Uterine Rupture In Second Trimester Research Articles

EP20.36: Complete uterine rupture in second trimester

EP20.36: Complete uterine rupture in second trimester

Uterine Rupture in Second Trimester Due to Misoprostol Use: A Case Report and Literature Review

Uterine Rupture in Second Trimester Due to Misoprostol Use: A Case Report and Literature Review

Intravesical fetus after second-trimester uterine rupture: a case report

Background: Second-trimester miscarriage can be managed by surgical or medical methods, which are generally safe. However, rare but life-threatening complications like rupture of the uterus might occur; which may present atypically. Case presentation: A 31-year-old multigravida woman with a history of prior four cesarean deliveries presented with a missed miscarriage at 16 weeks gestation. After proper counseling, she opted to proceed with medical management with misoprostol. Six hours after the fifth dose the patient started to complain of hematuria. Ultrasound scan showed an empty uterus with the fetus inside the urinary bladder. Laparotomy was done revealing a ruptured uterus at the site of the previous scar, with the fetus and placenta inside the urinary bladder. Conclusion: Second-trimester uterine rupture may have atypical presentation. High index of suspicion, guided by imaging techniques, is essential for early diagnosis to reduce maternal morbidity.

Outcome of Cesarean scar pregnancy managed expectantly: systematic review and meta-analysis.

To explore the outcome in women managed expectantly following the diagnosis of Cesarean scar pregnancy (CSP). An electronic search of MEDLINE, EMBASE and ClinicalTrials.gov databases was performed utilizing combinations of relevant medical subject headings for 'Cesarean scar pregnancy' and 'outcome'. Reference lists of relevant articles and reviews were hand-searched for additional reports. Observed outcomes included: severe first-trimester vaginal bleeding; clinical symptoms (abdominal pain, vaginal bleeding) requiring treatment; uncomplicated miscarriage; complicated miscarriage requiring intervention; first- or second-trimester uterine rupture or hysterectomy; third-trimester bleeding, uterine rupture or hysterectomy; maternal death; incidence of abnormally invasive placenta (AIP); prevalence of placenta percreta; ultrasound signs suggestive of AIP; and live birth. Meta-analyses of proportions using a random-effects model were used to combine data. Cases were stratified based on the presence or absence of embryonic/fetal heart activity at the time of diagnosis. A total of 17 studies (69 cases of CSP managed expectantly, 52 with and 17 without embryonic/fetal heart beat) were included. In women with CSP and embryonic/fetal heart activity, 13.0% (95% CI, 3.8-26.7%) experienced an uncomplicated miscarriage, while 20.0% (95% CI, 7.1-37.4%) required medical intervention. Uterine rupture during the first or second trimester of pregnancy occurred in 9.9% (95% CI, 2.9-20.4%) of cases, while hysterectomy was required in 15.2% (95% CI, 3.6-32.8%) of all cases. Forty (76.9% (95% CI, 65.4-86.5%)) women progressed to the third trimester of pregnancy, of whom 39.2% (95% CI, 15.4-66.2%) experienced severe bleeding. Finally, 74.8% (95% CI, 52.0-92.1%) had a surgical or pathological diagnosis of AIP at delivery and around two-thirds (69.7% (95% CI, 42.8-90.1%)) of them had placenta percreta. In women with CSP but no embryonic/fetal cardiac activity, an uncomplicated miscarriage occurred in 69.1% (95% CI, 47.4-87.1%) of cases, while surgical or medical intervention during or immediately after miscarriage was required in 30.9% (95% CI, 12.9-52.6%). Uterine rupture during the first trimester of pregnancy occurred in 13.4% (95% CI, 2.7-30.3%) of cases, but hysterectomy was not required in any case. CSP with positive embryonic/fetal heart activity managed expectantly is associated with a high burden of maternal morbidity including severe hemorrhage, early uterine rupture, hysterectomy and severe AIP. Despite this, a significant proportion of pregnancies complicated by CSP may progress to, or close to, term, thus questioning whether termination of pregnancy should be the only therapeutic option offered to these women. Expectant management of CSP with no cardiac activity may be a reasonable option in view of the low likelihood of maternal complications requiring intervention, although close surveillance is advisable to avoid adverse maternal outcome. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

The Importance of Initial Evaluation by Trans Vaginal Sonography in Rudimentary Horn Pregnancy: A Case Report and Literature Review

Rudimentary horn pregnancy (RHP) as a rare incidence has been estimated at 1:76,000- 1:150,000 pregnancies. It has been also reported that 80-90% of RHP lead to uterine rupture in second trimester. Early diagnosis with the use of 3-dimentional ultrasonography (3-DUS) that is followed by laparoscopic resection of RH and ipsilateral fallopian tube is likely to be considered as the best management strategy that prevents maternal morbidity and mortality. We present a case of 9-week pregnancy in a non-communicating rudimentary horn with positive fetal heart rate (FHR) that was diagnosed by 3-DUS and successfully treated with laparoscopic resection.

Placenta Percreta Causing Rupture of Uterus in Second Trimester of Pregnancy in Non Scarred Uterus with an Unusual Presentation: A Case Report and Review of Literature

Placenta percreta causing second trimester, spontaneous uterine rupture in non high risk women is less frequent and fewer cases have been reported in the literature. We report a case of uterine rupture in second trimester of pregnancy due to placenta percreta with non specific symptoms in otherwise uncomplicated pregnancy without any high risk factors. This case report describes the case of young woman presenting second gravid with 21 weeks pregnancy with complaints of whole abdomen pain and dysuria. Ultrasonography shows single intrauterine dead fetus; placenta was fundoposterior in upper segment, a hypoechoic area seen below the placenta suggestive of abruption placentae or placenta accreta. Suddenly patient deteriorated in two hours of hospital stay, frank hemoperitoneum detected, emergency laparotomy done, per operatively whole fundal area of uterus became papery thin and cystic on touch, a small rent seen on fundal surface of uterus. The placenta was densely adhered to the fundoposterior aspect of the uterus. Patient had emergency subtotal hysterectomy. This case highlights that placenta percreta is a rare but serious complication of pregnancy which may present in early pregnancy without any associated high risk factors for placenta percreta with unusual symptoms.

Spontaneous uterine rupture following intercourse

Uterine rupture in the second trimester is rare (1), with most cases being associated with terminations (2). In only one case report did the second-trimester uterine rupture follow intercourse (1). We present a case of spontaneous uterine rupture at 18 weeks' gestation that immediately followed intercourse in a patient with a previous uterine scar. A 34-year-old woman, gravida 2, para 1, presented at 18 weeks' gestation with severe abdominal pain of 1 h duration. Her pain immediately followed intercourse and became diffuse within 30 min. It was associated with left shoulder pain but not with vaginal bleeding, fluid leak, nausea or vomiting. Her previous pregnancy required a primary low segment transverse cesarean for breech presentation, following which she became pregnant 4 months postpartum. On admission, she was pale with perioral cyanosis and pulse 84 beats/min and blood pressure (BP) 90/60 mmHg. She had direct tenderness over the uterus without rebound or guarding and bowel sounds were audible. Ultrasound of the pelvis documented a positive fetal heart activity, and the uterus showed an ill-defined contour with a significant amount of fluid surrounding it and extending to occupy the perihepatic space, so uterine rupture was suspected. Hemoglobin (Hb) was 11.3 g/dL. Despite fluid resuscitation, BP continued to drop, so she was taken to the operating room for an exploratory laparotomy. The uterus was found to be ruptured at the site of the previous scar, extending 4 cm from the right angle, with approximately 2 L of fresh and clotted blood in the abdominal cavity. The gestational sac containing the fetus was extracted intact. The placenta was implanted on the scar but could be removed easily. Repair of the scar was performed in two layers. Her postoperative course was uneventful and she was discharged on the third postoperative day. Placental pathology was normal. Uterine rupture at term in women with a previous uterine scar is well described in the literature, but it can also occur, though less frequently, before the third trimester. A MEDLINE search from 1972 to July 2002 using the keywords “second trimester” and “uterine rupture” identified no more than 10 cases where the rupture occurred spontaneously without the concomitant use of uterotonic agents and in the absence of placenta percreta, which is recognized as a possible cause of uterine rupture (3). In one case report, as in our case, the abdominal pain started after intercourse (1). The exact role of sexual intercourse in the initiation of labor is still unclear. It is well known that stimulation of the nipples and clitoris and ultimately orgasm, which causes a wave of contractions throughout the uterus, stimulate the endogenous release of oxytocin. On the other hand, seminal plasma contains large quantities of prostaglandin D synthase and semen is presumed to be the biological source that has the highest prostaglandin concentration (4). All of these factors may induce contractions in a susceptible uterus, especially taking into consideration the short interval between the previous cesarean delivery and conception in our patient, a factor that has been associated with a threefold increased risk of symptomatic uterine rupture (5). Second-trimester uterine rupture is a surgical emergency that should be recognized promptly as delay in diagnosis can have catastrophic consequences. Although intercourse cannot be directly implicated as a cause of uterine rupture, the close proximity of the intercourse to the rupture and its hypothetical role in labor initiation led us to hypothesize that in our case, the uterine rupture was probably induced by intercourse. Therefore, the differential diagnosis for any pregnant woman presenting with acute abdominal pain in the context of a prior uterine scar, especially if this followed intercourse, should include uterine rupture, regardless of the gestational age. Anwar H. Nassar Department of Obstetrics and Gynecology American University of Beirut Medical Center PO Box 113-6044/B36 Beirut Lebanon e-mail: an21@aub.edu.lb

Richard Bunge.

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