Immediate closure of uterine wall following spontaneous rupture at 23 weeks' gestation, allowing prolongation of pregnancy.

Abstract

Uterine rupture is a dramatic complication of pregnancy associated with increased fetal morbidity and mortality. It occurs frequently during a vaginal birth in women with a previous Cesarean section1. Corporeal rupture has also been reported and usually occurs after previous laparoscopic myomectomy2. More recently, other conditions have been associated with uterine rupture, such as after mid-gestational open maternal fetal surgery3, after laparoscopic salpingectomy4 and even in a previously unscarred uterus5. We report a case of recurrent uterine rupture in a pregnant woman following a previous vaginal delivery with retention and manual removal of the placenta. A 35-year-old woman presented to the emergency room at 23 + 6 weeks' gestation with acute abdominal pain located on the left side of the uterus. Her obstetric history was significant, with her first pregnancy delivering vaginally at term with manual removal of the placenta which was located in the left cornual region, close to the tubal ostium. In a second pregnancy, spontaneous uterine rupture near the left cornual region of the unscarred uterus occurred at 35 weeks and resulted in fetal demise. The third and fourth pregnancies were twin and singleton pregnancies, respectively, both of which miscarried. The latter was treated with dilation and curettage. Before allowing this current pregnancy, the integrity of the uterine wall was ascertained with ultrasound and hysteroscopy. In the current pregnancy, a diagnosis of uterine rupture was confirmed as a fetal foot and amniotic sac could be seen protruding through the uterine wall scar. An emergency laparotomy was performed under combined epidural and intrathecal analgesia. The site of the rupture was again close to the left ostium. The decision to perform immediate closure of the uterine wall was based on the following: (1) fetal wellbeing and prematurity status; (2) presence of posterior placenta; and (3) absence of intraperitoneal hemorrhage. The patient wanted the best outcome for her baby and consented to this approach. For closure of the uterine wall, a 6-cm single-layer suture with vicryl-0 was performed (Figure 1). Perfusion of nitroglycerine was given for uterine relaxation and phenylephrine perfusion was also needed to counteract the nitroglycerine actions. On completion of surgery, iatrogenic preterm prelabor rupture of membranes (PPROM) occurred. In the postoperative course, the patient received betamethasone for fetal lung maturation, magnesium sulfate for fetal neuroprotection, and ampicillin and erythromycin were administered for 7 days as per the management protocol of PPROM. Uterine relaxation after the surgery was achieved by administration of nifedipine XL 30 mg twice daily until delivery. The patient was kept hospitalized. The thickness of the uterine scar was assessed daily by ultrasound and measurements varied between 3 and 5 mm. The patient underwent an emergency Cesarean section at 27 weeks for unexplained fetal bradycardia. An intact scar was observed at the time of the Cesarean section. A 970-g female was delivered with Apgar scores of 8, 9 and 9, at 1, 5 and 10 mins, respectively. At 4 months corrected age, the infant showed normal neurodevelopment. In this case, abnormal implantation of the placenta into the cornual region seemed to attenuate the uterine musculature and predisposed the uterus to uterine rupture in a subsequent pregnancy. Immediate repair of the uterine defect was chosen in the presence of a preterm live fetus that remained within the uterine cavity, and an absence of intraperitoneal hemorrhage. Immediate closure of the uterine wall should be considered in specific cases, such as this, to enable continuation of pregnancy. L. Leduc*†, B. Monet†, A Sansregret†, R. Gauthier†, J. Bourque† and F. Rypens‡ †Department of Obstetrics & Gynecology, CHU Sainte-Justine, 3175 Côte Sainte-Catherine, Montreal, Quebec H3T 1C5, Canada; ‡Department of Radiology, CHU Sainte-Justine, Montreal, Quebec, Canada *Correspondence. (e-mail: [email protected])