Low Transverse Incision Research Articles

Uterine Rupture Risk After Periviable Cesarean Delivery

To investigate the risk of uterine rupture in women with prior periviable cesarean delivery and prior term cesarean delivery independent of initial incision type. We conducted a retrospective longitudinal cohort study using Washington state birth certificate data and hospital discharge records, identifying primary cesarean deliveries performed at 20-26 weeks and 37-41 weeks of gestation with subsequent delivery between 1989 and 2008. We compared subsequent uterine rupture risk in the two groups considering both primary incision type and subsequent labor induction and augmentation. We identified 456 women with index periviable cesarean delivery and 10,505 women with index term cesarean delivery. Women with index periviable cesarean delivery were younger, more frequently of nonwhite race, more likely to smoke, and more likely to have hypertension. Women in the periviable group had more index classical incisions (42% compared with 1%, P<.001) and fewer subsequent inductions and augmentations (8% compared with 16%, P<.001). Uterine rupture in the subsequent pregnancy occurred more frequently among women in the index periviable group than those in the index term group (8/456 [1.8%] compared with 38/10,505 [0.4%], odds ratio [OR] 4.9, 95% confidence interval [CI] 2.3-10.6). This relationship persisted among women with a low transverse incision (4/228 [1.8%] compared with 36/9,558 [0.4%], OR 4.7, 95% CI 1.7-13.4). Cesarean delivery at periviability compared with term is associated with an increased risk for uterine rupture in a subsequent pregnancy, even after low transverse incision. These data support judicious use of cesarean delivery at periviable gestational ages and inform subsequent counseling. II.

Neonatal Tracheostomy – Issues and Solutions

AIMS: To record and analyse the technical aspects of neonatal tracheostomy and to suggest some solutions.Materials and Methods: This is a retrospective observational cohort of 37 cases of neonatal tracheostomies performed over 30 years (1985-2014).Results: Thirty-three of the 37 tracheostomies were done as an elective procedure and four done emergently. Eighteen neonatal tracheostomies were done with a low transverse cervical incision and 19 were done with low vertical cervical incision. Three patients had bleeding while exposing the trachea. Trachea could not easily be identified in 2 cases. Commercial tracheostomy tubes were used in only 20 cases. In 17 patients, the conventional endotracheal tubes 2.5 or 3fr size were used. There were 3 instances of wound infection out of which one has peri-tracheostomy necrotizing cellulitis and the neonate succumbed to sepsis. Two cases had surgical emphysema. No case had pneumothorax.Conclusion: We described tracheostomy in neonates in a resource constrained centre. Various makeshift arrangements can be used in absence of standard supplies.

Neonatal tracheostomy - issues and solutions.

To record and analyse the technical aspects of neonatal tracheostomy and to suggest some solutions. This is a retrospective observational cohort of 37 cases of neonatal tracheostomies performed over 30 years (1985-2014). Thirty-three of the 37 tracheostomies were done as an elective procedure and four done emergently. Eighteen neonatal tracheostomies were done with a low transverse cervical incision and 19 were done with low vertical cervical incision. Three patients had bleeding while exposing the trachea. Trachea could not easily be identified in 2 cases. Commercial tracheostomy tubes were used in only 20 cases. In 17 patients, the conventional endotracheal tubes 2.5 or 3fr size were used. There were 3 instances of wound infection out of which one has peri-tracheostomy necrotizing cellulitis and the neonate succumbed to sepsis. Two cases had surgical emphysema. No case had pneumothorax. We described tracheostomy in neonates in a resource constrained centre. Various makeshift arrangements can be used in absence of standard supplies.

Risk of uterine rupture among women attempting vaginal birth after cesarean with an unknown uterine scar

The purpose of this study was to estimate the association of uterine rupture and previous incision type, either unknown or low transverse, among women who attempt a trial of labor after 1 previous cesarean delivery. We conducted a secondary analysis of a prospective multicenter observational study of 15,519 women with term singletons who attempted a trial of labor after 1 previous cesarean delivery. Odds ratios for the association between uterine incision location, either unknown or low transverse, and uterine rupture were estimated with the use of multivariable logistic regression. Between 1999 and 2002, 99 of the 15,519 women (0.64%) who attempted a trial of labor after 1 previous cesarean delivery experienced a uterine rupture. Pregnant women with an unknown scar had lower odds of uterine rupture (adjusted odds ratio, 0.71; 95% confidence interval, 0.37-1.37) compared with women with a known low transverse scar. Other adverse maternal outcomes did not differ between the 2 groups of women. Among this cohort, women with an unknown uterine incision who attempted a trial of labor were not at increased risk of uterine rupture compared with women with a known low transverse incision.

Comparison of Subcuticular Suture Materials in Cesarean Skin Closure.

Aim. Comparison of the rate of wound complications, pain, and patient satisfaction based on used subcuticular suture material. Methods. A total of 250 consecutive women undergoing primary and repeat cesarean section with low transverse incision were prospectively included. The primary outcome was wound complication rate including infection, dehiscence, hematoma, and hypertrophic scar formation within a 6-week period after operation. Secondary outcomes were skin closure time, the need for use of additional analgesic agent, pain score on numeric rating scale, cosmetic score, and patient scar satisfaction scale. Results. Absorbable polyglactin was used in 108 patients and nonabsorbable polypropylene was used in 142 patients. Wound complication rates were similar in primary and repeat cesarean groups based on the type of suture material. Skin closure time is longer in nonabsorbable suture material group in both primary and repeat cesarean groups. There was no difference between groups in terms of postoperative pain, need for additional analgesic use, late phase pain, and itching at the scar. Although the cosmetic results tended to be better in the nonabsorbable group in primary surgery patients, there was no significant difference in the visual satisfaction of the patients. Conclusions. Absorbable and nonabsorbable suture materials are comparable in cesarean section operation skin closure.

The Never Ending Debate Single-Layer Versus Double-Layer Closure of the Uterine Incision at Cesarean Section

The Never Ending Debate Single-Layer Versus Double-Layer Closure of the Uterine Incision at Cesarean Section

Patient Satisfaction and Cosmetic Outcome in a Randomized Study of Cesarean Skin Closure

INTRODUCTION: To determine which of the two most common methods of cesarean skin closure resulted in greater patient satisfaction and better cosmetic outcome. METHODS: We conducted a prospective, multicenter, randomized clinical trial in which women undergoing cesarean delivery via low transverse skin incisions were allocated to skin closure with suture or staples. Patients were asked to rate their satisfaction with closure method and with skin cosmesis using a Likert scale. We used a validated scar assessment tool (the Patient and Observer Scar Assessment Scale with subjective and objective components) to evaluate cosmetic outcome. To minimize interobserver variability, we limited cosmetic outcome assessments to the primary research site. Standardized assessments were performed by one of seven trained clinicians who were blinded to the skin-closure technique. RESULTS: A total of 746 women were randomized from 2010–2012: satisfaction data were available for 606 (81%). Overall satisfaction with closure method and satisfaction with skin cosmesis were significantly higher in women who received suture closure (Table 1). There was a positive correlation between cosmetic satisfaction and overall satisfaction. Both the subjective and objective components of the Patient and Observer Scar Assessment Scale favored suture.CONCLUSION: Suture closure was associated with greater patient satisfaction and improved patient and physician cosmetic assessments as compared with staple closure of the skin incision at cesarean delivery.

Caesarean myomectomy: Victor Bonney reports the first case in 1913

In the early 20th century, maternal mortality with caesarean section was as high as 2%. Victor Bonney (1872–1953), a fellow ad eundem of the Royal College of Obstetricians and Gynaecologists, was brave to attempt a caesarean myomectomy at that time. BJOG reported Bonney's case Figure 1, which he claimed was a first. He performed a caesarean and removed six fibroids in a 30-year-old nulliparous woman with ‘fibroids of the uterus, complicated by pregnancy’ (Bonney V. J Obstet Gynaecol Br Emp 1913;24:311–2). He also advocated trial of vaginal birth in these cases, referring to a mother who ‘safely passed through three subsequent pregnancies’ with a uterine scar. He warned of the risk of scar rupture, drawing attention to ‘faulty suturing or weak union on account of sepsis’. Proud of his achievement, he subsequently presented the caesarean myomectomy case at the Royal Society of Medicine (Bonney V. Proc R Soc Med 1914;7:121–3). Fast forward a hundred years. Today caesareans are safe, even available on demand. Myomectomy at caesareans is rare, and is only carried out by senior surgeons in exceptional cases (Rich DA et al. BJOG 2002;109:105–6). Caesarean rates have skyrocketed, and many professional organisations have issued guidelines to reduce their use. Trials of vaginal birth are promoted after caesarean delivery. Even though low transverse uterine incisions have replaced the more risky vertical incisions originally used, rupture of the uterine caesarean scar in a subsequent pregnancy remains its most serious complication. Making trial of vaginal birth after caesarean safer and understanding reasons for its failure are the current questions our profession faces. In this BJOG issue, a cohort study of 75 086 women attempting vaginal birth after caesarean (Knight H et al. BJOG 2014;121:133–42) shows a two-thirds success rate, and repetition of caesarean during this trial is found to be associated with a history of emergency caesarean, in particular after a failed induction of labour. See the editors' profiles on www.BJOG.org.

Transabdominal cerclage placement in patients with prior uterine incisions: Risk of scar disruption

The object of this study was to describe pregnancy outcomes in women who had a transabdominal cerclage (TAC) placed after a prior uterine incision due to caesarean section or hysterotomy. This is a retrospective observational study of 57 women referred to a maternal–fetal medicine specialist (JES) for TAC placement after a previous uterine incision from 1989–2012. Pregnancy outcomes post-TAC placement are reported, including gestational age at delivery, survival rate and complications directly related to labour and the previous uterine scar. Of 51 women who had a prior uterine incision and were pregnant at TAC, 49 (96.1%) delivered viable infants at a mean gestational age of 35.9 weeks. One patient had intrauterine fetal demise at 16 weeks for causes likely unrelated to TAC and another had uterine rupture associated with a unicornuate uterus and advancing labour at 31 weeks. This study includes women with low transverse incisions, classical uterine incisions and higher order multiples. It was concluded that in women with a prior uterine incision, placement of a TAC is associated with low risk (2%) of uterine rupture.

Uterus-sparing myomectomy for uterine pyomyoma following cesarean section

Uterine myoma complicates approximately 1% of pregnancies [1,2]. Pregnancy complicated by uterine myoma presents various problems throughout the perinatal period, including repeated spontaneous abortions, premature delivery, and disorders at delivery. In recent years, the rate of pregnancies complicated by uterine myoma is thought to have increased, because of the increase in late marriages, or because of an increase in diagnoses as a result of advances in imaging technology, including ultrasound. Some studies have reported patients with uterine myoma complicated by infection. However, among these patients, cases of pyomyoma in which the myoma was filled with ichorous pus, were rare. Since 1945, only 13 patients with pyomyoma that occurred during pregnancy and the puerperium were reported [3]. Among these patients, four underwent Cesarean section (C-section) [3e5]. Moreover, for most of these cases, the only option was total abdominal hysterectomy. Here, we report a patient with an infected uterine myoma that developed after a C-section that was indicated for a pregnancy complicated by uterine myoma. After the pyomyoma was discovered during open surgery, myomectomy was performed to conserve the uterus. The patient was a 36-year-old nulligravida, with no significant past or family history. At week 6 of her pregnancy, a transvaginal ultrasound revealed a 13 cm uterine myoma involving the muscle layer and the fetal sac in the uterine cavity. The rest of the pregnancy was uneventful, and the myoma did not increase in size. At week 37 day 6, the patient underwent abdominal C-section at the pelvic level. A baby girl was delivered through a low transverse incision of the uterus. The infant’s weight was 2512 g, the 1-minute Apgar score was 9, and the 5-minute Apgar score was 10. The volume of intraoperative blood loss was 690 mL, which included

Surgical Staples Compared With Subcuticular Suture for Skin Closure After Cesarean Delivery

To compare the risk of cesarean wound disruption or infection after closure with surgical staples compared with subcuticular suture. Women with viable pregnancies at 24 weeks of gestation or greater undergoing scheduled or unscheduled cesarean delivery were randomized to wound closure with surgical staples or absorbable suture. Staples were removed at postoperative days 3-4 for low transverse incisions and days 7-10 for vertical incisions. Standardized wound evaluations were performed at discharge (days 3-4) and 4-6 weeks postoperatively. The primary outcome was a composite of wound disruption or infection within 4-6 weeks. Secondary outcomes included operative time, highest pain score on analog scale, cosmesis score, and patient scar satisfaction score. Analyses were by intent to treat. Of 398 patients, 198 were randomized to staples and 200 to suture (but four received staples). Baseline characteristics including body mass index, prior cesarean delivery, labor, and type of skin incision were similar by group. The primary outcome incidence at hospital discharge was 7.1% for staples and 0.5% for suture (P<.001, relative risk 14.1, 95% confidence interval [CI] 1.9-106). Of 350 (87.9%) with follow-up at 4-6 weeks, the cumulative risk of the primary outcome at 4-6 weeks was 14.5% for staples and 5.9% for suture (P=.008, relative risk 2.5, 95% CI 1.2-5.0). Operative time was longer with suture closure (median time of 58 versus 48 minutes; P<.001). Pain scores at 72-96 hours and at 6 weeks, cosmesis score, and patient satisfaction score did not differ by group. Staples closure compared with suture is associated with significantly increased composite wound morbidity after cesarean delivery. : ClinicalTrials.gov, www.clinicaltrials.gov, NCT01008449. : I.

The professional responsibility model of obstetric ethics and caesarean delivery

In this chapter, we provide an account of the professional responsibility model of obstetric ethics, and identify its implications for two major topics: patient-choice caesarean delivery and trial of labour after caesarean delivery. The professional responsibility model of obstetric ethics is based on the ethical concept of medicine as a profession and the ethical principles of beneficence and respect for autonomy. The obstetrician has beneficence-based and autonomy-based obligations to the pregnant woman and beneficence-based obligations to the fetus when it is a patient. Because the viable fetus is a patient, the ethics of caesarean delivery requires balancing of obligations to the pregnant and fetal patient. The implication of the professional responsibility model for patient-choice caesarean delivery is that the obstetrician should respond to such requests with a recommendation against non-indicated caesarean delivery and for vaginal delivery. These recommendations should be explained and discussed in the informed consent process. It is ethically permissible to implement an informed, reflective decision for non-indicated caesarean delivery. The implication for trial of labour after caesarean delivery is that, in settings properly equipped and staffed, the obstetrician should offer both trial of labour after caesarean delivery and planned caesarean delivery to women who have had one previous low transverse incision. The obstetrician should recommend against trial of labour after caesarean delivery for women with a previous classical incision.

Birth injury after cesarean section at 24 weeks of gestation: a large scalp laceration

Cesarean section (CS), compared with vaginal delivery, has a lower incidence of neonatal birth injury. Previously, we reported a femur fracture after term CS in this journal [1]. In a pregnant woman with chronic abruption oligohydramnios sequence, CS was performed at 24 weeks under general anesthesia due to continued oligohydramnios and elevated C-reactive protein level (4.5 mg/dL). The obstetrician had 20 years of experience. Being in head presentation, lower segment transverse incision was made with surgical knife: the incision was stopped before entering the uterine cavity to avoid direct injury to the fetal scalp. The uterine cavity was entered with a finger and the incision was extended laterally by both index fingers (Fig. 1a). Then the doctor recognized something ‘‘white’’ just beneath the fingers. In retrospect, it was the skull bone: the scalp skin may have been lacerated by the fingers, sliding off from the underlying skull bone (Fig. 1b). This was well reconstructed. Bleeding from the laceration was slight, requiring no blood transfusion. Extra-or-subdural hematoma or intra-ventricular hemorrhage was absent. The infant, weighing 544 g with Apgar score 4/7 (1/5 min), died the next day due to prematurity. Autopsy was not performed. The scalp laceration itself was not considered to have influenced the outcome. Another similar experience: a scalp laceration in an infant after 23 weeks’ CS. Oligohydramnios due to premature rupture of the membranes and signs of intrauterine infection required CS. The fetal head was deeply engaged and thus the hand was put deeply into the uterine cavity, pulling out the fetal head with the fingers. In retrospect, the scalp, being pushed and possibly scratched by the fingers, was lacerated at the parietal area. The infant died next day due to prematurity. The laceration was not considered to have influenced the outcome. There is a close similarity between the two patients: preterm CS, oligohydramnios, and intrauterine infections. A previous report [2] also showed that ruptured membranes and thus oligohydramnios were the risk factors of fetal scalp laceration, in which, however, infants suffering laceration were almost term infants (average of 38.67 weeks), with the earliest and the lightest being 29 weeks and 825 g of birth weight, respectively. Its context was that obstetricians should avoid direct injury to the fetal scalp with the knife or scalpel [2]. The present significance is different: pushing or scratching the scalp skin with fingers was the considered culprit. Skin and the underlying skull bone, especially at the parietal area, are more loosely connected than skin and other body parts such as the extremities or the trunk. This is more exaggerated in preterm infants. Intra-uterine infection, weakening the skin, may also have caused scalp laceration. Oligohydramnios, pushing the fetal head tightly to the uterine wall, obliged the obstetrician to put fingers into the narrow space between the fetal head and the uterine wall, which may also have caused this injury. The CS procedure was performed gently, considering the infant’s prematurity; however, a much gentler maneuver S. Matsubara (&) R. Usui Department of Obstetrics and Gynecology, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan e-mail: matsushi@jichi.ac.jp

Reverse breech extraction in cases of second stage caesarean section

Our objective was to examine the feasibility of reverse breech extraction to disengage fetal head from the pelvis at second stage caesarean section (CS). A total of 50 consecutive women with singleton term pregnancies undergoing urgent CS at second stage were retrospectively evaluated. A total of 29 were delivered by the reverse breech manoeuvre (study group) and 21 women were delivered by the conventional approach (control group). The reverse breech extraction was successful in all cases of the study group. The mean estimated blood loss during operation, haemoglobin drop, Apgar scores at 1 and 5 min as well as cord PH were similar between the groups. The mean newborn weights were similar, 3492 ± 426 and 3610 ± 392 g in the study and control group, respectively. One case of an inadvertent extension of the low transverse incision was encountered in each group. Also, in three cases of the study group the incision was intentionally extended to an inverted T-shape to facilitate the manoeuvre. None of the newborns in both groups had trauma related to the extraction or were admitted to the neonatal intensive care unit. All women following CS had a low rate complication rate in the postpartum period. We conclude that reverse breech extraction seems to be feasible to disengage fetal head from the pelvis at second stage CS. Maternal and newborn complications following this manoeuvre seem to be low.

Elective repeat cesarean delivery compared with spontaneous trial of labor after a prior cesarean delivery: a propensity score analysis

The purpose of this study was to determine outcomes, after the use of propensity score techniques, to create balanced groups according to whether a woman undergoes elective repeat cesarean delivery (ERCD) or trial of labor (TOL). Women who were eligible for a TOL with 1 previous low transverse incision were categorized according to whether they underwent an ERCD or TOL. A propensity score technique was used to develop ERCD and TOL groups with comparable baseline characteristics. Outcomes were assessed with conditional logistic regression. The rates of endometritis, operative injury, respiratory distress syndrome, and newborn infant infection were lower and the rates of hysterectomy and wound complication were higher in the ERCD group. Propensity score techniques can be used to generate comparable ERCD and TOL groups. Some types of maternal morbidity (such as hysterectomy) are higher; other types (such as operative injury) are lower in the ERCD group. Although the absolute risk is low, neonatal morbidity appears to be lower in the ERCD group.

Does obesity complicate perioperative course in patients undergoing abdominal hysterectomy?

Obesity is traditionally believed to increase the incidence of perioperative complications in abdominal surgery. Recently this paradigm has been challenged mainly by observations from surgical specialties other than gynecology. Our aim was to assess the impact of obesity on perioperative course in women undergoing total abdominal hysterectomy. We analyzed medical charts of 126 patients who underwent total abdominal hysterectomy for benign gynecological conditions through a low transverse incision in the Department of Obstetrics and Gynecology of the Provincial Specialist Hospital in Czestochowa, Poland. Perioperative course was compared between obese [n = 55; body mass index (BMI) ≥ 30 kg/m(2): mean 32.6 ± 3.2 kg/m(2)] and non-obese patients (n = 71; mean BMI 24.3 ± 3 kg/m(2)). The mean operative time in obese women was significantly prolonged (112 ± 32 vs. 100 ± 31 min, P = 0.036). However, complication rates and other perioperative outcomes were comparable between the groups. In our study, mild obesity does not significantly affect the perioperative course in women undergoing total abdominal hysterectomy.

Risk factors for wound complications in morbidly obese women undergoing primary cesarean delivery

Objective: To determine factors influencing separation and infectious type wound complications (WCs) in morbidly obese women undergoing primary cesarean delivery (CD). Methods: Retrospective cohort study evaluating infectious and separation WC in morbidly obese (body mass index [BMI] > 35 kg/m2) women undergoing primary CD between January 1994 and December 2008. Chi-square, Fisher’s exact and Student’s t tests used to assess associated factors; backward logistic regression to determine unadjusted and adjusted odds ratios. Results: Of 623 women, low transverse skin incisions were performed in 588 (94.4%), vertical in 35 (7%). Overall WC rate was 13.5%, which varied by incision type (vertical 45.7% vs. 11.6% transverse; p < 0.01), but not BMI class. Incision type and unscheduled CD were associated with infection risk, while incision type, BMI, race and drain use were associated with wound separation. Conclusion: In morbidly obese women both infectious and separation type WC are more common in vertical than low transverse incisions; therefore transverse should be preferred.

Cesarean section in morbidly obese parturients: practical implications and complications.

The prevalence of obesity has reached pandemic proportions across nations. Morbid obesity has a dramatic impact on pregnancy outcome. Cesarean section in these women poses many surgical, anesthetic, and logistical challenges. In view of the increased risk of cesarean delivery in morbidly obese women, the practical implications and complications are reviewed in this article. A Medline search was conducted to review the recent relevant articles in english literature on cesarean section in morbidly obese women. The types of incisions and techniques used during cesarean delivery, intra-operative and postpartum complications, anesthetic and logistical issues, maternal morbidity and mortality were reviewed. Morbidly obese women with a body mass index (BMI >40 kg/m2 are at increased risk of pregnancy complications and a significantly increased rate of cesarean delivery. Low transverse skin incisions and transverse uterine incisions are definitely superior and must be the first option. Closure of the subcutaneous layer is recommended, but the placement of subcutaneous drains remains controversial. Thromboprophylaxis adjusted to body weight and prophylactic antibiotics help in reducing postpartum morbidity. Morbidly obese women are at increased risk of postpartum infectious morbidity. Weight reduction in the postpartum period and thereafter must be strongly encouraged for optimal future pregnancy outcomes and well-being.

Low dose intrathecal morphine effects on post‐hysterectomy pain: a randomized placebo‐controlled study

Spinal anesthesia with different doses of intrathecal morphine has been shown to relieve post-operative pain. We studied in a prospective randomized, double-blind fashion the effects of morphine 0, 100, 200, or 300 μg added to intrathecal bupivacaine on first post-operative 24 h patient-controlled analgesia morphine (PCA-morphine) consumption after abdominal hysterectomy under general anesthesia. One hundred and forty-four American Society of Anesthesiologists I-II women were assigned to receive spinal anesthesia with 12 mg of hyperbaric bupivacaine combined with 100, 200, and 300 μg morphine or saline before standardized general anesthesia was induced. Low transverse incision abdominal hysterectomy was performed. Post-operative outcome measures were recorded at 1, 2, 4, 6, 12, and 24 h. Primary outcome was 24 h PCA-morphine. Secondary outcomes were pain by visual analogue scale (0-10), nausea, pruritus, sedation, and respiratory depression. Intrathecal morphine reduced accumulated 24 h post-operative morphine consumption. Morphine 100 μg significantly reduced morphine consumption vs. placebo at 0-6 h, 6-12 h, and for the entire 0-24 h time interval post-operation. Morphine 200 μg further significantly reduced morphine consumption vs. morphine 100 μg at 0-6 h and for the entire 0-24 h post-operation. There was no further reduction of morphine consumption seen with morphine 300 μg. No serious side effects were seen. Emesis was similar in all groups, and pruritus was experienced only in the morphine groups. Intrathecal morphine supplementation to bupivacaine reduces first 24 h PCA-morphine consumption after abdominal hysterectomy under general anesthesia, and we found no benefit from increasing the dose over 200 μg.

Intestinal adhesion due to previous uterine surgery as a risk factor for delayed diagnosis of uterine rupture: a case report

IntroductionUterine rupture is a life-threatening condition both to mothers and fetuses. Its early diagnosis and treatment may save their lives. Previous myomectomy is a high risk factor for uterine rupture. Intestinal adhesion due to previous myomectomy may also prevent early diagnosis of uterine rupture.Case presentationA 38-year-old primiparous non-laboring Japanese woman with a history of myomectomy was admitted in her 34th week due to lower abdominal pain. Although the pain was slight and her vital signs were stable, computed tomography revealed massive fluid collection in her abdominal cavity, which led us to perform a laparotomy. Uterine rupture had occurred at the site of the previous myomectomy; however, the small intestine was adhered tightly to the rupture, thus masking it. The baby was delivered through a low uterine segment transverse incision. The ruptured uterine wall was reconstructed.ConclusionIntestinal adhesion due to a prior myomectomy occluded a uterine rupture, possibly masking its symptoms and signs, which may have prevented early diagnosis.