Uterine Rupture Research Articles

РАЗРЫВ НЕОПЕРИРОВАННОЙ МАТКИ В ПЕРВОЙ ПОЛОВИНЕ БЕРЕМЕННОСТИ: КЛИНИЧЕСКОЕ НАБЛЮДЕНИЕ

Abstract. Introduction. Uterine rupture is a rare and life-threatening complication for patient and fetus. This pathology is mostly associated with pregnancy and occurs in late preterm periods, but there are also some cases of non-pregnant uterus ruptures described. Aim. This study is aimed at showing and analyzing the importance of uterine ruptures, even without any uterine scars and in the first half of pregnancy. Materials and Methods. This paper describes the clinical case of a multigravida patient with the rupture of unscarred uterus in the second trimester of pregnancy. Results and Discussion. A 32-year-old female patient was admitted to the department of gynecology at the gestational age of 16 weeks, complaining of severe abdominal pains, with the signs of intraabdominal bleeding. Histopathic rupture of the uterus was detected in the emergency laparotomy. Conclusions. Absence of uterine scars does not prevent from potential rupture of the uterus Timely diagnosis is necessary, and an emergency surgical intervention must be performed to save the patient’s life at any suspicion on uterine rupture. Even with early pregnancies, uterine rupture risks must be considered, especially regarding women with a history of uterine cavity surgeries. There is a question of the necessity to perform elective hysteroscopy during pregnancy planning to patients with the past history of uterine curettage

Placenta Accreta Spectrum Disorders - The Impact of the Creation of a Multidisciplinary Team on Maternal Outcomes in Portugal.

To describe a cohort of placenta accreta spectrum (PAS) cases from a tertiary care institution and compare the maternal outcomes before and after the creation of a multidisciplinary team (MDT). Retrospective study using hospital databases. Identification of PAS cases with pathological confirmation between 2010 and 2021. Division in two groups: standard care (SC) group - 2010-2014; and MDT group - 2015-2021. Descriptive analysis of their characteristics and maternal outcomes. During the study period, there were 53 cases of PAS (24 - SC group; 29 - MDT group). Standard care group: 1 placenta increta and 3 percreta; 12.5% (3/24) had antenatal suspicion; 4 cases had a peripartum hysterectomy - one planned due to antenatal suspicion of PAS; 3 due to postpartum hemorrhage. Mean estimated blood loss (EBL) was 2,469 mL; transfusion of packed red blood cells (PRBC) in 25% (6/24) - median 7.5 units. Multidisciplinary team group: 4 cases of placenta increta and 3 percreta. The rate of antenatal suspicion was 24.1% (7/29); 9 hysterectomies were performed, 7 planned due to antenatal suspicion of PAS, 1 after intrapartum diagnosis of PAS and 1 after uterine rupture following a second trimester termination of pregnancy. The mean EBL was 1,250 mL, with transfusion of PRBC in 37.9% (11/29) - median 2 units. After the creation of the MDT, there was a reduction in the mean EBL and in the median number of PRBC units transfused, despite the higher number of invasive PAS disorders.

#367 : The Use of Intrauterien Balloon Therapy in Reproductive Medicine and Surgery

Background and Aims: The use of balloon therapy in obstetric practice, especially in postpartum haemorrhage is well established and has recently been reviewed. However, little attention has been drawn regarding the use of intrauterine balloon (IUB) in gynaecological practice. This study focuses on the various usage of IUB in gynaecological practice. Methods: An electronic literature search through Medline, EMBASE and Clinicaltrial.gov from inception to August 2022 was conducted with mesh combinations of the following keywords: balloon, uterus, gynaecology, Foley catheter, complication, tamponade, hysteroscopy and laparoscopy. Results: The study focuses on the 3 following areas: (1) Indications: prevention & removal of intrauterine adhesions, management of ectopic pregnancy, facilitation of endoscopic surgery and other clinical usages; (2) Practical aspects of balloon therapy including ultrasound guidance, choice of balloon, inflation volume, duration of balloon therapy; and (3) Potential complications including pain, infection, uterine rupture and how they can be avoided. Conclusions: IUB therapy is a simple, inexpensive and effective method that can be applied in various gynaecological conditions ranging from IUA to intrauterine haemorrhage. Complications are rare, but in most cases can be avoided with correct use.

Maternal education and its association with maternal and neonatal adverse outcomes in live births conceived using medically assisted reproduction (MAR)

BackgroundTo examine the association between maternal education and adverse maternal and neonatal outcomes in women who conceived using medically assisted reproduction, which included fertility medications, intrauterine insemination, or in vitro fertilization.MethodsWe conducted a retrospective cohort study utilizing the US Vital Statistics data set on national birth certificates from 2016 to 2020. Women with live, non-anomalous singletons who conceived using MAR and had education status of the birthing female partner recorded were included. Patients were stratified into two groups: bachelor’s degree or higher, or less than a bachelor’s degree. The primary outcome was a composite of maternal adverse outcomes: intensive care unit (ICU) admission, uterine rupture, unplanned hysterectomy, or blood transfusion. The secondary outcome was a composite of neonatal adverse outcomes: neonatal ICU admission, ventilator support, or seizure. Multivariable modified Poisson regression models with robust error variance adjusted for maternal age, race, marital status, prenatal care, smoking during pregnancy, neonatal sex, and birth year estimated the relative risk (RR) of outcomes with a 95% confidence interval (CI).Results190,444 patients met the inclusion criteria: 142,943 had a bachelor’s degree or higher and 47,501 were without a bachelor’s degree. Composite maternal adverse outcomes were similar among patients with a bachelor’s degree (10.1 per 1,000 live births) and those without a bachelor’s degree (9.4 per 1,000 live births); ARR 1.05, 95% CI (0.94–1.17). However, composite adverse neonatal outcomes were significantly lower in women with a bachelor’s degree or higher (94.1 per 1,000 live births) compared to women without a bachelor’s degree (105.9 per 1,000 live births); ARR 0.91, 95% CI (0.88–0.94).ConclusionsOur study demonstrated that lower maternal education level was not associated with maternal adverse outcomes in patients who conceived using MAR but was associated with increased rates of neonatal adverse outcomes. As access to infertility care increases, patients who conceive with MAR may be counseled that education level is not associated with maternal morbidity. Further research into the association between maternal education level and neonatal morbidity is indicated.

Factors Associated with Maternal Near-Miss (MNM) Among Women in Eastern Province, Rwanda

The World Health Organization (WHO) defines Maternal Near-Miss (MNM) as a situation where a woman nearly dies but survives a life-threatening condition during pregnancy and childbirth. Maternal mortality rate, used to gauge obstetric care quality globally, can aid in achieving the SDG target 3.1, which aims to lower the global maternal mortality ratio below 70 per 100,000 live births. A retrospective cross-sectional design was employed to assess the prevalence and factors associated with MNM at Kirehe District Hospital in Rwanda. 350 women admitted to the hospital's maternity units from January to December 2020 were sampled. Data from patients' medical records was extracted, focusing on demographics, MNM characteristics based on WHO criteria, and clinical outcomes. Statistical analysis was performed with SPSS version 21. Women aged 20-29 constituted the majority, primarily with primary education and working in agriculture. From the 350, 6.3% encountered severe postpartum haemorrhage, 3.1% severe preeclampsia, and 2% uterine rupture. 53.7% underwent cesarean section, 38.9% had vaginal deliveries, and 4.9% experienced abortion. The MNM prevalence for 2020 was 10.2%. Age and marital status correlated with MNM; younger, married, or widowed women exhibited higher MNM rates. Among maternal factors, only labor duration significantly related to MNM. The MNM rate at Kirehe District Hospital remains a concern. Cesarean section was predominant. Age and marital status played pivotal roles in MNM occurrences. Access to enhanced maternal healthcare and improved labor monitoring can mitigate severe complications.

MRI Assessment of Cesarean Scar Pregnancies: A Case Series

Cesarean scar pregnancies (CSPs) are a type of ectopic pregnancy that occur when an embryo implants within the fibrous scar tissue of a previous cesarean surgery. If not promptly detected and treated, CSPs can result in serious maternal complications, such as uterine rupture and hemorrhage. TVUS (transvaginal ultrasonography) represents the imaging of choice for the diagnosis of CSPs; however, recent studies proposed a complementary role of MRI due to its capability in soft tissue characterization that may impact the therapeutical decision-making process. The purpose of our study was to explore the role of MRI in the diagnosis and its impact on therapeutical options in CSPs. Our experience showed that MRI has a complementary role to TVSU in correctly diagnosing CSPs, identifying the type, and guiding the therapeutical approach.

Outcome of subsequent pregnancies in women with prior uterine rupture

ObjectiveTo report maternal and neonatal outcomes of subsequent pregnancies in a series of women with a prior uterine rupture. MethodsThe records of all 103,542 deliveries (22,286 by cesarean section) performed in a single tertiary medical center from 2009 to 2021 were reviewed. Women with a prior uterine rupture, defined as a separation of the entire thickness of the uterine wall, with extrusion of fetal parts and intra-amniotic contents into the peritoneal cavity documented in the operative report of the previous cesarean delivery or laparotomy, were identified for inclusion in the study. ResultsThe cohort included 38 women with 50 pregnancies (50 neonates). Women had been scheduled for elective cesarean delivery at early term. Mean gestational age at delivery was 36 + 4 weeks (±5 days). In 7 pregnancies (14 %), spontaneous labor occurred before the scheduled cesarean delivery (at 36 + 6, 35 + 4, 35 + 3, 34 + 6, 34 + 3, 32 + 6 and 31 + 0 gestational weeks). A recurrent uterine scar rupture was found in 4 pregnancies (8 %), and uterine scar dehiscence, in 2 pregnancies (4 %), all identified during elective repeat cesarean delivery. In none of these cases was there a clinical suspicion beforehand; all had good maternal and neonatal outcomes. One parturient with placenta previa-accreta had a planned cesarean hysterectomy. ConclusionWomen with prior uterine rupture have good maternal and neonatal outcomes in subsequent pregnancies when managed at a tertiary medical center, with planned elective term cesarean delivery, or even earlier, at the onset of spontaneous preterm labor.

Uterine rupture due to adenomyosis in an adolescent: A case report and review of literature

BACKGROUND Uterine rupture is a fatal medical complication with a high mortality rate. Most cases of uterine rupture occur in late pregnancy or during labor and are mainly related to uterine scarring due to previous surgical procedures. Adenomyosis is a possible risk factor for uterine rupture. However, spontaneous uterine rupture due to severe adenomyosis in a non-gravida-teenaged female has not been reported in the literature to date. CASE SUMMARY A 16-year-old girl was referred to our hospital for acute abdominal pain and hypovolemic shock with a blood pressure of 90/50 mmHg. Radiologic studies revealed a huge endometrial mass with multiple nodules in the lung, suggesting lung metastasis. The patient underwent an emergency total hysterectomy and wedge resection of the lung nodules. Histologically, the uterus showed diffuse adenomyosis with glandular and stromal dissociation. Lung nodules were endometrioma with massive hemorrhage. Immunohistochemistry demonstrated that the tumor cells were positive for PAX8, ER, and PR expression, leading to a final diagnosis of pulmonary endometriosis and uterine adenomyosis. Following surgery, the patient remains in good condition without recurrence. CONCLUSION This is the first case of spontaneous uterine rupture due to adenomyosis in a non-gravida adolescent.

Notable Stingray Spine-Associated Strandings Involving Two Female Bottlenose Dolphins in Florida and Massachusetts, USA, in the Context of Literature and Database Reviews

Trauma from stingray spines (caudal barbs) has been intermittently documented as a cause of mild to fatal illness in odontocetes, particularly bottlenose dolphins (Tursiops truncatus), as well as in pinnipeds, sirenians, the loggerhead sea turtle, great white shark, and cobia. Although stingray spines have been noted to cause serious injury to various organ systems, their potential involvement in cetacean reproductive tract pathology has not been previously described. In North America, published descriptions of wild cetacean strandings associated with stingray spines have all involved bottlenose dolphins in the southeastern United States, plus a bottlenose dolphin and a common dolphin (Delphinus delphis) in Mexico. In 2018, uterine rupture was observed in a gravid bottlenose dolphin found deceased in Florida with stingray spine penetration into the abdominal cavity. Gross necropsy and histopathology findings were compatible with the stingray spine being involved with the rupture. To provide fuller insight into the case, a scientific literature review was conducted, and results of an unpublished 1998 necropsy involving a coastal female bottlenose dolphin that stranded in the northeastern state of Massachusetts with stingray spine presence was reviewed. Additionally, a query of the nationwide U.S. marine mammal stranding database was conducted for stingray spine-associated cetacean strandings from 1995 to 2019. Of 61 cetacean strandings revealed in the query to involve stingray spine presence, 59 were bottlenose dolphins from the southeastern U.S. states, plus Puerto Rico and Virginia; a bottlenose dolphin in southern California and a short-finned pilot whale (Globicephala macrorhynchus) were also noted. Query results did not support a bottlenose dolphin sex predilection for stingray spine-associated strandings; most such strandings involved adults. Behavioral, environmental, anthropogenic, and climatic events may influence marine mammal–stingray interactions. Continued vigilance for stingray spine-associated pathologic changes is warranted during marine mammal stranding investigations at diverse geographic sites.

The incidence, indications, risk factors and pregnancy outcomes of peripartum hysterectomy at a tertiary hospital between 2013 and 2022.

To analyze the incidence, indications, risk factors and pregnancy outcomes of postpartum hemorrhage resulting in peripartum hysterectomy (PH). We retrospectively reviewed patients with postpartum hemorrhage requiring surgical procedures at ≥ 28weeks of gestation from January 1, 2013 to December 31, 2022 at a tertiary hospital in Shanghai, China. The patients were divided into a PH group and a non-PH group. Maternal clinical characteristics, the management of postpartum hemorrhage, pregnancy outcomes were compared between groups. Logistic regression was used to analyze the correlations between risk factors and PH. The incidence of hysterectomy was 0.2/1000 deliveries (31/150194). The variables significantly associated with PH were placenta previa with placenta increta/percreta (OR36.26), uterine rupture (OR266.16) and an estimated blood loss ≥ 3513mL (OR431.11). The proportion of cases involving hemorrhagic shock, disseminated intravascular coagulation, bladder injury, neonatal severe asphyxia, neonatal death and hypoxic-ischemic encephalopathy were significantly higher in the PH group (P < 0.05). The most common indications of PH were placental pathology. Efforts should be made to reduce the rate of cesarean deliveries and uterine curettage to lower the probability of abnormal placental invasion and appropriate medical indications for trial of labor after cesarean should be strictly followed to avoid the risk of uterine rupture.

Safety and Efficacy of Cervical Ripening and Induction of Labor Using Prostaglandin E1 in Primiparas, Multiparas and Grand Multiparas.

To compare the efficacy and safety of cervical ripening and induction of labor with prostaglandin E1 among primiparas, multiparas and grand multiparas. This was a retrospective cohort study. Between January and December 2017, 1713 women underwent cervical ripening and induction of labor with prostaglandin E1: 523 were primiparas, 656 were multiparas, and 534 were grand multiparas. Four hundred and seventy-nine (91.6%) primiparas delivered vaginally as did 640 (97.6%) multiparas and 521 (97.6%) grand multiparas. Forty-four (8.4%) primiparas underwent cesarean delivery compared to 16 (2.4%) multiparas and 13(2.4%) grand multiparas. Induction to delivery interval was significantly longer in primiparas (29.7 ± 22.8h). There were no cases of uterine rupture, and the rates of postpartum hemorrhage and endometritis were similar among the three groups. Neonatal outcomes including Apgar score < 7 and umbilical artery pH < 7.1 were not significantly different between the groups. Using prostaglandin E1 for cervical ripening and labor induction is efficient and safe in primiparas, multiparas and grand multiparas.

Characteristics and outcomes of pregnant women hospitalized with severe maternal outcomes in eastern Ethiopia: Results from the Ethiopian Obstetric Surveillance System study.

The aim of the present study was to identify facility-based incidence of severe obstetric complications through a newly established obstetric surveillance system in eastern Ethiopia. Monthly registration of obstetric hemorrhage, eclampsia, uterine rupture, severe anemia and sepsis was introduced in 13 maternity units in eastern Ethiopia. At each hospital, a designated clinician reported details of women admitted during pregnancy, childbirth or within 42 days of termination of pregnancy from April 01, 2021 to March 31, 2022 developing any of these conditions. Detailed data on sociodemographic characteristics, obstetric complications and status at discharge were collected by trained research assistants. Among 38 782 maternities during the study period, 2043 (5.3%) women had any of the five conditions. Seventy women died, representing a case fatality rate of 3.4%. The three leading reasons for admission were obstetric hemorrhage (972; 47.6%), severe anemia (727; 35.6%), and eclampsia (438; 21.4%). The majority of the maternal deaths were from obstetric hemorrhage (27/70; 38.6%) followed by eclampsia (17/70; 24.3%). Obstetric hemorrhage, severe anemia and eclampsia were the leading causes of severe obstetric complications in eastern Ethiopia. Almost one in 29 women admitted with obstetric complications died. Audit of quality of care is indicated to design tailored interventions to improve maternal survival and obstetric complications.

Current Trends of Alternatives to Hysterectomy in Adenomyosis: A Review Article

Adenomyosis is a common gynecological problem characterized by the growth of endometrial glands and stroma within the myometrium. Previously, the definitive diagnosis of adenomyosis was made through histopathology after a hysterectomy. However, in the last two decades, several uterine-sparing treatment options have emerged, including High-Intensity Focused Ultrasound (HIFU), which has become a promising option. HIFU is a non-invasive local thermal ablation technique that can be performed via ultrasound or MRI guidance. Additionally, “Laparoscopic uterine artery occlusion with uterus sparing pelvic plexus block and partial adenectomy for adenomyosis” has become a popular option. While conventional adenomyomectomy carries a high risk of recurrence and uterine rupture, some novel surgical techniques have been described to mitigate these complications and preserve future fertility. There are also “new surgical techniques of laparoscopic resection of adenomyoma under real-time intraoperative ultrasound elastography guidance”. Diagnostic imaging techniques such as transvaginal ultrasound, MRI, and hysteroscopic evaluation have revolutionized the diagnosis of adenomyosis and opened up possibilities for conservative treatment options. Hysteroscopy can be used for direct visualization and biopsy collection, though it is not the first-line treatment option. With the increasing incidence of adenomyosis and the desire for fertility preservation among younger patients, there is a growing need for effective uterine-sparing treatments. Bangabandhu Sheikh Mujib Med. Coll. J. 2023;2(1): 55-58

Recurrent ipsilateral interstitial ectopic pregnancy after salpingectomy

Introduction: This case highlights the long-term obstetric risks following salpingectomy. These include recurrent ipsilateral interstitial ectopic pregnancy and uterine rupture. Case Report: A 29-year-old lady presented with acute abdominal pain as well as signs and symptoms of hemorrhagic shock at 14 weeks of gestation. She was subsequently diagnosed with a ruptured right-sided interstitial ectopic pregnancy, which was managed surgically. The patient had a past history of open salpingo-oophorectomy for a complicated right-sided ectopic pregnancy involving the ovary at 12 weeks of gestation in her previous pregnancy. A subsequent pregnancy a year later was complicated by impending uterine rupture at 30 weeks of gestation. A healthy baby was delivered by Cesarean section. Conclusion: A meticulous surgical technique is of the essence when performing a salpingectomy for whatever pathology. The risk of a recurrent ipsilateral interstitial ectopic pregnancy must always be considered. Also, the risk of antenatal and intrapartum uterine rupture must be addressed in future pregnancies following interstitial pregnancies.

Risk of uterine rupture in multiparous women after induction of labor with prostaglandin: A national population-based cohort study.

To assess whether, after induction of labor with prostaglandin, multiparous (≥2 para) women have an increased risk of uterine rupture compared with nulliparous or uniparous women. This was a retrospective population-based cohort study including women who underwent induction with prostaglandin in all maternity wards in Sweden between May 1996 and December 2019 (n = 56 784). The study cohort was obtained by using data from the Swedish Medical Birth Register, which contains information from maternity and delivery records. The main outcome measure was uterine rupture. Overall, multiparous women induced with prostaglandin had an increased risk of uterine rupture compared with nulliparous women (adjusted odds ratio [OR], 3.33 [95% confidence interval (CI), 1.38-8.04]; P < 0.007). Multiparous women with no previous cesarean section (CS) induced with prostaglandin had more than three times higher risk of uterine rupture (crude OR, 3.55 [95% Cl, 1.48-8.53]; P = 0.005) compared with nulliparous women and four times higher risk compared with uniparous women (OR, 4.10 [95% CI, 1.12-15.00]; P < 0.033). Multiparous women with previous CS had a decreased risk of uterine rupture compared with uniparous women with one previous CS (crude OR, 0.41 [95% Cl, 0.21-0.78]; P = 0.007). Our study implies that multiparity in women with no previous CS is a risk factor for uterine rupture when induced with prostaglandin. This should be taken into consideration when deciding on the appropriate method of induction.

Scope and Suction: Hysteroscopic-Guided Suction Evacuation of Cesarean Scar Pregnancy—A Safe and Efficacious Treatment for Selected Patients

(Abstracted from Gynecol Minim Invasive Ther 2023;12:72–76) A continual rise of cesarean rates indicates a need to further study the possible development of lower uterine niches or cesarean scar defects, which can be described by adjacent myometrial thickness and residual myometrial thickness (RMT). Pregnancy complications such as placenta accreta spectrum disorders and uterine rupture are associated with RMTs of &lt;2.2 mm.

Frequency of Uterine Rupture and Its Maternal and Fetal Outcomes of Uterine Rupture among Pregnant Women

A uterine rupture is when the uterine wall is torn during labor or right after birth. It is although not common but when occurs it is catastrophic obstetrical emergency for both mother and fetus needs prompt diagnosis and expert management. Moreover it may leads women to irreversible infertility as it rottenly ends at hysterectomy. Objective: To determine the frequency of uterine rupture and its maternal and fetal outcomes among pregnant women. Methods: This Cross Sectional study was conducted at Civil Hospital Karachi in the department of Obstetrics and Gynecology Unit II from 8th December 2018 to 7th June 2019. A total of 317 pregnant women of gestational age &gt;28 weeks, fulfilling the inclusion criteria were enrolled .The data were collected on prepared proforma. Results: This study includes 317 patients with age ranges from 25 to 35 years with mean age of 28.44 ± 3.62 years. In this study, frequency of uterine rupture among pregnant women was found in 7(2.2%) women and maternal mortality 1(7.69%). Conclusions: Findings of this study suggests that uterine perforation is still high and remained important factor for maternal and fetal outcome.

Uterine fibroids associated with pregnancy – is myomectomy during pregnancy feasible? Review and case presentation

Uterine myomas affect 2-10% of pregnant women. They are hormone-dependent tumors, and 30% of them will increase in response to hormonal changes during pregnancy. Therefore, significant growth is expected in pregnancy, but, actually, most of them do not change in size. They are usually asymptomatic, but they may be associated with severe abdominal pain and adverse pregnancy outcomes. Conservative management is the first option. If the conservative treatment fails and the symptoms are severe, a myomectomy can be performed, with serious risks of severe hemorrhage, uterine rupture, miscarriage and preterm labor. We present the case of a 31-year-old primigravida presenting in our service for severe abdominal pain, pollakiuria and constipation. The ultrasound examination revealed a 13-week pregnancy, with no ultrasound signs of fetal structural abnormalities, and several fibroids, in contact with each other, developed as one fibroid mass, intramural and subserous, in the lower uterine segment and into both parametria, with a diame­ter of 100/95/87 mm. During the following weeks, the symptoms progressed, and the fibroid volume almost doubled. At 17 weeks of pregnancy, due to the severity of the symptoms, rapidly growing myomas and suggestive ultrasound aspect of degeneration, we performed a myomectomy. The surgery was uneventful. The patient was monitored weekly. Detailed second-trimester and third-trimester scans confirmed the normal pregnancy evolution. Doppler evaluation of both uterine arteries showed a normal spectrum. The fetal growth was favorable, at a percentile of 50 at 32 weeks of pregnancy. No short-term or long-term complications of the surgery have been noted so far. Myomectomy during pregnancy should be considered in cases of symptomatic uterine fibroids not responding to conservative management or in large or rapidly growing myomas, large or medium myomas located in the lower uterine segment, or deforming the placental site, following appropriate counseling of the patient regarding the associated risks.

Incidence of Recurrent Uterine Rupture: A Systematic Review and Meta-analysis.

We aimed to quantify the incidence of recurrent uterine rupture in pregnant women. A literature search of PubMed, Web of Science, Cochrane Central, and ClinicalTrials.gov for observational studies was performed from 2000 to 2023. Of the 7,440 articles screened, 13 studies were included in the final review. We included studies of previous uterine ruptures that were complete uterine ruptures , defined as destruction of all uterine layers, including the serosa. The primary outcome was the pooled incidence of recurrent uterine rupture. Between-study heterogeneity was assessed with the I2 value. Subgroup analyses were conducted in terms of the country development status, year of publication, and study size (single center vs national study). The secondary outcomes comprised the following: 1) mean gestational age at which recurrent rupture occurred, 2) mean gestational age at which delivery occurred without recurrent rupture, and 3) perinatal complications (blood loss, transfusion, maternal mortality, and neonatal mortality). A random-effects model was used to pool the incidence or mean value and the corresponding 95% CI with R software. The pooled incidence of recurrent uterine rupture was 10% (95% CI 6-17%). Developed countries had a significantly lower uterine rupture recurrence rate than less developed countries (6% vs 15%, P =.04). Year of publication and study size were not significantly associated with recurrent uterine rupture. The mean number of gestational weeks at the time of recurrent uterine rupture was 32.49 (95% CI 29.90-35.08). The mean number of gestational weeks at the time of delivery without recurrent uterine rupture was 35.77 (95% CI 34.95-36.60). The maternal mortality rate was 5% (95% CI 2-11%), and the neonatal mortality rate was 5% (95% CI 3-10%). Morbidity from hemorrhage, such as bleeding and transfusion, was not reported in any study and could not be evaluated. This systematic review estimated a 10% incidence of recurrent uterine rupture. This finding will enable appropriate risk counseling in patients with prior uterine rupture. PROSPERO, CRD42023395010.

Prior Cesarean Birth and Risk of Uterine Rupture in Second-Trimester Medication Abortions Using Mifepristone and Misoprostol: A Systematic Review and Meta-analysis.

To assess the risk difference of uterine rupture when using current mifepristone and misoprostol regimens for second-trimester abortion among individuals with prior cesarean birth compared with those without prior cesarean birth. We searched the terms second trimester, induction, mifepristone, and abortion in PubMed, EMBASE, POPLINE, ClinicalTrials.gov , and Cochrane Library from inception until December 2022. We included randomized trials and observational studies including a mixed cohort, with and without uterine scar, of individuals at 14-28 weeks of gestation who used mifepristone and misoprostol to end a pregnancy or to manage a fetal death. We excluded case reports, narrative reviews, and studies not published in English. Two reviewers independently screened studies. Absolute risks with binomial CIs were calculated from pooled data. Using R software, we estimated total risk difference by the Mantel-Haenszel random-effects method without continuity correction. For studies with zero events, a continuity correction of 0.5 was applied for individual risk differences and plotted graphically with forest plots. Statistical heterogeneity was assessed with Higgins I2 statistics. Funnel plot assessed for publication bias. Of 198 articles identified, 22 met the inclusion criteria: seven randomized trials (n=923) and 15 observational studies (n=6,195). Uterine rupture risk with prior cesarean birth was 1.1% (10/874) (95% CI 0.6-2.1) and without prior cesarean birth was 0.01% (2/6,244) (95% CI 0.0-0.12). The risk difference was 1.23% (95% CI 0.46-2.00, I2 =0%). Of the 12 reported uterine ruptures, three resulted in hysterectomy. Uterine rupture with mifepristone and misoprostol use during second-trimester induction abortion is rare, with the risk increased to 1% in individuals with prior cesarean birth. PROSPERO, CRD42022302626.