Complete Uterine Rupture Research Articles

Gebe Bir Kedide Abdominal Travmaya Bağlı Tam Uterus Rüptürü

Gebe Bir Kedide Abdominal Travmaya Bağlı Tam Uterus Rüptürü

Asymptomatic spontaneous complete uterine rupture in a term pregnancy after uterine packing during previous caesarean section: a case report

Uterine rupture is a life-threatening obstetrical complication with significant neonatal and maternal morbidity. The authors report a 36-year-old woman with a history of previous caesarean section because of pre-eclampsia and antepartum haemorrhage at 31 gestational weeks during her first pregnancy. Postpartum haemorrhage occurred and the uterine cavity was packed with gauze for reducing blood loss. After two years, she underwent elective, repeat caesarean section at 38+1 gestational weeks with no abdominal pain or vaginal bleeding. During the operation, a six- to seven-cm-long defect was found in the lower uterine segment, with complete separation of the uterine scar and disruption of the visceral peritoneum. A live baby was delivered. The postoperative course was uneventful. Uterine dehiscence and rupture should be suspected in the presence of risk factors such as previous caesarean section, especially uterine packing involved. Spontaneous silent rupture can occur in women without any alarming symptoms.

Signs, symptoms and complications of complete and partial uterine ruptures during pregnancy and delivery

ObjectivesUterine rupture is a rare but potentially catastrophic complication of pregnancy that requires rapid diagnosis. Classically, its signs and symptoms combine pain, fetal heart rate (FHR) abnormalities, and vaginal bleeding. The purpose of this study is to identify these signs and symptoms as well as the immediate complications of complete and incomplete (partial) ruptures of the uterine wall, whether or not they follow a previous cesarean delivery. Study designRetrospective study of case records from two university hospital maternity units, from 1987 to 2008. ResultsIn a total of 97,028 births during the study period, we identified 52 uterine ruptures (0.05%): 25 complete and 27 partial. Most (89%) occurred in women with a previous cesarean delivery. In complete ruptures, FHR abnormalities were the most frequent sign (82%), while the complete triad of FHR abnormalities–pain–vaginal bleeding was present in only 9%. The signs and symptoms of partial ruptures were very different; these were asymptomatic in half the cases (48%). Neonatal mortality reached 13.6% among the complete ruptures; 27 and 40% of these newborns had pH<6.80 and pH<7.0, respectively. Among the incomplete ruptures, only 7.7% of the newborns had a pH<7.0 and there were no deaths. ConclusionAlthough complete rupture of the uterus has a severe neonatal prognosis, the complete set of standard symptoms is present in less than 10% of cases. FHR abnormalities are by far the most frequent sign.

Unexplained Spontaneous Complete Uterine Rupture in the Second Trimester: A Rare Event. Case Report and Literature Review

Abstract Background: Rupture of a pregnant uterus occurs most often in a scarred uterus, and spontaneous rupture of an unscarred uterus in the second trimester is very rare. Case: An extremely rare case of spontaneous uterine rupture involving uterine fundus at 16 weeks of gestation in an unscarred uterus, and with no apparent risk factors, is reported. Results: Surgery was performed to remove the fetus and placenta, the patient received a transfusion of red blood cells as well as antibiotics. The postoperative period was uneventful, and the patient was discharged in stable condition. Conclusions: Uterine rupture should be considered as a possibility in a pregnant woman with severe abdominal pain, regardless of gestation, and even in absence of classic risk factors. (J GYNECOL SURG 30:108)

Use of ICD-10 codes to monitor uterine rupture: validation of a national birth registry

ObjectivesUterine rupture is a rare but severe complication in pregnancies after a previous cesarean section. In Denmark, the monitoring of uterine rupture is based on reporting of relevant diagnostic codes to the Danish Medical Birth Registry (MBR). The aim of our study was to examine the validity of registration of uterine rupture in the MBR within the population of pregnant women with prior cesarean section by conducting a review of the medical records. Study designWe reviewed 1709 medical records within the population of singleton pregnant woman delivering at term between 1997 and 2007. We retrieved the medical records of all women in the MBR with a code for uterine rupture during labor regardless of whether or not a prior cesarean section had been reported to the registry. In addition medical records of all women with a code for previous cesarean section and delivery of a child with adverse perinatal outcome were retrieved. ResultsAmong women recorded in the MBR with a previous cesarean section and uterine rupture, only 60.4% actually had a uterine rupture (partial or complete). At least 16.2% of complete uterine ruptures were not reported to the registry. Considering only complete uterine ruptures, the sensitivity and specificity of the codes for uterine rupture were 83.8% and 99.1%, respectively. ConclusionDuring the study period the monitoring of uterine rupture in the MBR was inadequate.

Trial of labor compared to repeat cesarean section in women with no other risk factors than a prior cesarean delivery

To compare outcomes with trial of labor after cesarean (TOLAC) or elective repeat cesarean delivery on maternal request (ERCD-MR). Prospective cohort study. Danish university hospital. Women with TOLAC (n=1161) and women with ERCD-MR (n=622) between 2003 and 2010. Exclusion criteria were diabetes, two prior cesarean sections, index cesarean at a different hospital, a delivery after the index cesarean, twin gestation, gestational age <37(+0) weeks and stillbirth. Data were obtained from the Aarhus Birth Cohort database, which comprised prospective registration of the deliveries. Adverse neonatal outcomes, risk factors for emergency cesarean, and uterine rupture in case of TOLAC. TOLAC was associated with an increased risk of neonatal depression [odds ratio (OR) 3.6, 95% confidence interval (CI) 1.1-19.1] and neonatal intensive care unit admission (adjusted OR 1.9, 95% CI 1.3-2.8). Within the TOLAC group 67% delivered vaginally. In the TOLAC group 1.3% (n=15) of the women had a complete uterine rupture. None of these infants had sequelae after 12months. Significant risk factors for emergency cesarean were no prior vaginal delivery (adjusted OR 1.8, 95% CI 1.1-3.0), index emergency cesarean during labor (adjusted OR 3.0, 95% CI 2.3-4.1), maternal age ≥35years (adjusted OR 1.9, 95% CI 1.3-2.8), pre-pregnancy body mass index ≥30 (adjusted OR 2.1, 95% CI 1.3-3.3), and birthweight 4000-4499g (adjusted OR 1.5, 95% CI 1.1-2.1). Uterine rupture was associated with the use of epidural analgesia (OR 2.2, 95% CI 1.1-4.9) and no prior vaginal delivery (p=0.03). TOLAC is an acceptable individualized option for women without major risk factors.

Fertility after complete uterine rupture

This review will address fertility and pregnancy outcome in women with history of uterine rupture. Increasing rates of primary Cesarean delivery and vaginal birth after one or more Cesarean sections will lead to higher rates of uterine rupture. Recent advances in reproductive medicine, open fetal surgery and gynecological surgery may also play a role in increasing uterine rupture rate. The implementation of the American College of Obstetricians and Gynecologists and Royal College of Obstetricians and Gynecologists guidelines on birth after Cesarean section will decrease the Cesarean section rate but may transiently increase the rate of uterine rupture. The maternal and perinatal risks of multiple Cesarean birth are much higher than those of uterine rupture. Women with prior uterine rupture are fertile. They have higher risk of recurrent uterine rupture. Every obstetrician is bound to face the challenge of uterine rupture or women with prior uterine rupture. Those women should have a favorable maternal and perinatal outcome when managed in a tertiary center.

Spontaneous Complete Uterine Rupture in a Nonlaboring, Early Third-trimester Uterus: Missed Diagnosis by Ultrasound

Objective Describe potential consequences and remedy for not intermittently auscultating fetal heart tones during travel to the imaging department and misdiagnosing a ruptured uterus on ultrasound as a synechiae.Study Design Retrospective chart review of case.Results Spontaneous uterine rupture in pregnancy is a rare and catastrophic event. Fetal monitoring is an important component for diagnosis, but fetal heart auscultation is usually discontinued while the patient is receiving imaging. We present a ruptured uterus at 28 weeks with delayed diagnosis secondary to interrupted fetal heart tone auscultation and a misdiagnosis of a rupture as a synechiae resulting in a seriously compromised newborn at delivery.Conclusion Intermittent fetal heart tone auscultation is a possible method of monitoring when the patient is off continuous fetal monitoring.

Bénéfices et risques maternels de la tentative de voie basse comparée à la césarienne programmée en cas d’antécédent de césarienne

To assess maternal outcomes during trial of labor (TOL) and elective repeat caesarean delivery (ERCD) in women with a previous caesarean delivery. French and English publications were searched using PubMed and Cochrane Library. Maternal mortality remains a very rare event regardless of the planned mode of delivery (EL2). It is potentially reduced after a TOL but the presence of biases in many studies does not allow any conclusion (EL3). Maternal morbidity is mainly due to the failure of the TOL and to the risk of unplanned caesarean delivery during labor (EL2). The risk of complete uterine rupture significantly increases with TOL versus ERCD but it remains low at about 0.2 to 0.8% for women with one scar on the uterus (EL2). The occurrence of a post-surgical wound, mostly from the bladder, is rare (less than 0.5%) regardless of the planned mode of delivery (EL2). Facing the risk of hemorrhage requiring hysterectomy or blood transfusion, data are heterogeneous because of the nature of the populations studied. These risks do not seem to vary with the mode of delivery (EL3). The risk of post-partum venous thrombo-embolic complications and infections (endometritis and maternal fever) appears to be similar in both TOL and ERCD (EL3). The risk of infection is primarily related to the additional presence of obesity (EL2). While maternal morbidity progressively increases with the number of iterative caesarean sections, maternal morbidity in TOL after a previous caesarean delivery decreases with the number of successful TOL (EL2). In patients with a previous caesarean delivery, the risks of maternal complications are rare and similar between TOL and ERCD. There is an increased risk of complete uterine rupture in case of TOL. Nevertheless TOL has a favorable benefit/risk balance in most cases and its success reduces the risk of short and long-term maternal complications (EL3).

Dinoprostone Use and Rupture of Uterus in Primigravida: A Report of Two Cases

Two cases of complete and incomplete uterine rupture following the use of dinoprostone gel for induction of labor (IOL) at 41 weeks of pregnancy in primigravidas; one of the two being diagnosed after vaginal delivery is presented herewith to alert cautious use of this important agent. NJOG 2011 Nov-Dec; 6 (2): 49-50 DOI: http://dx.doi.org/10.3126/njog.v6i2.6758

P11.11: Interobserver variation in measurements of Cesarean scar defect and myometrium with 3D ultrasonography

Results: Thirty-eight women were diagnosed of Cesaeran scar defect at TUS. The number of previous Caesarean sections in patients with uterine dehiscence and ectopic pregnancy in Cesarean scar is shown in Table 1. Eleven patients (29%) showed a uterine dehiscence. Seven cases were repaired by laparoscopy and 4 cases required hysterectomy. Five ectopic pregnancies (13%) were diagnosed at TUS. Two patients required hysterectomy, 2 were treated with local methotrexate guided by TUS and 1 was surgically sutured. Two patients (5%) had a complete uterine rupture. One of them diagnosed 6 months after Cesarean section and required hysterectomy. The other which was diagnosed during puerperium period was treated by surgical repair. Conclusions: TUS is useful for detecting Cesarean scar defects providing information for a treatment in case of complications.

Prelabor uterine rupture and extrusion of fetus with intact amniotic membranes: a case report

Abstract Introduction: The increasing rate of cesarean sections is an important issue globally, especially in developed countries. During the last decade, despite decreasing rates of vaginal delivery attempts after a previous cesarean section, the risk of uterine rupture has remained. Uterine rupture is a significant and catastrophic obstetric complication associated with maternal and fetal morbidity and mortality. We report here a very rare case of prelabor uterine rupture with intact membranes. Case report: A 28-year-old, gravida 3, para 2 Turkish woman was referred to our emergency unit at 34 weeks’ gestation because of the absence of fetal movements and abdominal pain. She had had a vaginal birth in 2007 and a cesarean section in 2009. In the delivery room, the fetal extremities were palpated at the abdominal wall, and an ultrasonography revealed ruptured uterus and fetal death. A midline laparotomy was carried out to open the peritoneal cavity. An intact amniotic sac with fetus was observed in the abdominal cavity, and the uterus was also observed to be ruptured. The male fetus, weighing 2500 g, was dead. The rupture was extending from the left lateral side of cervix to the fundus. The tear was repaired by primarily suturing the uterus in two layers after ligation of the left uterine artery to control hemorrhage. The total estimated blood loss was about 1300 mL. The patient received two units of blood transfusion during the operation. In the 4th postoperative day, the patient was discharged. Conclusion: Complete uterine rupture is a rare but catastrophic event, and if diagnosed late, can result in mortality. Uterine rupture is rare during a trial of vaginal labor in a patient with a history of cesarean section; it is much rarer to occur before any trial of vaginal labor in such a patient. If a patient with a history of cesarean section, especially with an unknown type of incision, presents with complaints of abdominal tenderness or vaginal bleeding in the 3rd trimester, the possibility of complete uterine rupture must be considered.

Uterine Rupture: Changing Trends in Obstetrics and Lessons for Obstetricians

ABSTRACT Objectives To determine the impact of improved obstetric care on the incidence, risk factors, management modalities and fetomaternal outcome of uterine rupture. Materials and methods Retrospective analysis of clinical records of uterine rupture cases at the department of Obstetrics and Gynecology, Abha General Hospital, Abha, KSA, from January 2007 to January 2012. Outcome measures Maternal and perinatal morbidity and mortality. Results Analysis showed 33 cases of uterine rupture among 34,590 deliveries, the incidence being 1/1048 (0.09%). Majority of the cases (73%) were unbooked. Important risk factors were previous cesarean section (88%) and grand multiparity (80%). Previous one C-section was also found to be an important risk factor (80%) for uterine rupture. Most of the patients were in their 30s. The frequency of complete and incomplete uterine rupture was almost the same (52 and 48% respectively). Total abdominal hysterectomy was required in 9 (27%), repair in 23 (70%) and one (3%) woman underwent subtotal hysterectomy. None of the patients agreed for tubal ligation. Seven (21%) cases were associated with bladder injury and three (9%) had vascular injury. There was no maternal mortality, 11 (33%) intrauterine fetal deaths and a live birth rate was 67%. Conclusion The absolute incidence of uterine rupture has not decreased inspite of the availability of ANC care and facilities for institutional deliveries. Only the etiological profile has changed. Our study found previous C-section as the most important emerging cause for uterine rupture. Reduction in Csection rate, awareness about the signs and symptoms of impending rupture, careful monitoring during induction in a scarred uterus on the part of caregivers and counseling about need for timely booking and importance of institutional delivery are important factors for reducing uterine rupture. How to cite this article Zia S, Rafique M, Rizwan A, Amin AB, Khan T. Uterine Rupture: Changing Trends in Obstetrics and Lessons for Obstetricians. J South Asian Feder Obst Gynae 2012;4(3):155-158.

Spontaneous prelabor uterine rupture in a primigravida: a case report and review of the literature

A rare case of prelabor uterine rupture in a primigravida was reported. A woman with a history of uterine perforation during hysteroscopy became pregnant after donor oocyte in vitro fertilization. To provide more insight into the possible risk factors for prelabor uterine rupture in primigravidae, a literature review was performed.

The Evaluation of Uterine Rupture in 61 Turkish Pregnant Women

Aim: The aim of our study, to evaluate the patients with complete or incomplete uterine rupture which occurred during pregnancy retrospectively and to analyze and present of the risk factors, maternal and perinatal outcomes, and complications. Method: Sixty one patients diagnosed as uterine rupture were investigated retrospectively in our clinic between 1999 and 2009. Result: The incidence of uterine rupture for our department in a ten year period was calculated as 0.12 %. Fifty four patients (88.5%) were in low socioeconomic status. Fifty one (83.6%) patients did not receive any antenatal care. Forty eight (78.6%) of the cases had previous ute rine surgery due to cesarean, myomectomy or metroplasty. Twenty six cases (42.6%) were grand multiparous. Primer repair of uterus was performed in 58 (95.1%) of the patients. Subtotal abdominal hyste rectomy was performed in three patients (4.9%). There were 15 fetal deaths while no maternal death was occurred. Conclusion: Rupture of the pregnant uterus is a major obstetric comp lication that occurs often with no warning signs. Uterine rupture is a potential complication for patients with non-scarred uterus as well as scarred uterus. Grand multiparty is a very important risk factor, especially in patients without uterine scar. Despite to its low rate, uterine rupture is a very important complication for mother and fetus. Early diagnosis, immediate preoperative resuscitation, rapid replacement of blood loss, and urge surgical therapy are very important in treatment of uterine rupture. Hysterectomy is not the first choice in case of uterine rupture management.

Pregnancy outcome and fertility after complete uterine rupture: a report of 20 pregnancies and a review of literature

To review the pregnancy outcome in women with previous complete uterine rupture. Hospital records of uterine rupture were reviewed from January 1981 to June 2010. All files of these patients were reviewed and patients were contacted by telephone calls to inquire about any further pregnancies after the uterine rupture. Out of 69,452 deliveries, there were a total of 27 cases of uterine rupture. There were 20 pregnancies after repair of complete uterine rupture and 10 of them resulted in live babies, all delivered by cesarean section. Eight pregnancies ended as first-trimeter miscarriages. One pregnancy resulted in preterm vaginal delivery at 24 weeks. There was only one repeat uterine rupture. There were no cases of cesarean hysterectomy. Four women agreed to undergo tubal ligation after the last delivery and two used other contraceptive methods. Two women were being followed for secondary infertility. Pregnancy after uterine rupture is associated with relatively good maternal and neonatal outcome when followed in a tertiary center.

Posterior Uterine Rupture Causing Fetal Expulsion into the Abdominal Cavity: A Rare Case of Neonatal Survival

Introduction. Uterine rupture is a potentially catastrophic complication of vaginal birth after caesarean section. We describe the sixth case of posterior uterine rupture, with intact lower segment scar, and the first neonatal survival after expulsion into the abdominal cavity with posterior rupture. Case Presentation. A multiparous woman underwent prostaglandin induction of labour for postmaturity, after one previous caesarean section. Emergency caesarean section for bradycardia revealed a complete posterior uterine rupture, with fetal and placental expulsion. Upon delivery, the baby required inflation breaths only. The patient required a subtotal hysterectomy but returned home on day 5 postnatally with her healthy baby. Discussion. Vaginal birth after caesarean section constitutes a trial of labour, and the obstetrician must be reactive to labour events. Posterior uterine rupture is extremely rare and may occur without conventional signs. Good maternal and fetal outcome is possible with a prompt, coordinated team response.

Distinctive ultrasonographic finding of complete uterine rupture in early mid-trimester.

In many cases of uterine rupture, diagnosis is often impossible when characteristic clinical symptoms are absent. We encountered a case of suspected peritoneal pregnancy in which we were able to make a definitive diagnosis by ultrasonography of complete uterine rupture in early mid-trimester. The possibly distinctive finding is the high-echo area that extends from the endometrium to the uterine serosa. This contiguous, highly echogenic finding should be recognized as characteristic of complete rupture of the uterus.

The Role of Uterine Closure in the Risk of Uterine Rupture

A potentially modifiable risk factor for uterine rupture during labor is the uterine closure technique. There is no consensus at present on the most appropriate uterine closure, in part because previous studies examining the relationship between the technique used for closure and subsequent pregnancy outcome have been small and greatly underpowered. Two decades ago, the 2-layer technique was the most common and popular procedure for uterine closure. In the 1990s, single-layer closure gained popularity with obstetricians because of its shorter operative time and need for fewer hemostatic sutures, and presently this technique is commonly used. A retrospective study published in 2002 comparing the single- and 2-layer techniques reported that single-layer closure was associated with a 4-fold increased risk of subsequent uterine rupture in women undergoing a trial of labor after a previous cesarean. This multicenter, case–control study was designed to compare the independent contribution of a number of risk factors for uterine rupture in 2 groups of women who had a prior single low-transverse cesarean delivery; the study group was comprised of women who experienced complete uterine rupture during a trial of labor and the control group was comprised of women without uterine rupture during labor. Risk variables examined included maternal age, gestational age at delivery, prior vaginal delivery, maternal diabetes, interdelivery interval, induction of labor, cervical maturation, oxytocin or prostaglandin use, birth weight, prior method of uterine closure, and type of suture material. Univariable and multivariable conditional logistic regression analysis was conducted to estimate the effect of each variable on the risk of uterine rupture. The primary independent variable examined was type of closure (single or double layer or unknown). There were 96 cases of uterine rupture and 288 controls selected for analysis. Adverse outcomes occurred in 29% (28/96) of the neonates. The rate of single-layer closure was higher in the case group than in the controls (cases: 36%, 35/96, vs. controls: 20%, 58/288, P < 0.05). Multivariable analysis showed that single-layer closure (adjusted odds ratio [aOR], 2.69; 95% confidence interval [CI], 1.37–5.28) and birth weight more than 3500 gm (aOR, 2.03; 95% CI, 1.21–3.38) were associated with increased rates of uterine rupture, whereas previous vaginal birth was a protective factor (aOR, 0.47; 95% CI, 0.24–0.93, all 3 comparisons: P < 0.05). Single-layer closure was the only significant variable related to uterine rupture with adverse neonatal outcome (aOR, 2.89; 95% CI, 1.01–8.27). These findings indicate that prior single-layer closure has more than twice the risk of uterine rupture than double-layer closure, and suggest that the single-layer technique should be avoided in women who may choose future vaginal birth after cesarean delivery.

The Role of Uterine Closure in the Risk of Uterine Rupture

A potentially modifiable risk factor for uterine rupture during labor is the uterine closure technique. There is no consensus at present on the most appropriate uterine closure, in part because previous studies examining the relationship between the technique used for closure and subsequent pregnancy outcome have been small and greatly underpowered. Two decades ago, the 2-layer technique was the most common and popular procedure for uterine closure. In the 1990s, single-layer closure gained popularity with obstetricians because of its shorter operative time and need for fewer hemostatic sutures, and presently this technique is commonly used. A retrospective study published in 2002 comparing the single- and 2-layer techniques reported that single-layer closure was associated with a 4-fold increased risk of subsequent uterine rupture in women undergoing a trial of labor after a previous cesarean. This multicenter, case-control study was designed to compare the independent contribution of a number of risk factors for uterine rupture in 2 groups of women who had a prior single low-transverse cesarean delivery; the study group was comprised of women who experienced complete uterine rupture during a trial of labor and the control group was comprised of women without uterine rupture during labor. Risk variables examined included maternal age, gestational age at delivery, prior vaginal delivery, maternal diabetes, interdelivery interval, induction of labor, cervical maturation, oxytocin or prostaglandin use, birth weight, prior method of uterine closure, and type of suture material. Univariable and multivariable conditional logistic regression analysis was conducted to estimate the effect of each variable on the risk of uterine rupture. The primary independent variable examined was type of closure (single or double layer or unknown). There were 96 cases of uterine rupture and 288 controls selected for analysis. Adverse outcomes occurred in 29% (28/96) of the neonates. The rate of single-layer closure was higher in the case group than in the controls (cases: 36%, 35/96, vs. controls: 20%, 58/288, P < 0.05). Multivariable analysis showed that single-layer closure (adjusted odds ratio [aOR], 2.69; 95% confidence interval [CI], 1.37-5.28) and birth weight more than 3500 gm (aOR, 2.03; 95% CI, 1.21-3.38) were associated with increased rates of uterine rupture, whereas previous vaginal birth was a protective factor (aOR, 0.47; 95% CI, 0.24-0.93, all 3 comparisons: P < 0.05). Single-layer closure was the only significant variable related to uterine rupture with adverse neonatal outcome (aOR, 2.89; 95% CI, 1.01-8.27). These findings indicate that prior single-layer closure has more than twice the risk of uterine rupture than double-layer closure, and suggest that the single-layer technique should be avoided in women who may choose future vaginal birth after cesarean delivery.