Pregnancy and delivery after complete uterine rupture

Incidence of Recurrent Uterine Rupture: A Systematic Review and Meta-analysis

OBJECTIVE

We aimed to quantify the incidence of recurrent uterine rupture in pregnant women.

DATA SOURCES

A literature search of PubMed, Web of Science, Cochrane Central, and ClinicalTrials.gov for observational studies was performed from 2000 to 2023.

METHODS OF STUDY SELECTION

Of the 7,440 articles screened, 13 studies were included in the final review. We included studies of previous uterine ruptures that were complete uterine ruptures , defined as destruction of all uterine layers, including the serosa. The primary outcome was the pooled incidence of recurrent uterine rupture. Between-study heterogeneity was assessed with the I2 value. Subgroup analyses were conducted in terms of the country development status, year of publication, and study size (single center vs national study). The secondary outcomes comprised the following: 1) mean gestational age at which recurrent rupture occurred, 2) mean gestational age at which delivery occurred without recurrent rupture, and 3) perinatal complications (blood loss, transfusion, maternal mortality, and neonatal mortality).

TABULATION, INTEGRATION, AND RESULTS

A random-effects model was used to pool the incidence or mean value and the corresponding 95% CI with R software. The pooled incidence of recurrent uterine rupture was 10% (95% CI 6-17%). Developed countries had a significantly lower uterine rupture recurrence rate than less developed countries (6% vs 15%, P =.04). Year of publication and study size were not significantly associated with recurrent uterine rupture. The mean number of gestational weeks at the time of recurrent uterine rupture was 32.49 (95% CI 29.90-35.08). The mean number of gestational weeks at the time of delivery without recurrent uterine rupture was 35.77 (95% CI 34.95-36.60). The maternal mortality rate was 5% (95% CI 2-11%), and the neonatal mortality rate was 5% (95% CI 3-10%). Morbidity from hemorrhage, such as bleeding and transfusion, was not reported in any study and could not be evaluated.

CONCLUSION

This systematic review estimated a 10% incidence of recurrent uterine rupture. This finding will enable appropriate risk counseling in patients with prior uterine rupture.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42023395010.

Outcome of subsequent pregnancies post uterine rupture in previous delivery: A case series, a review, and recommendations for appropriate management

OBJECTIVES

To provide clinicians with concrete solutions on the best management of and counseling for patients in a subsequent pregnancy following uterine rupture.

METHODS

A retrospective analysis of patients treated between 2005 and 2020 at Sheba Medical Center was conducted. All patients who had undergone a complete uterine rupture and subsequently had a full-term pregnancy were included. A literature review was conducted using Pubmed database and including previously published literature reviews.

RESULTS

Fifteen patients with subsequent pregnancies following uterine rupture were included in our cohort. Mean interval between rupture and subsequent pregnancy was 3.8 years (range 2.2-6.9 years). One patient had repeat uterine rupture of less than 2 cm at 36⁺⁵ weeksof pregnancy. A total of 17 studies were selected in this literature review, including a total of 774 pregnancies in 635 patients. The risk of repeated uterine rupture was 8.0% (62/774), ranging from 0% to 37.5%. Overall, the risk of maternal death was of 0.6% (4/635), with only four cases reported in three studies.

CONCLUSION

The risk of recurrence after uterine rupture is significant but should not prevent patients from conceiving.

Outcome of subsequent pregnancies in women with complete uterine rupture: A population-based case-control study

INTRODUCTION

In the attempt of a trial of labor after a cesarean section approximately one in 200 women experience a complete uterine rupture. As a complete uterine rupture is associated with an adverse perinatal outcome, data regarding subsequent pregnancies are needed to provide proper care and guidance to women with a complete uterine rupture when informing them of future possibilities. The objective of this study was to investigate the fetal and maternal outcomes in subsequent pregnancies after a complete uterine rupture.

MATERIAL AND METHODS

Retrospective population-based case-control study. Denmark 1997-2017. A total of 175 women with complete uterine rupture during an attempted trial of labor after cesarean (TOLAC) at term (cases) and a corresponding group of 272 women with no uterine rupture during an attempted TOLAC at term (controls) were labeled as index deliveries. Index deliveries were included from January 1, 1997 to December 31, 2008. From the date of the index delivery to December 31, 2017 the information on subsequent pregnancies and deliveries, and on referral to hospital with any obstetric or gynecological diagnosis were retrieved from the Danish Medical Birth Registry and National Patient Registry. Main outcome measures were miscarriage, perinatal death, neonatal morbidity, preterm birth, and recurrence of uterine rupture. Outcome measures were compared between cases and controls.

RESULTS

After the index deliveries; there were 109 pregnancies and 70 deliveries after gestational age 22⁺⁰  weeks in the population of cases. In the population of controls, there were 183 pregnancies and 126 deliveries after 22⁺⁰  weeks. Cases had a significantly higher risk of miscarriage (odds ratio [OR] 3.99; 95% confidence interval [CI] 1.36-13.17). The incidence of uterine rupture was 8.6% among cases and 0.8% among controls (OR 11.7; 95% CI 1.36-543.1). Among cases, 98.6% had live-born infants, and none of these had severe neonatal morbidity. No significant association was found between previous complete uterine rupture and preterm delivery, placenta previa, hysterectomy in relation to subsequent births, diagnosis such as meno/metrorrhagia, dysmenorrhea, or procedures such as hysteroscopy or hysterectomy.

CONCLUSIONS

In pregnancies following complete uterine rupture continuing after 22⁺⁰  weeks, maternal and fetal outcomes are good when managed promptly with cesarean delivery.

Subsequent Pregnancy Outcome in Women with Prior Complete Uterine Rupture: A Single Tertiary Care Centre Experience

Limited data is available to assess the burden of maternal morbidity, mortality, and perinatal outcome after subsequent pregnancy in women with prior uterine rupture. Therefore, this retrospective descriptive study was conducted to determine subsequent pregnancy outcomes in a larger series of women with prior complete uterine rupture. All pregnant women who had complete uterine rupture were managed according to the standard Institute protocol. The women who conceived following a uterine repair from July 2011 to June 2020 were recruited into the study. Outcome measures included severe maternal morbidities and perinatal outcomes. Fifty-three women with prior complete uterine rupture were conceived subsequently. Two women had an abortion in the first and second trimester, respectively. None of the women developed recurrence of uterine rupture. However, three women developed uterine dehiscence in a total of 16 women who went into spontaneous labour before elective cesarean delivery at 32, 36, and 37 weeks, respectively. None of the women had placenta previa, placenta accreta, bowel injury, bladder injury and none required a hysterectomy. However, 16.7% of women needed a blood transfusion. None of the women required mechanical ventilation, inotropic support, and intensive care unit stay. Seventeen babies required neonatal intensive care admission, and prematurity (90%) was the most common reason, followed by low APGAR scores. In conclusion, subsequent pregnancy outcomes in women with prior uterine rupture appear acceptable in institutionalized care. Timing of cesarean delivery may have to be weighed against the risk of prematurity-associated neonatal morbidity and mortality.

Recurrent uterine rupture in third trimester of pregnancy

We report a case of recurrent upper segment uterine rupture in a 31-year-old woman at 32+5/40 weeks of gestation. She had fundal uterine rupture 3 years ago in her first pregnancy at 40 weeks of gestation. There was no history of uterine malformation or prior uterine surgery. However, we noted that she had had three laparoscopic procedures for endometriosis treatment. She was scheduled to have an elective repeat caesarean section at 34+6/40 weeks of gestation in the index pregnancy. Unfortunately, she presented at 32+5/40 weeks with features of acute abdomen and signs of fetal distress. She had a category 1 caesarean section and was found to have fundal uterine rupture at the same site. She had a smooth uneventful recovery following a timely intervention and discharged home on day 5 postoperatively in a good condition with her baby girl.

Successful Pregnancy after Previous Uterine Rupture

Uterine rupture is a rare and catastrophic incidence with high maternal and fetal morbidity rates. It is most commonly seen in the scarred uterus. The unscarred uterus is least susceptible to rupture with the incidencebeing 1 in 8000 deliveries. In the past, pregnancy after uterine rupture was not widely advised and patients underwent hysterectomy or tubal ligation but with the evolving practice, women are motivated for pregnancy which can be successful with proper obstetric care and emphasis on time and mode of delivery. Here we present a case of 31 years old female, gravida-2 para-1 living 0 with previous uterine rupture after medical induction of labor with stillbirth 4 years ago. She underwent emergency laparotomy with the repair. The patient spontaneously conceived and had close antenatal care throughout the pregnancy. The patient was admitted at 34 weeks of gestation and kept under close surveillance. Corticosteroid was administered. She underwent spontaneous labor at 37 weeks of gestation and emergency cesarean section was planned, delivered via a breech presentation to a live baby of 2.4 kg, APGAR score of 8/10, 9/10 at 1 and 5 minutes.