Spontaneous uterine rupture during the 1st trimester: A rare but life-threatening emergency

A cesarean section scar dehiscence during the first trimester of an intrauterine pregnancy: a rare case report and literature review

Uterine rupture is specified as a complete laceration of the uterine wall, including its serosa, leading to a connection between the endometrial and peritoneal chambers. It can occur in any stage of pregnancy and is considered a severe and perhaps fatal complication. A 35-year-old woman at 9 weeks of gestation with a medical history of five prior cesarean sections presented with lower abdominal pain that had lasted for 5 hr. We detected small amounts of free fluid in the Douglas pouch using ultrasound. Subsequently, a laparotomy revealed a cesarean scar dehiscence from a non-cesarean scar pregnancy. Patients who experience a uterine rupture may have vague symptoms, severe abdominal discomfort, abnormal uterine bleeding, and severe hemorrhagic shock, depending on their gestational age. Ultrasound imaging can be used to diagnose this fatal condition in addition to laparoscopy to immediately identify and treat the issue in urgent cases.

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.

First-trimester uterine rupture: a case report and systematic review of the literature

OBJECTIVE

This study aimed to present a case of first-trimester uterine rupture and perform a systematic review to identify common presentations, risk factors, and management strategies.

DATA SOURCES

Searches were performed in PubMed, Ovid, and Scopus using a combination of key words related to "uterine rupture," "first trimester," and "early pregnancy" from database inception to September 30, 2020.

STUDY ELIGIBILITY CRITERIA

English language descriptions of uterine rupture at ≤14 weeks of gestation were included, and cases involving pregnancy termination and ectopic pregnancy were excluded.

METHODS

Outcomes for the systematic review included maternal demographics, description of uterine rupture, and specifics of uterine rupture diagnosis and management. Data were extracted to custom-made reporting forms. Median values were calculated for continuous variables, and percentages were calculated for categorical variables. The risk of bias was assessed using the Joanna Briggs Institute critical appraisal checklist for case reports and case series.

RESULTS

Overall, 61 cases of first-trimester uterine rupture were identified, including our novel case. First-trimester uterine ruptures occurred at a median gestation of 11 weeks. Most patients (59/61 [97%]) had abdominal pain as a presenting symptom, and previous uterine surgery was prevalent (44/61 [62%]), usually low transverse cesarean delivery (32/61 [52%]). The diagnosis of uterine rupture was generally made after surgical exploration (37/61 [61%]), with rupture noted in the fundus in 26 of 61 cases (43%) and in the lower segment in 27 of 61 cases (44%). Primary repair of the defect was possible in 40 of 61 cases (66%), whereas hysterectomy was performed in 18 of 61 cases (30%). Continuing pregnancy was possible in 4 of 61 cases (7%).

CONCLUSION

Uterine rupture is an uncommon occurrence but should be considered in patients with an acute abdomen in early pregnancy, especially in women with previous uterine surgery. Surgical exploration is typically needed to confirm the diagnosis and for management. Hysterectomy is not always necessary; primary uterine repair is sufficient in more than two-thirds of the cases to achieve hemostasis. Continuing pregnancy, although uncommon, is also possible.

Spontaneous unscarred uterine rupture in a primigravid patient at 11 weeks of gestation managed surgically: A rare case report

INTRODUCTION

Spontaneous rupture of the primigravid uterus is a rare but catastrophic obstetrical emergency. It usually occurs late in pregnancy or during labour, mainly in multiparous women. But, spontaneous unscarred uterine rupture in a primigravid patient that also in first trimester is very rare. There are only 12 papers in Pub Med database regarding spontaneous unscarred uterine rupture in primigravid in early pregnancy.

CASE PRESENTATION

A 23-year-old primigravid female at 11th week of pregnancy, with no significant medical or surgical history, presented with sudden onset of generalised abdominal pain for four hours with multiple episodes of vomiting. On physical examination, patient was pale, in haemorrhagic shock with diffuse abdominal tenderness. Ultrasonography showed extra uterine gestational sac with massive haemoperitoneum. Eventually, patient was subjected to emergency laparotomy after resuscitation.

CLINICAL DISCUSSION

Spontaneous rupture of unscarred gravid uterus is a catastrophic rare condition that can be missed leading to maternal and foetal mortality. There are no pathognomonic features indicating the condition therefore it should be differentiated from other causes of acute abdominal emergencies.

CONCLUSION

Spontaneous rupture of unscarred gravid uterus should be differentiated from other acute abdominal emergencies. Patient may land up in emergency department in the state of shock, emergency physicians should be aware of its symptoms or presentations.

Spontaneous uterine rupture during the first trimester of a partial molar pregnancy in a scar uterus: A rare case report

Introduction

Spontaneous uterine rupture in the first trimester is a redoubtable obstetric emergency that carries a high risk for both mother and fetus.

Cases presentation

We present the case of a spontaneous uterine rupture in a patient with a scarred uterus at 9 weeks' gestation treated by laparotomy in emergency obstetrical department of Ibn Rochd University Hospital of Casablanca; whose histological examination of the removed material found a partial mole.

Clinical discussion

Spontaneous uterine rupture in the first trimester is rare and usually occurs in a scarred or malformed uterus. Clinicians should consider this diagnosis in the presence of an acute abdominal pain in early pregnancy with or without first trimester metrorrhagia.

Conclusion

Since the rate of uterine surgeries is increasing, it is necessary to highlight the risk of uterine rupture occurring early in order to improve their management. Molar pregnancy is a factor of fragility of the uterine wall and uterine rupture must be suspected in any molar pregnancy associated with a hemoperitoneum.

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Spontaneous uterine rupture in the first trimester is rare.

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Diagnosis suspected in the presence of any acute abdominal pain in early pregnancy.

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Uterine scarring is the main factor promoting early uterine rupture

Second trimester rupture uterus, unusual presentation

Introduction

Spontaneous uterine rupture before onset of labour is extremely rare. This is even more so in the second trimester of pregnancy, in nulliparous women and in the absence of myometrial surgery. The initial presentation of this potentially catastrophic event may be non-specific, with upper or lower abdominal discomfort, vague gastrointestinal or urinary symptoms preceding rapid deterioration.

Discussion

This case report demonstrates that a high index of suspicion, rapid diagnosis aided by imaging modalities and immediate surgical intervention are crucial steps in successful management. A postulated etiology in our patient is that of an upper scar from a previous uterine curettage with abnormal placentation predisposing to spontaneous rupture.

Presentation of case

A case of spontaneous uterine rupture at 16 week's gestation in a multiparous, 32 year old patient with no history of myometrial surgery. She had presented with lower abdominal discomfort, progressing to severe pain with hypotension and tachycardia. An urgent ultrasound pelvis showed a live fetus, free intra-peritoneal fluid with blood clots. An emergency laparotomy performed revealed 2 L of hemoperitoneum, with the fetus intact in the amniotic sac. The uterine fundal rupture was successfully repaired.

Conclusion

Despite the gestation, in women presenting with symptoms and signs suggestive of acute abdomen and hemodynamic instability, prompt resuscitation must be instituted, and a high index of suspicion for rupture must be suspected.

Spontaneous unscarred uterine rupture and surgical repair at 11 weeks of gestation in a twin pregnancy

A uterine rupture may result in a massive hemoperitoneum, which can be fatal to both the fetus and mother. Most uterine ruptures during pregnancy occur within a scarred uterus, rarely occurring in an unscarred uterus. Here, we report a very rare case of spontaneous rupture in an unscarred uterus at 11 weeks of gestation of a twin pregnancy and its surgical repair. A 37-year-old nulliparous infertile woman became pregnant with twins after artificial insemination and gonadotropin therapy. She underwent emergency surgery at 11 weeks of gestation due to an acute abdomen caused by massive hemoperitoneum. Upon laparotomy, one fetus with placenta was extruded into the abdominal cavity through a 3-cm myometrium rupture on the left posterior wall of the uterus. After surgical repair of the rupture site, the remaining fetus was alive and was successfully delivered by cesarean section at 34 weeks of gestation.

Uterine body placenta accreta spectrum: A detailed literature review

Placenta accreta spectrum (PAS) is a major obstetrical problem whose incidence is rising. Current guidelines recommend screening of all women with placenta previa and risk factors for PAS between 20 and 24 weeks. Risk factors, diagnosis, and management of previa PAS are well established, but an apparently normal location of the placenta does not exclude PAS. Literature data are scarce on uterine body PAS, which carries a high risk of maternal and neonatal adverse outcome, but is still easily missed on prenatal ultrasound. We conducted a comprehensive review to identify possible risk factors, clinical presentations, and diagnostic modalities of uterine PAS. A total of 133 cases were found during a 70-year period (1949-2019). The vast majority of them presented with signs of uterine rupture, even prior to the viability threshold of 24 weeks (up to 45%). Major risk factors included previous cesarean delivery, uterine curettage, uterine surgery, Asherman's syndrome, manual removal of the placenta, endometritis, high parity, young maternal age, in vitro fertilization, radiotherapy, uterine artery embolization, and uterine leiomyoma. Diagnosis was pre-symptomatic in only 3% of cases. Future studies should differentiate between previa PAS and uterine body PAS.

First Trimester Uterine Rupture: A Case Report and Literature Review

The aim is to report a case of spontaneous uterine rupture in the first trimester of pregnancy and to review the literature on the topic.

METHODS

A literature search was performed using PubMed and Scopus. Relevant English articles were identified without any time or study limitations. The data were aggregated, and a summary statistic was calculated.

RESULTS

A 35-year-old gravida 5, para 2 was admitted at our department because of fainting and abdominal pain. The woman had a first-trimester twin pregnancy and a history of two previous cesarean sections (CSs). Suspecting a uterine rupture, an emergency laparotomy was performed. The two sacs were completely removed, and the uterine rupture site was closed with a double-layer suture. The patient was discharged from hospital four days later in good condition. On the basis of this experience, a total of 76 case reports were extracted from PubMed and included in the review. Fifty-three patients out of 76 (69.74%) underwent previous surgery on the uterus. Most women (67.92%) had a CS, and in this group a cesarean scar pregnancy (CSP) or a placenta accreta spectrum (PAS) disorder was found to be the etiology in 77.78% of cases. Furthermore, 35.85% of the women had hysterectomy after uterine rupture. Twenty-three patients out of 76 (30.26%) had an unscarred uterus. Of this group, most women presented a uterine anomaly (43.48%). Moreover, 17.39% of these women had a hysterectomy.

CONCLUSION

According to the literature, the current pandemic use of CS explains most cases of first-trimester uterine rupture.

Uterine rupture in pregnancy after an intervention complicated by uterine perforation: Case report and systematic review of literature

OBJECTIVES

The present study is a descriptive study of characteristics of women who had a uterine rupture during pregnancy with a history of uterine perforation and no previous caesarean section.

STUDY DESIGN

We present a case report of a woman with a uterine rupture in pregnancy subsequent to a perforation made by uterine sounding and we performed a systematic review including all case-reports of uterine ruptures after perforation during dilatation and curettage or due to uterine sounding.

RESULTS

14 case-reports were included in this review. 12 out of 14 women presented with abdominal pain prior to the uterine rupture. In eight out of 14 cases an abdominal ultrasound was performed and in five ultrasounds a uterine wall defect was detected, in two other cases free fluid was visible and in one case fetal bradycardia was seen. Neonatal outcome was uneventful in six cases, there where two immature fetuses born and in two cases there was fetal demise.

CONCLUSION

Uterine rupture in a (supposed) unscarred uterus is a relatively unknown complication. We recommend clinicians to be aware of uterine rupture in pregnant women with abdominal pain and a history of uterine manipulation. When a uterine rupture is suspected and mother and fetus are in suspected good condition, an ultrasound examination could be an easy and fast next step.

Successful delivery after surgical repair of uterine rupture at 15 weeks of gestation: case report and brief review

OBJECTIVE

Second-trimester uterine rupture is a rare disorder and it is unclear if it should be managed with caesarean section, repair or hysterectomy. This article provides a case report of second-trimester uterine rupture repair, and reviews the risk factors, signs and symptoms, suturing technique and newborn outcome.

METHODS

PubMed was searched using the terms 'uterine rupture', 'second trimester' and 'repair' Only cases of second-trimester uterine rupture repair that led to successful prolongation of pregnancy were included.

RESULTS

The main risk factor of uterine rupture is previous caesarean section (5/10, 50%). Eight of 10 cases presented with abdominal pain and three cases presented in shock. Haemoperitoneum was present in five cases. The mean and median gestational age at delivery were 33.4 and 33.5 weeks, respectively (range 28-37 weeks), with mean and median delayed interval delivery of 95.5 and 91 days, respectively (range 14-147 days). Neonatal outcome was good for 10 of 11 newborns. Despite the early onset of uterine rupture, there were no cases of extremely preterm delivery. One early preterm infant, seven moderate-to-late preterm infants and one term infant were delivered.

CONCLUSIONS

The lack of extremely preterm deliveries and good neonatal outcomes encourage attempts to repair the uterus after second-trimester rupture.

First trimester spontaneous uterine rupture in a young woman with uterine anomaly

Spontaneous uterine rupture is a life-threatening obstetrical emergency carrying a high risk for the mother and the fetus. Spontaneous uterine rupture in early pregnancy is very rare complication and it occurs usually in scarred uterus. Uterine anomalies are one of the reasons for spontaneous unscarred uterine rupture in early pregnancy. Obstetricians must consider this diagnosis when a pregnant patient presented with acute abdomen in early pregnancy. We present a case of spontaneous uterine rupture at 12 weeks of gestation in 24-year-old multigravida who had uterine anomaly presenting as an acute abdomen. Our preoperative diagnosis was ectopic pregnancy. Emergency laparotomy confirmed a spontaneous uterine rupture. Uterine anomaly is a risk factor for spontaneous uterine rupture in the early pregnancy. Clinical signs of uterine rupture in early pregnancy are nonspecific and must be distinguished from acute abdominal emergencies.

Spontaneous hemopertitoneum - a matter of life and death

Spontaneous hemopertitoneum in pregnancy (SHiP) is a rare but potential catastrophic complication with high maternal and fetal mortality. The main cause of morbidity and mortality is delayed diagnosis and treatment. In this paper we will document the findings of an interesting case managed in our unit. We also discuss the etiology, diagnosis and management of this condition with high potential to lead to medico‐legal cases.