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

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.

Spontaneous Rupture of the Unscarred Uterus: A Review of the Literature

Importance

Uterine rupture is defined as a nonsurgical disruption of all layers of the uterus. Most ruptures occur in the presence of a scar, usually secondary to a previous cesarean delivery. Rupture of an unscarred uterus is rare and is associated with severe maternal and neonatal outcomes.

Objective

To outline the literature on potential predisposing factors, clinical findings, and maternal and fetal outcomes of a rupture of an unscarred uterus.

Evidence Acquisition

PubMed was searched for the phrases "uterine rupture," "unscarred," and "spontaneous." Individual case reports, retrospective case series, and review articles in English between 1983 and 2020 were included.

Results

We found 84 case reports in 79 articles. The mean maternal age was 29.3 (SD, 5.7) years; 38 women (45.2%) were nulliparous. Uterine rupture occurred in 37% of the women at term; in 9.9%, the gestational age was ≤12 weeks. The most common clinical presentations were abdominal pain (77.4%), signs of hypovolemic shock (36.9%), fetal distress (31%), and vaginal bleeding (22.6%). The most common risk factors were the use of uterotonic drugs for induction or augmentation of labor and a prior curettage procedure. The most frequently ruptured site was the body of the uterus. Hysterectomy managed 36.9% of the ruptures. Four women died (4.8%). Perinatal mortality was 50.6%. Perinatal death was higher in developing than developed countries.

Conclusions and relevance

Although rare, spontaneous rupture of the unscarred uterus has serious consequences to the mother and the fetus and should be included in the differential diagnosis of acute abdomen in pregnancy.

Uterine Rupture Following Non-Operative Vaginal Delivery: A Close Save of Delayed Presentation With Hemoperitoneum to a Rural Tertiary Care Hospital

Hemoperitoneum as a result of uterine rupture in a previously unscarred uterus is a rare entity to encounter and a potentially life-threatening condition. Ruptures can occur in a scarred uterus either spontaneously, due to operative manipulations, or with the use of uterotonic medications. In an unscarred uterus, spontaneous ruptures are known with high parity, use of oxytocin, and prolonged, neglected labor. Ruptures can be silent with no symptoms resulting in a delay in diagnosis and a near-miss situation. Here, we report the case of a 25-year-old young female who was referred to our tertiary care hospital in rural central India six hours after full-term vaginal delivery, which was followed by pain in the lower abdomen. She had no history of cesarean section, laparoscopic procedures, or surgical termination of pregnancy, which would have predisposed her uterus to rupture. She was severely pale on arrival, and a contrast-enhanced computerized tomography scan revealed rupture of the left side of the uterus with hemoperitoneum and a large pelvic hematoma. Because the patient was in hemorrhagic shock, she was immediately taken for laparotomy with simultaneous resuscitative measures and blood transfusion on flow. Extensive uterine rupture, extending through the cervix to the round ligament of the left side involving the left lateral uterine wall, with active bleeding from the site of the defect was confirmed. The hematoma was 10 × 10 cm in size and was evacuated, following which peripartum hysterectomy was done. The left ureter was traced and safeguarded while applying the clamp on Mackenrodt’s ligament. The patient recovered completely following the procedure. She was discharged on day 13 in stable condition. She is currently doing well on follow-up and is a good example of a maternal near miss. In this report, we emphasize that, even in the absence of any obvious risk factor, uterine rupture can occur during labor, and monitoring the vitals of patients in the immediate postpartum period is essential to detect and promptly manage this serious condition for preventing maternal mortality.

Uterine rupture in patients with a history of multiple curettages: Two case reports

BACKGROUND

Uterine rupture is a serious obstetric emergency, a severe event, and a serious threat to maternal and fetal life. It is a rare and not well characterized by the fact that multiple operations of uterine cavities contribute to uterine rupture during pregnancy. Atypical uterine rupture is easily misdiagnosed as other obstetric or surgical diseases. In current guidelines, abdominocentesis is a contraindication for late pregnancy. Therefore, the cases presented in this report provide new ideas for clinical diagnosis and treatment of uterine rupture.

CASE SUMMARY

Case 1, a 34-year-old woman (gravida 5, para 2), 32 wk and 4 d of gestation, presented with acute upper abdominal pain for 8 h with nausea and vomiting. Computed tomography (CT) revealed pelvic and abdominal effusion. We extracted 3 mL unclotted blood from her abdominal cavity. An emergency caesarean section was performed. A uterine rupture was found, and the fimbrial portion of the left fallopian tube was completely adhered to the rupture. The prognosis of both the mother and the infant was good. Case 2, a 39-year-old woman (gravida 10, para 1) at 34 wk and 3 d of gestation complained of persistent lower abdominal pain for half a day. Her vital signs were normal. CT revealed a high probability of pelvic and abdominal hemoperitoneum. We extracted 4 mL dark red blood without coagulation. An emergency laparotomy was performed. Uterine rupture was identified during the operation. Postoperative course in both the mother and infant was uneventful.

CONCLUSION

For pregnant women in the second or the third trimester with persistent abdominal pain, abdominal effusion, fetal distress and even fetal death, the possibility of uterine rupture should be highly suspected. CT can identify acute abdominal surgical or gynecological and obstetric diseases. Abdominocentesis is helpful for diagnosing and clarifying the nature of effusion, but its clinical value need to be confirmed by further clinical studies.