for future offspring respiratory morbidity.Materials and methods: In this population-based retrospective cohort study, all singleton deliveries between 1991 and 2014 were included. Known offspring chromosomal or congenital anomalies and cases of perinatal mortality were excluded from the analysis. The incidence of hospitalizations with respiratory morbidities, predefined in a set of ICD-9 codes, was compared between offspring delivered with or without uterine rupture. Cox proportional hazards models were conducted, to control for each confounder separately.Results: During the study period 238,622 deliveries met the inclusion criteria, of those 127 (0.053%) were complicated by uterine rupture. Rates of respiratory related hospitalizations were 7.1 and 4.9%, among offspring delivered with or without uterine rupture, respectively (p = .22), and in the Kaplan- Meier survival curves, no significant differences were found between the groups (log rank test p = .241). While using Cox proportional hazards models and controlling for each confounder separately, uterine rupture was not found to be an independent risk factor for long-term respiratory morbidity of the offspring.Conclusion: Uterine rupture was not found as an independent risk factor for offspring long-term respiratory morbidity. The limited number of cases in the exposed group, could only demonstrate a trend with no significance, and therefore further investigation is required.

No. 361-Caesarean Delivery on Maternal Request

A maternal request for an elective CS in the absence of a maternal or fetal indication may raise risk-benefit considerations and ethical concerns for a health care provider. Appropriate counselling of the patient on the risks and benefits in proceeding with a CDMR without medical indication is essential. Providers should have a clear knowledge of the risks and benefits of providing an elective CS without medical indications compared to the risks and benefits of supporting an attempt at vaginal delivery, so that the patient may reach an informed decision. The principle of patient autonomy should be respected but other ethical principles (beneficence, non-maleficence and justice) need to be taken into consideration during the counselling process. There are no studies to estimate maternal and neonatal risks in CDMR. Often studies on CS before the onset of labour are used as surrogates to determine risks and benefits. After exploring the reasons behind the patient's request, and discussing the risks and benefits, if a patient insists on her choice a physician may pursue one of the following two options: 1) Agree to perform the CS after 39+0 weeks gestation; 2) Disagree and refer the patient for a second opinion.

Uterine rupture in a gravid, unscarred uterus: A case report

•

The risk of uterine rupture in a gravid, unscarred uterus is largely unknown.

•

The risk factors for uterine rupture, when summed, can accumulate to a devastating and unforeseen end-result, such as fetal and maternal demise.

•

Low suspicion for rare occurrences such as uterine rupture in an unscarred uterus can delay diagnosis, with increased likelihood of fetal and maternal morbidity and mortality.

When advising a pregnant patient who has previously had a cesarean section about the risks of trial of labor, it is important to explain the risk of uterine rupture. Subjective symptoms of abdominal pain or objective findings of non-reassuring fetal status and loss of fetal station are often indicative of this disease process, which most commonly is caused by a defect on the uterus from the cesarean delivery. Any uterine surgical intervention (myomectomy, for example) is the leading risk factor for uterine rupture. This case report presents a patient who had no such history. However, the maternal and fetal clinical status rapidly deteriorated and required emergency cesarean delivery, at which point a complete uterine rupture was diagnosed. Low suspicion for rare occurrences such as uterine rupture in an unscarred uterus can delay diagnosis, with increased likelihood of fetal and maternal morbidity and mortality.

Influence of interpregnancy interval on uterine rupture

OBJECTIVE

This study aims to assess the independent influence of interpregnancy interval (IPI) on uterine rupture using a population-based cohort of all Ohio births, regardless of prior cesarean (PCS) or trial of labor (TOL) status.

STUDY DESIGN

Population-based retrospective cohort study of all live births in Ohio (2006-2012). Frequency of uterine rupture was quantified and stratified by number of prior cesarean deliveries and IPI. The relative and adjusted risk of IPI on uterine rupture was calculated using multivariate logistic regression.

RESULTS

Of 1,034,522 live births recorded during the 7-year study period, 249 cases of uterine rupture were identified for analysis. Two-thirds of uterine rupture cases (n = 158) occurred in women with one or more PCS and one-third (n = 91) had no prior cesarean. IPI 24-59 months had the lowest frequency of uterine rupture and was used as the referent group. IPI 12-23 and IPI ≥ 60 months were not significantly associated with risk of uterine rupture, p = .847, .540 respectively. In women with PCS, IPI < 12 months was associated with greater than two-fold increased risk of uterine rupture (aRR 2.4, CI 1.5-3.8). No association between IPI < 12 months and uterine rupture was observed in women with no PCS, p = .696.

CONCLUSION

IPI < 12 months is independently associated with uterine rupture in women with prior cesarean, but does not appear to influence risk in women with an unscarred uterus.

Delayed diagnosis of intrapartum uterine rupture - maternal and neonatal consequences

Objective: To assess the maternal and neonatal outcomes following delayed diagnosis of uterine rupture (diagnosis during the early postpartum period) in comparison to women with an intrapartum diagnosis of uterine rupture.Methods: Retrospective study of electronic medical records (EMR) from 2005 to 2018 in a single large academic tertiary care. Demographic, obstetric and maternal characteristics and outcomes were retrieved and compared. Univariate, followed by multivariate analyses were applied to evaluate the association between maternal and neonatal outcomes. Only complete uterine ruptures were included. The primary outcome of this study was defined as hysterectomy rates. Secondary outcomes were maternal and neonatal morbidity parameters.Results: During the study period, 143 parturients with uterine rupture were identified from 174,189 deliveries (0.08%). Of these, 29 (20.3%) had delayed diagnosis with a median time from delivery to the operation of 4.5 hours (IQR 0.83-28 hours). Factors that were identified as independent risk factors for delayed diagnosis: an unscarred uterus (aOR 27.0, 95% CI 6.58-111.1), epidural analgesia during labor (aOR 7.9, 95% CI 2.32-27.05) and grand-multiparity (aOR 4.6, 95% CI 1.40-14.99). Maternal outcomes demonstrated that parturients with a delayed diagnosis had significantly higher rates of blood transfusions, puerperal fever, and hysterectomy (p<.001 for all). In a multivariate model, the delayed diagnosis was found to be independently associated with hysterectomy (aOR 4.90, 95% CI 1.28-19.40). There were no differences regarding to neonatal outcomes.Conclusion: Parturients with delayed diagnosis of uterine rupture have unique characteristics and poorer maternal outcomes. It is possible that awareness of this population will enable earlier diagnosis and may help improve outcomes.

Maternal outcome after complete uterine rupture

INTRODUCTION

Complete uterine rupture, a rare peripartum complication, is often associated with a catastrophic outcome for both mother and child. However, few studies have investigated large datasets to evaluate maternal outcomes after complete ruptures, particularly in unscarred uteri. This paucity of studies is partly due to the rarity of both the event and the serious outcomes, such as peripartum hysterectomy and maternal death. The incidence of uterine rupture is expected to increase, due to increasing cesarean section rates worldwide. Thus, it is important to have more complete knowledge about the immediate maternal outcome following a complete uterine rupture. The objective was to identify maternal outcomes and their risk factors following complete uterine ruptures.

MATERIAL AND METHODS

This was a population-based study using data from the Medical Birth Registry of Norway, the Patient Administration System and medical records. Maternities with complete uterine rupture after start of labor in Norway during 1967-2008 (n = 247 births), identified among 2 209 506 women. Uterine ruptures were identified from both registries and were further studied through a review of medical records. Only complete ruptures were included in analysis. The associations between maternal outcomes and demographic and labor risk factors were estimated. Odds ratios (ORs) were determined with crude logistic regressions for each risk factor. Separate multivariable logistic regressions were performed to calculate adjusted odds ratios and 95% confidence intervals (CIs).

RESULTS

We identified 88 (35.6%) healthy mothers, 107 (43.3%) severe postpartum hemorrhages without hysterectomy, 51 (20.6%) peripartum hysterectomies, and three (1.2%) maternal deaths. Peripartum hysterectomy decreased significantly in the last years of study. Unscarred uterine ruptures significantly increased the risk of peripartum hysterectomy compared with scarred uterine ruptures (AOR 2.6, 95% CI 1.3-5.3). Other factors that increased the risk of peripartum hysterectomy following rupture were: maternal age ≥35 years (AOR 2.3, 95% CI 1.1-5.0), parity ≥3 vs parity 1-2 (AOR 2.8, 95% CI 1.2-6.7), and rupture detection after vaginal delivery (AOR 2.2, 95% CI 1.1-4.8).

CONCLUSIONS

Unscarred uteri, older maternal age, parity ≥3, and rupture detection after vaginal delivery showed the highest associations with the risk of peripartum hysterectomy after complete uterine rupture.