Spontaneous postpartum rupture of an intact 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.

Late Presentation of Uterine Rupture Following Vaginal Birth After Cesarean Delivery: A Case Report

Background  A trial of labor after cesarean delivery is associated with uterine rupture rates of 0.5 to 0.9%, which can have devastating neonatal and maternal consequences. While uterine rupture typically occurs during labor, it can clinically manifest after delivery. Case  A 23-year-old multiparous female presented in labor at term. Her obstetrical history was significant for a prior low transverse cesarean delivery. She had an uncomplicated labor course and spontaneous vaginal delivery. Immediately after delivery, she complained of severe right shoulder and left lower quadrant pain. Bedside ultrasound revealed a 10-cm, complex, adnexal mass adjacent to the uterus without free fluid. She was hemodynamically stable and appeared clinically well. On repeat ultrasound, the mass was unchanged; however, the patient now had free intraperitoneal fluid along the liver edge. Emergent laparotomy revealed a uterine rupture along her prior hysterotomy with extension into the right uterine artery. A 10-cm broad ligament hematoma ruptured posteriorly resulting in a 1-L hemoperitoneum. She received multiple blood products intraoperatively and recovered well postpartum. Conclusion  Delivery after trial of labor after cesarean delivery usually decreases acuity; however, these patients remain at risk for significant complications. Clinicians should continue to assess patients in the immediate postpartum period and proceed with surgical intervention if necessary.

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.

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.