Hemoperitoneum in a patient with spontaneous rupture of the posterior wall of an unscarred uterus in the second trimester of pregnancy

Antepartum Rupture of the Posterior Uterine Wall in a Woman With Two Previous Cesarean Deliveries

Uterine rupture is a rare pregnancy complication. In patients with a previous cesarean delivery, it usually involves the scarred area. Uterine rupture of the posterior wall is even rarer and mostly described during labor. Conditions that confer fragility to the posterior uterine wall have been associated with an increased risk of uterine rupture. There are very few cases of spontaneous posterior uterine wall rupture in a non-labor setting in pregnant women without risk factors. We report the case of a pregnant woman admitted to the hospital due to placental abruption at 26 weeks' gestation. Once fetal and maternal stability were assured, expectant management was maintained. At 29 weeks, an emergent cesarean delivery due to fetal bradycardia was performed, and a large rupture of the posterior uterine wall was diagnosed. Subsequently, a hysterectomy was performed. The patient was discharged nine days after the procedure and the newborn on the 64th day of life.

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.

It Is Not Always an Ectopic or Heterotopic Pregnancy

Uterine rupture is a life-threatening peripartum complication. Spontaneous uterine rupture in early pregnancy is very rare. The diagnosis of uterine rupture should be considered when a pregnant patient presents with an acute abdomen because its clinical signs in early pregnancy are non-specific and the differentiation with other acute abdominal emergencies is challenging. Here, we present a case of acute abdominal pain. The patient was a 14-week pregnant 39-year-old female (gravida 4, para 2+1) with a history of two lower-segment cesarean sections. Our preoperative diagnosis was either heterotopic pregnancy or acute abdomen. Emergency laparotomy confirmed the presence of a spontaneous uterine rupture.

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.

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

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

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Immediate laparotomy is the gold standard management.

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Delay in diagnosis and management can lead foeto-maternal morbidity.

Complete Uterine Rupture: A Case Report

Background: Uterine rupture during pregnancy is a considerable obstetric complication. The presence of a previous uterine scar is the most significant risk factor. Early clinical diagnosis is paramount to maternal and fetal survival. Case Report: A 36- year-old woman, gravida 2 para 2, presented with sudden acute abdominal pain at 38 weeks of gestation. The patient had a history of cesarean delivery one year ago. Ultrasound scans showed an empty endometrial cavity and fetus outside the uterus. Emergency laparotomy was performed, a live baby boy weighing 3.420 kg was delivered, and the uterine disruption was repaired. Conclusion: Increasing trends in the cesarean section may lead to a higher number of uterine ruptures. The survival of patients after uterine rupture depends on the time interval between rupture and intervention, and the availability of appropriate medical team and equipment. Health professionals caring for pregnant women should be alert for the symptoms and risk factors of uterine rupture.

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.

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.

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

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

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

Spontaneous partial uterine laceration in primigravida at 16 weeks of gestation: A case report

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Uterine laceration is extremely rare and little known, however it sometimes causes massive intraperitoneal bleeding and has poor prognosis.

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Inner myometrial laceration may be caused by intrapartum physical stress, whereas uterine laceration in relatively early pregnancy might be occurred by tissue inadaptable for uterine enlargement.

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To diagnosis uterine laceration in early pregnancy is quite difficult because of the absence of specific clinical findings.

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Not only uterine rupture but also uterine laceration should be considered, and exploratory laparotomy should be performed appropriately when hemoperitoneum is strongly suspected.

Introduction

Although uterine rupture is well discussed, uterine laceration and partial myometrial laceration are little known. A previous report hypothesized that the stress of labor was associated with uterine laceration.

Presentation of case

We present a rare case of uterine laceration in a patient in the second trimester. A 34-year-old primigravida woman at 16 weeks’ gestation without a history of uterine surgery complained of sudden low abdominal pain. Ultrasonography showed fetal death and intraperitoneal free fluid. A laparotomy was performed, and partial uterine laceration in the posterior wall along with active bleeding was confirmed.

Discussion

The etiology of uterine laceration in early pregnancy might be different from both classical uterine rupture and previously published uterine laceration. We hypothesized that tissue inadaptable for uterine enlargement, such as that owing to endometriosis and subtle injury by surgical approach, may be associated with the onset mechanism.

Conclusion

The diagnosis of uterine laceration in early pregnancy is quite difficult because of the absence of specific clinical findings. However, it sometimes causes massive intraperitoneal bleeding and has poor prognosis. Therefore, when uterine laceration is suspected as a cause of hemoperitoneum in a pregnant women, clinicians should perfume exploratory laparotomy appropriately.

Spontaneous rupture of unscarred uterus in the third trimester after in vitro fertilization-embryo transfer because of bilateral salpingectomy: A case report

RATIONALE

Rupture of an unscarred uterus after in vitro fertilization-embryo transfer (IVF-ET) in a primiparous woman is rare. Assisted reproductive technology (ART)-induced rupture of an unscarred uterus is usually attributable to increased dizygotic twinning rates. Salpingectomy can result in cornual scarring and increase the risk of uterine rupture as well as the mortality rate in a subsequent ectopic pregnancy. Here, we present the first reported case of a spontaneous, third-trimester, uterine rupture in a primiparous woman after IVF-ET due to a history of bilateral salpingectomy because of bilateral oviduct and ovarian cysts; the patient did not have an ectopic pregnancy or any cornual or other uterine scarring during this pregnancy after IVF-ET.

PATIENT CONCERNS

A 24-year-old woman with a history of IVF-ET and bilateral salpingectomy was admitted to our hospital with unexplained acute upper abdominal pain during the third trimester.

DIAGNOSIS

The fetal heart rate was abnormal. Abdominal ultrasonography was negative. Computed tomography revealed a small amount of abdominal and pericardial effusion. Laboratory tests revealed increased white blood cells. A diagnosis of pregnancy complicated by acute abdomen was considered. Emergent exploratory laparotomy revealed a uterine rupture at the right fundus adjacent to the right cornual area.

INTERVENTIONS

The patient was successfully managed with simultaneous exploratory laparotomy and lower-segment cesarean section. The rupture site was repaired.

OUTCOMES

Two live infants were uneventfully delivered. Follow-up assessments of the mother and the female baby on the 42nd postpartum day yielded normal results. The male infant was diagnosed with left hydronephrosis and required an operation.

LESSONS

We conclude that the ART-associated increase in dizygotic twinning rates may be a neglected risk factor for spontaneous rupture of the unscarred uterus, especially in patients who have undergone salpingectomy. Uterine rupture should be considered in a patient with multiple pregnancy following IVF-ET who presents with acute abdominal pain and abnormal fetal heart rate. Timely exploratory laparotomy is the key to a good prognosis.

Uterine rupture in a primigravid patient, an uncommon but severe obstetrical event: a case report

BACKGROUND

A spontaneous rupture of the unscarred uterus in a primigravid patient is extremely rare and is associated with high perinatal and maternal morbidity and mortality.

CASE PRESENTATION

A 34-year-old white primigravid woman, 31 + 3 weeks of gestation, presented with pre-eclampsia and developed a sudden acute abdomen. An emergency laparotomy was performed and a uterine rupture was found as the cause of the event. A stillborn girl was born.

CONCLUSION

A rupture of the pregnant uterus should always be considered in a pregnant woman presenting with abdominal pain, even in a primigravid patient.

Confirmation of posterior uterine rupture in the second trimester by magnetic resonance imaging

Intrapartum uterine rupture is a life-threating and rare complication of pregnancy which seldom occurs in the second trimester. Typically, the diagnosis is made using ultrasound; however, magnetic resonance imaging can provide certain advantages in the emergent setting. We present a unique case of a posterior uterine rupture confirmed by magnetic resonance imaging involving the unscarred posterior uterine wall in a 20-year-old gravid female with two previous cesarean-sections.

Placental Abruption Revealed by Hemoperitoneum: A Case Report

Background Hemoperitoneum is a life-threatening surgical emergency. Diagnosis of the cause is often difficult, in particular, during pregnancy when it may be either obstetric or nonobstetric. Case We report the case of a hemoperitoneum caused by the backflow of blood through a uterine tube, due to placental abruption. Conclusion Hemoperitoneum in pregnant women with no other signs can reveal placental abruption. The difficulty in identifying the cause may delay appropriate management.

Spontaneous Unscarred Uterine Rupture at 15 Weeks of Pregnancy: A Case Report

BACKGROUND

Uterine rupture during pregnancy is a serious obstetric complication. The presence of a previous uterine scar is the most important risk factor, whereas rupture in an unscarred uterus is a rare event.

CASE REPORT

A 34-year-old woman, gravida 3 para 1, presented with sudden acute hypogastric pain at 15 weeks of gestation. The patient had no history of cesarean delivery. Ultrasound scans showed an empty endometrial cavity continuing directly into the amniotic sac that developed mainly outside the uterus. Because of the ultrasound findings and the patient's progressive anemia, a laparoscopy was performed that revealed a massive hemoperitoneum caused by the rupture of the uterine fundus with exteriorization of most of the amniotic sac. Laparoscopy was converted to laparotomy, the pregnancy was removed, and the uterine disruption was repaired.

CONCLUSION

Early diagnosis and prompt treatment of uterine rupture may significantly improve prognosis. This severe obstetric complication should be considered even in early gestational age pregnancies and in the absence of known risk factors.