Identifying risk factors for uterine rupture

Associations between the time interval from myomectomy to subsequent pregnancy and the obstetric outcomes: A population-based cohort study

OBJECTIVE

To investigate the associations between time interval from myomectomy to pregnancy (TIMP) and subsequent pregnancy and obstetric complications, and to explore whether these associations vary according to maternal age at birth.

METHODS

A retrospective population-based cohort study was conducted from 2008 to 2017. Data were extracted from the National Health Insurance Research Database and the Taiwan Maternal and Child Health Database, comprising 2024 379 births from 1 391 856 pregnancies. Eligible cases were identified using diagnostic and procedure codes; 4006 first singleton births in 4006 women after their first laparotomic myomectomy were identified. We estimated the risks of pregnancy and obstetric outcomes according to TIMP (<6, 6-11, and ≥12 months). Subgroup analysis was performed by further dividing according to maternal age at birth (18-34 vs ≥35 years old).

RESULTS

We observed higher risks of gestational hypertensive disorders (adjusted odds ratio [aOR] 1.97, 95% confidence interval [CI] 1.22-3.18, P = 0.005) and neonatal death (aOR 4.59, 95% CI 1.49-14.18, P = 0.008) for TIMP of <6 months versus TIMP of 6-11 months. Likewise, a TIMP ≥12 months was associated with increased risks of gestational hypertensive disorders (aOR 1.72, 95% CI 1.14-2.58, P = 0.010), and neonatal death (aOR 3.27, 95% CI 1.16-9.24, P = 0.025) versus a TIMP of 6-11 months. In subgroup analysis, women over 35 years old still had higher risks of gestational hypertensive disorders when TIMP was <6 months (aOR 2.26, 95% CI 1.17-4.37, P = 0.015) or ≥12 months (aOR 2.04, 95% CI 1.17-3.54, P = 0.012), and a higher risk of neonatal death when TIMP was <6 months (aOR 4.05, 95% CI 1.06-15.53, P = 0.041); whereas women aged 18-34 years old did not.

CONCLUSIONS

This study suggests that a TIMP between 6 and 11 months is associated with lower risks of gestational hypertensive disorders and neonatal death compared with a TIMP <6 months or ≥12 months, especially for women over 35 years old.

Unintended lower-segment hysterotomy extension at cesarean delivery and the risk for uterine rupture during a subsequent trial of labor

OBJECTIVE

To evaluate the association between unintended uterine extension in cesarean delivery and uterine scar disruption (rupture or dehiscence) at the subsequent trial of labor after cesarean delivery (TOLAC).

METHODS

This is a multicenter retrospective cohort study (2005-2021). Parturients with a singleton pregnancy who had unintended lower-segment uterine extension during the primary cesarean delivery (excluding T and J vertical extensions) were compared with patients who did not have an unintended uterine extension. We assessed the subsequent uterine scar disruption rate following the subsequent TOLAC and the rate of adverse maternal outcome.

RESULTS

During the study period, 7199 patients underwent a trial of labor and were eligible for the study, of whom 1245 (17.3%) had a previous unintended uterine extension and 5954 (82.7%) did not. In univariate analysis, previous unintended uterine extension during the primary cesarean delivery was not significantly associated with uterine scar rupture in the following subsequent TOLAC. Nevertheless, it was associated with uterine scar dehiscence, higher rates of TOLAC failure, and a composite adverse maternal outcome. In multivariate analyses, only the association between previous unintended uterine extension and higher rates of TOLAC failure was confirmed.

CONCLUSION

A history of unintended lower-segment uterine extension is not associated with an increased risk for uterine scar disruption following subsequent TOLAC.

Antepartum unscarred uterine rupture caused by placenta percreta: a case report and literature review

The main risk for uterine rupture is the presence of a uterine scar due to prior cesarean delivery or other uterine surgery. However, rupture in an unscarred uterus is extremely rare, and risk factors include multiple gestations, trauma, congenital anomalies, use of uterotonics and placenta accreta spectrum.

Placenta accreta spectrum, also known as morbidly adherent placenta, is becoming increasingly common and is associated with significant maternal and neonatal morbidity and mortality.

We report a case of unscarred uterine rupture due to placenta percreta in a multiparous woman that required emergency peripartum hysterectomy.

Uterine Sacculation on Point-of-care Ultrasound in a Pregnant Female Patient: A Case Report

Introduction

Uterine rupture is a rare but potentially fatal complication of pregnancy. The incidence of uterine rupture is estimated to be between 0.3 and 11 per 10,000. Additionally, uterine sacculation is a sac or outpouching of the uterus that can lead to uterine rupture in pregnancy. Here we describe a case of a patient who was found to have a uterine sacculation on point-of-care ultrasound in the emergency department (ED) that was complicated by uterine rupture.

Case Report

A 32-year-old female at approximately 18 weeks gestation presented to the ED with three days of abdominal discomfort. The patient’s medical history was significant for prior uterine fibroids requiring recent myomectomy. On arrival the patient was tachycardic, and her abdominal exam revealed distention with mild tenderness to palpation in all quadrants. A point-of-care transabdominal obstetric ultrasound was performed to evaluate the fetal heart rate, which was 157 beats per minute; it also revealed a defect in the uterine wall compatible with a uterine sacculation. The patient underwent magnetic resonance imaging, which revealed a sac-like structure in the fundal portion of the uterus containing a portion of gestational sac and pregnancy contents. Subsequently, she became hypotensive and tachycardic and was taken emergently to the operating room for concern for uterine rupture. Intraoperatively, uterine rupture was confirmed. The patient underwent surgical repair with evacuation of fetal tissue and recovered in the surgical intensive care unit.

Conclusion

Point-of-care ultrasound is a useful and readily available procedure to identify uterine sacculation. Early identification can help escalate the urgency of the patient complaint and may lead to a need for further maternal-fetal evaluation. Emergency physicians should keep a high index of suspicion when evaluating the pregnant patient with a history of uterine surgery.

Epidemiology of uterine rupture among pregnant women in China and development of a risk prediction model: analysis of data from a multicentre, cross-sectional study

OBJECTIVES

To describe the epidemiology of uterine rupture in China from 2015 to 2016 and to build a prediction model for uterine rupture in women with a scarred uterus.

SETTING

A multicentre cross-sectional survey conducted in 96 hospitals across China in 2015-2016.

PARTICIPANTS

Our survey initially included 77 789 birth records from hospitals with 1000 or more deliveries per year. We excluded 2567 births less than 24 gestational weeks or unknown and 1042 births with unknown status of uterine rupture, leaving 74 180 births for the final analysis.

PRIMARY AND SECONDARY OUTCOME MEASURES

Complete and incomplete uterine rupture and the risk factors, and a prediction model for uterine rupture in women with scarred uterus (assigned each birth a weight based on the sampling frame).

RESULTS

The weighted incidence of uterine rupture was 0.18% (95% CI 0.05% to 0.23%) in our study population during 2015 and 2016. The weighted incidence of uterine rupture in women with scarred and intact uterus was 0.79% (95% CI 0.63% to 0.91%) and 0.05% (95% CI 0.02% to 0.13%), respectively. Younger or older maternal age, prepregnancy diabetes, overweight or obesity, complications during pregnancy (hypertensive disorders in pregnancy and gestational diabetes), low education, repeat caesarean section (≥2), multiple abortions (≥2), assisted reproductive technology, placenta previa, induce labour, fetal malpresentation, multiple pregnancy, anaemia, high parity and antepartum stillbirth were associated with an increased risk of uterine rupture. The prediction model including eight variables (OR >1.5) yielded an area under the curve (AUC) of 0.812 (95% CI 0.793 to 0.836) in predicting uterine rupture in women with scarred uterus with sensitivity and specificity of 77.2% and 69.8%, respectively.

CONCLUSIONS

The incidence of uterine rupture was 0.18% in this population in 2015-2016. The predictive model based on eight easily available variables had a moderate predictive value in predicting uterine rupture in women with scarred uterus. Strategies based on predictions may be considered to further reduce the burden of uterine rupture in China.

Spontaneous uterine rupture of an unscarred uterus revealed by a subocclusive syndrome: A case report and review of the literature

Spontaneous uterine rupture of an unscarred uterus is a complication that has dramatic results for both mother and fetus. The clinical presentation commonly comprises abdominal pain and metrorrhagia however we report a case of spontaneous uterine rupture revealed by a subocclusive syndrome. We report a case of a young woman who came to the ER with 3 days of progressive abdominal pain and subocclusive syndrome. The current pregnancy was estimated at 32 weeks of amenorrhea and the patient was hemodynamically stable. An obstetric ultrasound was performed showing a progressive monofoetal pregnancy and moderate peritoneal effusion. In view of the presence of effusion on ultrasound and the subocclusive syndrome, an abdominal and pelvic CT scan with contrast was carried out, showing a fundal uterine rupture defect with contrast media extravasation and intraperitoneal hemoperitoneum. The patient was immediately transferred to the operating room for a caesarean section. Although CT scans use radiation, their contribution was essential to avoid maternal death.

Two uterine scars and a vaginal birth

Uterine scarring increases the risk of uterine rupture during labour, which can result in significant maternal and fetal morbidity and mortality. There is insufficient evidence for a clear recommendation on the safety of vaginal delivery in the context of a patient with both a uterine perforation and a previous lower uterine segment caesarean section. We present the case of a woman with a history of one previous caesarean section and uterine perforation with a uterine manipulator, who subsequently had an uncomplicated normal vaginal delivery.

Laparoscopic repair of uterine rupture following successful second vaginal birth after caesarean delivery: A case report

BACKGROUND

With the increasing trend of vaginal birth after caesarean delivery (VBAC), evaluation of the feasibility and safety of a second VBAC with grand multiparity is worth considering. Intrapartum uterine rupture is diagnosed in approximately one-fifth of all VBAC cases following successful vaginal delivery. To our knowledge, no report is available on the application of laparoscopy to repair postpartum uterine rupture after a successful second VBAC in China.

CASE SUMMARY

A 31-year-old woman (gravida 5, para 2) at 39 wk and 5 d of gestation was admitted to the hospital in labour. After a successful VBAC and observation for approximately 13 h, the patient complained of progressive abdominal pain. Given the symptoms, signs, and auxiliary examination results, intraperitoneal bleeding was considered. Because the patient was stable and ultrasound imaging was the only method available to assess the possibility of rupture, we recommended laparoscopy to clarify the diagnosis and for prompt laparoscopic uterine repair or exploratory laparotomy if necessary. Operative findings included transverse uterine scar rupture at the lower uterine segment of approximately 5.0 cm in length and 800 mL of intraoperative pelvic haemoperitoneum. Finally, she successfully underwent laparoscopic repair of uterine rupture and recovered very well according to three-dimensional magnetic resonance imaging at 42 d postpartum.

CONCLUSION

Routine postpartum intrauterine exploration is not beneficial to the mother and may even increase the risk of rupture. This case highlights a laparoscopic approach for repairing uterine rupture in the immediate postpartum period.

Spontaneous Uterine Rupture in a Multigravid Pregnant Woman with Unscarred Uterus on Chronic Steroid Use: A Case Report

BACKGROUND

Uterine rupture in pregnancy is associated with severe maternal and fetal complications. Although it is a rare event, uterine rupture has been associated with certain risk factors. Glucocorticoids are known to weaken skeletal muscles; however, there have been no studies on the effects of chronic steroid use on the uterine myometrium.

CASE

We present the case of a 40-year-old multigravid woman who experienced a posterior uterine wall rupture on an unscarred uterus. She was on chronic glucocorticoids for the treatment of psoriatic arthritis. We hypothesize that the catabolic effects of glucocorticoids on skeletal muscles also weakened the uterine myometrium, leading to a higher risk of uterine rupture.

CONCLUSION

Uterine rupture may be associated with chronic use of corticosteroids. Identifying the different risk factors for uterine rupture can lead to more prompt diagnosis and management of uterine rupture, resulting in better maternal and fetal outcomes.

Maternal outcome after complete uterine rupture

INTRODUCTION

Complete uterine rupture, a rare peripartum complication, is often associated with a catastrophic outcome for both mother and child. However, few studies have investigated large datasets to evaluate maternal outcomes after complete ruptures, particularly in unscarred uteri. This paucity of studies is partly due to the rarity of both the event and the serious outcomes, such as peripartum hysterectomy and maternal death. The incidence of uterine rupture is expected to increase, due to increasing cesarean section rates worldwide. Thus, it is important to have more complete knowledge about the immediate maternal outcome following a complete uterine rupture. The objective was to identify maternal outcomes and their risk factors following complete uterine ruptures.

MATERIAL AND METHODS

This was a population-based study using data from the Medical Birth Registry of Norway, the Patient Administration System and medical records. Maternities with complete uterine rupture after start of labor in Norway during 1967-2008 (n = 247 births), identified among 2 209 506 women. Uterine ruptures were identified from both registries and were further studied through a review of medical records. Only complete ruptures were included in analysis. The associations between maternal outcomes and demographic and labor risk factors were estimated. Odds ratios (ORs) were determined with crude logistic regressions for each risk factor. Separate multivariable logistic regressions were performed to calculate adjusted odds ratios and 95% confidence intervals (CIs).

RESULTS

We identified 88 (35.6%) healthy mothers, 107 (43.3%) severe postpartum hemorrhages without hysterectomy, 51 (20.6%) peripartum hysterectomies, and three (1.2%) maternal deaths. Peripartum hysterectomy decreased significantly in the last years of study. Unscarred uterine ruptures significantly increased the risk of peripartum hysterectomy compared with scarred uterine ruptures (AOR 2.6, 95% CI 1.3-5.3). Other factors that increased the risk of peripartum hysterectomy following rupture were: maternal age ≥35 years (AOR 2.3, 95% CI 1.1-5.0), parity ≥3 vs parity 1-2 (AOR 2.8, 95% CI 1.2-6.7), and rupture detection after vaginal delivery (AOR 2.2, 95% CI 1.1-4.8).

CONCLUSIONS

Unscarred uteri, older maternal age, parity ≥3, and rupture detection after vaginal delivery showed the highest associations with the risk of peripartum hysterectomy after complete uterine rupture.

[Uterine rupture of the unscarred uterus: A report of 10 cases]

INTRODUCTION

Uterine rupture in the healthy uterus is a rare obstetrical complication, not much suspected and with badly identified risk factors. Thus, there exists frequent delay for treatment and therefore fetal-maternal important morbidity and mortality. This article describes clinical signs and symptoms, management, and maternal and neonatal prognosis of uterine rupture.

METHODS

Descriptive retrospective study within 13 maternity hospitals, reporting 10 series of cases of uterine rupture on gravid healthy uterus during the third trimester of pregnancy.

RESULT

The incidence was 2.8/100,000 births. Surgical treatment was conservative in 9 out of 10 cases, the maternal prognosis was good with no maternal deaths and 6 out of 7 patients had at least one subsequent pregnancy. The fetal prognosis was more reserved, with 2 fetal or neonatal deaths and 1 with motor disability. 6/6 patients (100%) had at least one iterative Caesarean section during the following pregnancies with healthy fetuses.

CONCLUSION

In this series of 10 cases over 25years, maternal-fetal morbidity and mortality were significant, in agreement with the literature. Maternal prognosis remained favorable. When surgical treatment is conservative a subsequent pregnancy is possible and an iterative cesarean section must be performed.

Infant outcome after complete uterine rupture

BACKGROUND

Complete uterine rupture is a rare peripartum complication often associated with a catastrophic outcome for both mother and child. However, little has been written based on large data sets about maternal and infant outcome after complete ruptures. This is partly due to the rarity of the event and the serious maternal and infant outcome; it is also partly due to the use of international diagnostic codes that do not differentiate between the less catastrophic partial rupture and more catastrophic complete uterine rupture. As uterine rupture is expected to increase due to increased cesarean delivery rates worldwide, it is important to know more completely about the outcome following complete uterine rupture.

OBJECTIVE

We sought to explore risk factors associated with poor infant outcome in cases of complete uterine rupture.

STUDY DESIGN

This population-based study used data from the Medical Birth Registry of Norway, the Patient Administration System, and medical records. We included births with complete uterine rupture after start of labor in all maternity units in Norway during the period 1967 through 2008 (n = 244 births), identified among 2,455,797 births. Uterine ruptures were identified and further studied through a review of medical records. We estimated the associations between infant outcomes and demographic and labor risk factors using logistic regression analyses. Odds ratios with 95% confidence intervals for each risk factor were determined after adjustment for demographic factors and period of birth. The main outcome measure was infant outcome: healthy infant, intrapartum/infant deaths, hypoxic ischemic encephalopathy, and admission to the neonatal intensive care unit.

RESULTS

We identified 109 (44.7%) healthy infants, 56 (23.0%) infants needing neonatal intensive care unit admission, 64 (26.2%) intrapartum/infant deaths, and 15 (6.1%) infants with hypoxic ischemic encephalopathy. The highest number of intrapartum/infant deaths occurred in 1967 through 1977 (51.6%) and the fewest in 2000 through 2008 (15.0%). Unscarred uterine ruptures did not significantly increase intrapartum/infant deaths compared to scarred uterine ruptures. Placental separation and/or fetal extrusion had the highest odds ratio for intrapartum/infant deaths (odds ratio, 17.9; 95% confidence interval, 7.5-42.4). Time-to-delivery interval <20 minutes resulted in fewest intrapartum/infant deaths (9.9%), although there were 2 deaths at 10-minute interval. Time to delivery >30 minutes vs <20 minutes increased risk of death (odds ratio, 16.7; 95% confidence interval, 6.4-43.5).

CONCLUSION

Intrapartum/infant death after complete uterine rupture decreased significantly over the decades. Time to delivery >30 minutes and placental separation and/or fetal extrusion had the highest association with intrapartum/infant deaths after complete uterine rupture. Time to delivery <20 minutes limited the incidence of intrapartum/infant deaths.

Sonographic detection of an infected maternal urachal cyst during pregnancy

Infection of a maternal urachal cyst during pregnancy is rare; Sonography is an important diagnostic tool that can help minimize maternal and fetal complications. We describe the case of a 35-year-old multiparous woman presenting in the third trimester with 2 weeks of fever, abdominal pain, and urinary symptoms. Imaging showed a 5-cm complex anterior midline mass, found intraoperatively to be eroding into the uterus. Sonographic imaging aided in the diagnosis and management of the urachal cyst, and antepartum sonographic measurements of the lower uterine segment helped to counsel regarding a trial of labor. Following treatment, the patient stabilized and had an uncomplicated vaginal delivery.

Risk factors for complete uterine rupture

BACKGROUND

Complete uterine rupture is a rare peripartum complication associated with a catastrophic outcome. Because of its rarity, knowledge about its risk factors is not very accurate. Most previous studies were small and over a limited time interval. Moreover, international diagnostic coding was used in most studies. These codes are not able to differentiate between the catastrophic complete type and less catastrophic partial type. Complete uterine rupture is expected to increase as the rate of cesarean delivery increases. Thus, we need more accurate knowledge about the risk factors for this complication.

OBJECTIVE

The objective of the study was to estimate the incidence and risk factors for complete uterine rupture during childbirth in Norway.

STUDY DESIGN

This population-based study included women that gave birth after starting labor in 1967-2008. Data were from the Medical Birth Registry of Norway and Patient Administration System, complemented with information from medical records. We included 1,317,967 women without previous cesarean delivery and 57,859 with previous cesarean delivery. The outcome was complete uterine rupture (tearing of all uterine wall layers, including serosa and membranes). Risk factors were parameters related to demographics, pregnancy, and labor. Odds ratios for complete uterine rupture were computed with crude logistic regressions for each risk factor. Separate multivariable logistic regressions were performed to calculate the adjusted odds ratios and 95% confidence intervals.

RESULTS

Complete uterine rupture occurred in 51 cases without previous cesarean delivery (0.38 per 10,000) and 122 with previous cesarean delivery (21.1 per 10,000). The strongest risk factor was sequential labor induction with prostaglandins and oxytocin, compared with spontaneous labor, in those without previous cesarean delivery (adjusted odds ratio, 48.0, 95% confidence interval, 20.5-112.3) and those with previous cesarean delivery (adjusted odds ratio, 16.1, 95% confidence interval, 8.6-29.9). Other significant risk factors for those without and with previous cesarean delivery, respectively, included labor augmentation with oxytocin (adjusted odds ratio, 22.5, 95% confidence interval, 10.9-41.2; adjusted odds ratio, 4.4, 95% confidence interval, 2.9-6.6), antepartum fetal death (adjusted odds ratio, 15.0, 95% confidence interval, 6.2-36.6; adjusted odds ratio, 4.0, 95% confidence interval, 1.1-14.2), and previous first-trimester miscarriages (adjusted odds ratio, 9.6, 95% confidence interval, 5.7-17.4; adjusted odds ratio, 5.00, 95% confidence interval, 3.4-7.3). After a previous cesarean delivery, the risk of rupture was increased by an interdelivery interval <16 months (adjusted odds ratio, 2.3; 95% confidence interval, 1.1-5.4) and a previous cesarean delivery with severe postpartum hemorrhage (adjusted odds ratio, 5.6; 95% confidence interval, 2.4-13.2).

CONCLUSION

Sequential labor induction with prostaglandins and oxytocin and augmentation of labor with oxytocin are important risk factors for complete uterine rupture in intact and scarred uteri.

Traumatic uterine rupture in three felids

OBJECTIVE

To describe 3 near-full-term, young-adult felids (2 domestic shorthair cats, and 1 bobcat [Lynx rufus]) that experienced uterine rupture following trauma.

SERIES SUMMARY

Two of the animals had motor vehicular trauma and 1 had abdominal bite wounds. The 2 domestic cats that were treated with surgical exploration and ovariohysterectomy recovered uneventfully. The bobcat died during hospitalization prior to surgical intervention, and necropsy identified uterine rupture and associated peritonitis.

UNIQUE INFORMATION PROVIDED

Traumatic uterine rupture should be considered in known or suspected pregnant animals that experience blunt or penetrating trauma, particularly if they are in late-term pregnancy.

Uterine Rupture: A Seven Year Review at a Tertiary Care Hospital in New Delhi, India

Objective:

To identify the obstetric risk factors, incidence, and causes of uterine rupture, management modalities, and the associated maternal and perinatal morbidity and mortality in one of the largest tertiary level women care hospital in Delhi.

Materials and Methods:

A 7-year retrospective analysis of 47 cases of uterine rupture was done. The charts of these patients were analyzed and the data regarding demographic characteristics, clinical presentation, risk factors, management, operative findings, maternal and fetal outcomes, and postoperative complications was studied.

Results:

The incidence of rupture was one in 1,633 deliveries (0.061%). The vast majority of patients had prior low transverse cesarean section (84.8%). The clinical presentation of the patients with rupture of the unscarred uterus was more dramatic with extensive tears compared to rupture with scarred uterus. The estimated blood loss ranged from 1,200 to 1,500 cc. Hemoperitoneum was identified in 95.7% of the patient and 83% of the patient underwent repair of rent with or without simultaneous tubal ligation. Subtotal hysterectomy was performed in five cases. There were no maternal deaths in our series. However, there were 32 cases of intrauterine fetal demise and five cases of stillbirths.

Conclusions:

Uterine rupture is a major contributor to maternal morbidity and neonatal mortality. Four major easily identifiable risk factors including history of prior cesarean section, grand multiparity, obstructed labor, and fetal malpresentations constitute 90% of cases of uterine rupture. Identification of these high risk women, prompt diagnosis, immediate transfer, and optimal management needs to be overemphasized to avoid adverse fetomaternal complications.

A Case Series of Uterine Rupture: Lessons to be Learned for Future Clinical Practice

OBJECTIVE

In this article, we try to discuss risk factors and diagnostic difficulties for uterine rupture.

METHODS

Case series of 12 cases of uterine rupture observed in the Norfolk and Norwich University Hospital in the UK, with an average yearly birth rate of 6,000 deliveries, over a 6-year period.

RESULTS

In the present case series, there was no maternal mortality, and uterine rupture was a rare occurrence (12 in 36,000 births). Uterine rupture is associated with clinically significant uterine bleeding, fetal distress, expulsion or protrusion of the fetus, placenta or both into the abdominal cavity, and the need for prompt cesarean delivery and uterine repair or hysterectomy. The risk factors for rupture include previous cesarean sections, multiparity, malpresentation and obstructed labor, uterine anomalies, and use of prostaglandins for induction of labor. Previous cesarean section is, however, the most commonly associated risk factor. The most consistent early indicator of uterine rupture is the onset of a prolonged, persistent, and profound fetal bradycardia.

CONCLUSION

In this case series, we suggest that the signs and symptoms of uterine rupture are typically nonspecific, which makes diagnosis difficult. Delay in definitive therapy causes significant fetal morbidity. The inconsistent signs and the short time in prompting definitive treatment of uterine rupture make it a challenging event. For the best outcome, vaginal birth after previous cesarean section needs to be looked after in an appropriately staffed and equipped unit for an immediate cesarean delivery and advanced neonatal support.

Simultaneous uterine and urinary bladder rupture in an otherwise successful vaginal birth after cesarean delivery

Uterine rupture is the primary concern when a patient chooses a trial of labor after a cesarean section. Bladder rupture accompanied by uterine rupture should be taken into consideration if gross hematuria occurs. We report the case of a patient with uterine rupture during a trial of labor after cesarean delivery. She had a normal course of labor and no classic signs of uterine rupture. However, gross hematuria was noted after repair of the episiotomy. The patient began to complain of progressive abdominal pain, gross hematuria and oliguria. Cystoscopy revealed a direct communication between the bladder and the uterus. When opening the bladder peritoneum, rupture sites over the anterior uterus and posterior wall of the bladder were noted. Following primary repair of both wounds, a Foley catheter was left in place for 12 days. The patient had achieved a full recovery by the 2-year follow-up examination. Bladder injury and uterine rupture can occur at any time during labor. Gross hematuria immediately after delivery is the most common presentation. Cystoscopy is a good tool to identify the severity of bladder injury.