Maternal Death After Uterine Rupture in an Unscarred Uterus: A Case Report

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.

Clinical characteristics of uterine rupture without previous Cesarean section: A 25-year retrospective study

AIM

To investigate the clinical characteristics and risk factors of uterine rupture without preceding Cesarean section.

METHODS

The medical records of all deliveries at the Women's Hospital, Zhejiang University School of Medicine between 1992 and 2017 were reviewed. All cases of uterine rupture without previous Cesarean delivery were included. Two types of uterine rupture, incomplete and complete, were distinguished. The clinical characteristics of each patient were collected and analyzed, including demographic information, clinical manifestation, operative records, site of rupture, pregnancy and labor complication, obstetrics risk factors, and birth outcome.

RESULTS

There were 222 418 deliveries in total during the study period. Nineteen cases of uterine rupture without previous Cesarean section were identified. As a result, the incomplete rupture group had significant advanced gestational age, decreased maternal gravidity, lower incidence of dilation and curettage, and lower perinatal mortality rate. In aspect of the rupture site, the involvement of the lower segment of the uterus was significantly more common in the incomplete rupture group. In the complete rupture group, the participants with a gestation age less than 28 weeks were more likely to have a history of dilation and curettage than those with a gestation age over 28 weeks.

CONCLUSIONS

The history of dilation and curettage is the major risk factor of uterine rupture without Cesarean section. Our findings imply that obstetricians should be cautious of spontaneous uterine rupture in pregnant women who has a history of dilation and curettage.

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.

"Just a little help": A qualitative inquiry into the persistent use of uterine fundal pressure in the second stage of labor in Spain

INTRODUCTION

Uterine fundal pressure, or the Kristeller maneuver (KM), is a non-evidence-based procedure used in the second stage of labor to physically force the fetus to delivery. Even though officially banned, the KM is practiced in 25% of vaginal deliveries in Spain.

METHODS

Using semi-structured interviews (N = 10 women, N = 15 midwives, N = 3 obstetricians), we sought to understand how providers justify using the KM, and to describe the current circumstances in which the KM is practiced. Women described their preexisting knowledge of and experiences with the KM; providers described how they learned and practiced the KM. We used framework analysis to analyze the transcripts, and we consensus-coded across three independent investigators.

RESULTS

Providers reported practicing a new, gentler Kristeller to which official policy did not apply. Providers knew the KM posed risks, but they assumed the risks resulted from poor technical training. Providers did not learn the KM through standard means, and they practiced it in secret. Women knew about the KM before delivery, and many had planned to refuse the procedure. Providers made women's refusal more difficult by offering the KM in coded terms as "just a little help." Women did not experience the KM as gentle, and the force of the procedure made their refusal nearly impossible.

CONCLUSIONS

The normal birth policy has failed to achieve its objectives due to maternity care providers' unique logic surrounding a new KM technique. Women's ability to refuse the Kristeller is limited.

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

BACKGROUND

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

CASE

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

CONCLUSION

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

Unscarred Uterine Rupture: A Retrospective Analysis

INTRODUCTION

Uterine rupture is a catastrophic obstetrical emergency associated with a significant feto-maternal morbidity and mortality. Many risk factors for uterine rupture, as well as a wide range of clinical presentations, have been identified.

OBJECTIVES

To analyze the frequency, predisposing factors, and maternal and fetal outcomes of uterine rupture.

METHODS

A retrospective analysis of cases of unscarred uterine rupture was conducted at the Department of Obstetrics and Gynecology, RIMS, Imphal from June 1, 2010 to June 30, 2012.

RESULTS

Our analysis comprised 13 cases. Of these, 30.8 % were booked cases. Most of the cases (46.2 %) were Para 2. Uterine rupture occurred at term in 10 cases. The rupture occurred due to mismanaged labor (30.8 %), the use of oxytocin (23 %), instrumental delivery (15.4 %), obstructed labor (15.4 %), induction by prostaglandin gel (7.7 %), and placenta percreta (7.7 %). Maternal deaths and perinatal deaths were 30.8 and 53.8 %, respectively. Sub-total hysterectomy was done in 8 cases and in 1 patient laparotomy with repair was performed.

CONCLUSION

Ruptured uterus causes a high risk in patients. An unscarred uterus can undergo rupture even without etiological or risk factors. The patients with mismanaged labor, grand multiparas, and obstructed prolonged labor must be managed by properly trained personnel at a tertiary care center in order to avoid the morbidity or mortality.

Rupture of a pregnant unscarred uterus in an early secondary trimester: a case report and brief review

Rupture of a pregnant uterus in early pregnancy and an unscarred uterus are extremely rare, and some non-specific symptoms might appear before this occurrence. We report the case of a multiparous woman (gravida 3, para 2) with uterine fundal rupture in her early second trimester (17+ weeks of gestational age), who presented upper abdominal discomfort and vomiting for 3 days, and progressed into sudden acute abdomen and shock. During emergent laparotomy, the entire amniotic sac was found in the peritoneal cavity with a rupture of the uterine fundus. Although we could not confirm that the appearance of upper gastrointestinal symptoms and severe vomiting was associated with uterine rupture in this pregnant woman, abdominal symptoms or signs might be a hint or cause of severe catastrophic pregnancy-related complications.