Pregnancy after rupture of the pregnant uterus

Timing of planned cesarean delivery among patients with two previous cesarean sections

OBJECTIVES

The timing of planned repeat cesarean delivery (CD) is debateful in clinical practice. Planned repeat CD is typically scheduled before the spontaneous onset of labor to minimize the risk of uterine rupture during labor and the associated risk for fetal compromise. This timing should be balanced with the potential risk of delivering an infant who could benefit from additional maturation in utero. We aim to study the influence of gestational age at the time of repeat CD on maternal and fetal complications.

STUDY DESIGN

A population-based retrospective cohort study including all term singleton third CDs (≥ 37 weeks of gestation), between February-2020 and January-2022 at a tertiary medical center was conducted. Maternal and neonatal adverse outcomes were compared by gestational age at the time of the CD. A logistic regression models were constructed to adjust for confounders.

RESULTS

The study population included624 third CDs. Among them, two study groups were defined: 199 were at 37 + 0 to 37 + 6 weeks of gestation, and 44 were at ≥ 39 weeks of gestation at the time of delivery. 381 were at 38 + 0 to 38 + 6 weeks. Since our routine practice is to schedule elective CD at 38 + 0 to 38 + 6 weeks of gestation, we defined this group as the comparison group. In a multivariate analysis, both study groups were associated with significantly higher rates of emergent CDs after adjusting for maternal age, parity, ethnicity, premature rapture of membranes, spontaneous onset of labor and birthweight. After adjusting also for emergent CDs, CDs at 37 + 0 to 37 + 6 weeks of gestation were significantly associated with maternal and neonatal length of stay exceeding 4 days. Additionally, CDs at 37 + 0 to 37 + 6 weeks of gestation were also associated with composite of adverse neonatal and maternal outcomes.

CONCLUSIONS

Our study demonstrated that scheduling third CD at 38 + 0 to 38 + 6 weeks is associated with reduced risk of emergent CD, as well as beneficial maternal and neonatal outcomes.

Challenges and perspectives of abdominal pregnancy in a resource-limited setting: A case series

INTRODUCTION AND IMPORTANCE

Abdominal pregnancies, although rare, present unique challenges in both diagnosis and management. This case series reports on four cases of abdominal pregnancies diagnosed in a remote and underserved region of the Democratic Republic of Congo, highlighting the difficulties encountered in an under-equipped environment.

CASE PRESENTATION

The cases were documented in a remote village of DRC, which lacks specialized medical personnel and relies heavily on traditional healers. We report here 4 cases of abdominal pregnancies, their clinical presentations, diagnostic modalities, and surgical approaches. The cases varied in terms of clinical symptoms, gestational age, and placental implantation sites. Delayed diagnosis and presentation were common, resulting in significant hemoperitoneum and adverse fetal outcomes. All cases required laparotomy for both diagnosis and intervention.

CLINICAL DISCUSSION

Abdominal pregnancies can go undetected until advanced gestational age, with common physical findings including abdominal tenderness, abnormal fetal lie, fetal body parts readily palpable, and a displaced cervix. Laboratory tests may raise suspicion, but treatment options depend on intraoperative findings and gestational age. Advanced abdominal pregnancies are associated with high mortality rates for both the mother and the fetus. Laparotomy is typically required for diagnosis and intervention, with variations in placental implantation sites. Management of the placenta remains a debated topic, with partial or complete removal both viable options.

CONCLUSION

Abdominal pregnancies pose significant challenges in resource-poor settings, where limited healthcare resources and a shortage of specialized medical personnel can impede early diagnosis and appropriate management. Enhancing prenatal care, improving diagnostic capabilities, and increasing awareness among healthcare providers and communities are essential for optimizing outcomes in these complex obstetric cases.

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.

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.

Diagnosis of abdominal pregnancy still a challenge in low resource settings: a case report on advanced abdominal pregnancy at a tertiary facility in Western Kenya

Abdominal pregnancy is a rare form of ectopic pregnancy, occurring in 1: 10,000 to 1: 30,000 pregnancies and accounting for up to 1.4% of all ectopic pregnancies. It is classified as primary or secondary depending on the site of fertilization. However, when it does happen, it may remain unnoticed until term because the pregnancy can appear normal during clinical examination. Advanced abdominal pregnancy is associated with high mortality rate for both the mother and the baby at 1-20% and 40-95% respectively. We report a case of a 30-year-old female para 2+0, gravida 3 at 35⁺¹ who presented at a Tertiary facility in Eldoret Kenya with one-day history of per vaginal bleeding and 2 weeks' history of no fetal movements. The importance of this case report is to highlight the challenges associated with diagnosis of advanced abdominal pregnancy in low resource settings. Ultrasound alone cannot be relied on to make the diagnosis. Whenever an induction is not working, abdominal pregnancy should be considered.