Pregnancy in Women With a History of Uterine Rupture

Prenatal Detection and Conservative Management of Uterine Scar Dehiscence in Patient with Previous Uterine Rupture and Multiple Surgeries-A Case Report

Uterine rupture is a rare and life-threatening condition. It usually occurs in patients with uterine scars (most commonly for a previous myomectomy or caesarean section), but it can also affect an unharmed uterus. This complication is more frequent in the third trimester and during delivery. There is not yet a recognised method of prediction of uterine rupture and the ultrasound features still need a consensus. In this article, we have reported a case of uterine dehiscence diagnosed by a pelvic ultrasound and magnetic resonance (MRI) at 24 weeks of gestation. The finding was confirmed intraoperatively at the caesarean section at 29 weeks of gestation. The 40-year-old patient has had a previous pregnancy complicated by uterine rupture at 22 weeks of gestation, following six previous abdominal surgeries for stage IV endometriosis, diffuse and nodular adenomyosis, and pelvic adhesion syndrome. The early detection of uterine dehiscence allowed us to prolong the pregnancy and perform a subsequent fertility-sparing surgery, reducing maternal and neonatal morbidity and mortality. Our case report proves that women with severe endometriosis/adenomyosis are at a high risk of uterine rupture and scar dehiscence. The antenatal ultrasound can describe a uterine dehiscence (even in asymptomatic patients) and prevent complications.

Complete rupture of the pregnant uterus: A 12-year retrospective study

OBJECTIVE

To assess the frequency of uterine ruptures, clinical characteristics, and maternal and neonatal outcomes in a tertiary referral center.

METHODS

Information on complete uterine rupture between July 2010 and June 2022 was investigated retrospectively at a tertiary center.

RESULTS

There were 42 cases of complete uterine rupture in 144 474 deliveries, with an incidence rate of 0.029%. Twenty-seven cases had a scarred uterus and 15 had an unscarred uterus; Rupture of the lower uterine segment was predominant in the scarred uterus, whereas rupture of the body of the uterus was predominant in the non-scarred uterus (P ≤ 0.001). Newborns with Apgar score of 7 or less at 1 min in the non-scarred uterus group was more than that in the scarred uterus group (P = 0.001). There were no significant differences in the history of gynecologic surgery, induction of labor, mode of delivery, clinical features, maternal outcomes, neonatal weight, preterm birth rate, 5-min Apgar score, or neonatal mortality between the two groups (P > 0.05).

CONCLUSION

The clinical manifestations of uterine rupture are mainly abdominal pain, abnormal fetal heartbeat, or vaginal bleeding. Attention should also be paid to the history of previous uterine surgery. Strict prenatal management, early identification, and aggressive management can help improve maternal and child outcomes. Hysterectomy is not imperative.

Outcome of subsequent pregnancies in women with prior uterine rupture

OBJECTIVE

To report maternal and neonatal outcomes of subsequent pregnancies in a series of women with a prior uterine rupture.

METHODS

The records of all 103,542 deliveries (22,286 by cesarean section) performed in a single tertiary medical center from 2009 to 2021 were reviewed. Women with a prior uterine rupture, defined as a separation of the entire thickness of the uterine wall, with extrusion of fetal parts and intra-amniotic contents into the peritoneal cavity documented in the operative report of the previous cesarean delivery or laparotomy, were identified for inclusion in the study.

RESULTS

The cohort included 38 women with 50 pregnancies (50 neonates). Women had been scheduled for elective cesarean delivery at early term. Mean gestational age at delivery was 36 + 4 weeks (±5 days). In 7 pregnancies (14 %), spontaneous labor occurred before the scheduled cesarean delivery (at 36 + 6, 35 + 4, 35 + 3, 34 + 6, 34 + 3, 32 + 6 and 31 + 0 gestational weeks). A recurrent uterine scar rupture was found in 4 pregnancies (8 %), and uterine scar dehiscence, in 2 pregnancies (4 %), all identified during elective repeat cesarean delivery. In none of these cases was there a clinical suspicion beforehand; all had good maternal and neonatal outcomes. One parturient with placenta previa-accreta had a planned cesarean hysterectomy.

CONCLUSION

Women with prior uterine rupture have good maternal and neonatal outcomes in subsequent pregnancies when managed at a tertiary medical center, with planned elective term cesarean delivery, or even earlier, at the onset of spontaneous preterm labor.

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.

Pregnancies in Women with a Previous Complete Uterine Rupture

Objective

To study the outcomes of new pregnancies after a previous complete uterine rupture.

Design

Descriptive study based on population data from the Medical Birth Registry of Norway, the Patient Administration System, and the medical records. Sample. Maternities with a previous complete uterine rupture in Norway during the period 1967-2011 (N = 72), extracted from 2 455 797 maternities.

Method

We measured the rate of new complete ruptures and partial ruptures, as well as the maternal and perinatal outcomes of these pregnancies. The characteristics of both previous ruptures and new ruptures were described.

Results

Among 72 maternities, there were thirty-seven with previous ruptures in the lower segment (LS) and 35 outside the LS. We found three new complete ruptures and six uneventful partial ruptures, resulting in a rate of 4.2% and 8.3%, respectively. All three complete ruptures occurred preterm in scars outside the LS. The rate of the new complete rupture was 0% in those with previous ruptures in the LS and 8.6% in those with previous ruptures outside the LS. The corrected perinatal mortality was 1.3%, and prematurity (<37 weeks) was high (36.1%); this was noticed even in the absence of new ruptures and was mostly iatrogenic. Two hysterectomies were performed in the absence of rupture and two cases had abnormal invasive placenta.

Conclusion

The prognosis for pregnancies after a previous complete uterine rupture is favorable. Prematurity is a problem caused by both obstetrician and mother's anxiety; therefore, the timing of delivery is the most challenging. Management should include careful counseling, vigilance for symptoms, and immediate delivery when a rupture is suspected.

Risk Prediction Method of Obstetric Nursing Based on Data Mining

Obstetric nursing is not only complex but also prone to risks, which can have adverse effects on hospitals. Improper handling of existing risks in obstetric care can lead to enormous harm to patients and families. Therefore, it is necessary to pay attention to the risks of obstetric nursing, especially to predict the risks in a timely manner, and take effective measures to prevent them in time, so as to achieve the purpose of allowing patients to recover as soon as possible. Data mining has powerful forecasting function, so this paper proposes to combine the data-mining-based support vector machine method and XGBoost method into a forecasting model, which overcomes the shortcomings of unstable forecasting and low accuracy of a single forecasting model. The experimental results of this paper have shown that the prediction accuracy of the SVM-XGBoost combined prediction model has reached 100%, the accuracy of the single SVM prediction model is about 78%, and the accuracy of the single XGBoost prediction model is about 75%. Compared with the single SVM model and the XGBoost prediction model, the accuracy rate had increased by about 22% and 25%, and the precision rate and recall rate are also improved. Therefore, it is very suitable to use the SVM-XGBoost combined prediction model to predict the risk of obstetric nursing.

Uterine rupture during pregnancy: The URIDA (uterine rupture international data acquisition) study

OBJECTIVE

To describe the characteristics and peripartum outcomes of patients diagnosed with uterine rupture (UR) by an observational cohort retrospective study on 270 patients.

METHODS

Demographic information, surgical history, symptoms, and postoperative outcome of women and neonates after UR were collected in a large database. The statistical analysis searched for correlation between UR, previous uterine interventions, fibroids, and the successive perinatal outcomes in women with previous UR.

RESULTS

Uterine rupture was significantly associated with previous uterine surgery, occurring, on average, at 36 weeks of pregnancy in women also without previous uterine surgery. UR did not rise exponentially with an increasing number of uterine operations. Fibroids were related to UR. The earliest UR occurred at 159 days after hysteroscopic myomectomy, followed by laparoscopic myomectomy (251 days) and laparotomic myomectomy (253 days). Fertility preservation was feasible in several women. Gestational age and birth weight seemed not to be affected in the subsequent pregnancy.

CONCLUSION

Data analysis showed that previous laparoscopic and abdominal myomectomies were associated with UR in pregnancy, and hysteroscopic myomectomy was associated at earlier gestational ages. UR did not increase exponentially with an increasing number of previous scars. UR should not be considered a contraindication to future pregnancies.

Optimizing Term Delivery and Mode of Delivery

Full-term deliveries are defined as occurring between 39 weeks and 40 weeks and 6 days. Because contemporary research suggests improved outcomes with delivery in the term period compared with the early term period, nonindicated delivery should be pursued no earlier than 39 weeks. There are, however, multiple medical, obstetric, and fetal indications for delivery before 39 weeks, and the obstetric provider must weigh the risks and benefits of delivery versus expectant management on both the mother and fetus. This review serves to provide a basic framework of evidentiary support toward optimizing the term delivery.

Prelabour uterine rupture: characteristics and outcomes

OBJECTIVE

To describe the characteristics and outcomes of prelabour uterine ruptures.

DESIGN

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

SAMPLE

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

METHOD

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

RESULTS

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

CONCLUSION

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

TWEETABLE ABSTRACT

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

Timing of delivery in women with prior uterine rupture: a decision analysis

Background: Uterine rupture is an obstetric complication with high rates of associated maternal and neonatal morbidity and mortality. However, limited guidance for the timing of delivery in women with a history of prior uterine rupture exists.Objective: To determine the optimal gestational age of delivery in women with prior uterine rupture.Study design: A decision-analytic model was built using TreeAge software to compare the outcomes of repeat cesarean delivery when performed at 32, 33, 34, 35, or 36 weeks gestation in a theoretical cohort of 1000 women with prior uterine rupture. Strategies involved expectant management until a later gestational age accounting for the risks of spontaneous uterine rupture, spontaneous labor, uterine rupture following spontaneous labor, and stillbirth during each successive week that a woman was still pregnant. Maternal outcomes included uterine rupture, hysterectomy, and death. Neonatal outcomes included hypoxic-ischemic encephalopathy, cerebral palsy, and death. Probabilities were derived from the literature and total quality-adjusted life years (QALYs) were calculated. Sensitivity analyses were used to vary model inputs to investigate the robustness of our baseline assumptions.Results: In our theoretical cohort of 1000 pregnant women with a history of prior uterine rupture, cesarean delivery at 34 weeks maximized maternal and neonatal QALYs. Compared to delivery at 36 weeks, delivery at 34 weeks would prevent 38.6 uterine ruptures, 0.079 maternal deaths, 6.10 hysterectomies, and 12.1 neonatal deaths but results in 4.70 more cases of cerebral palsy. Univariate sensitivity analysis found that repeat cesarean at 34 weeks remained the optimal strategy until the probability of spontaneous repeat uterine rupture (baseline estimate: 0.68%) fell below 0.2% or rose above 0.9%, at which point, a strategy of delivery at 35 or 32 weeks became optimal, respectively. However, Monte Carlo simulation demonstrated that delivery at 35 weeks was the optimal strategy 37% of the time, whereas 34 weeks was the optimal strategy 17% of the time.Conclusion: The optimal time for repeat cesarean delivery in women with prior uterine rupture appears to be between 34-0/7 and 35-6/7 weeks gestation.