Spontaneous uterine rupture revealing vascular Ehlers-Danlos syndrome: An uncommon case report

Pregnancy and Delivery Outcomes in Vascular Ehlers-Danlos Syndrome: A Retrospective Multicentre Cohort Study

OBJECTIVE

We aim to increase knowledge on pregnancy and delivery risks in vascular Ehlers-Danlos Syndrome (vEDS). Our outcomes can contribute to establishing future guidelines for pregnancy and delivery management in women with vEDS.

DESIGN

Retrospective multicentre cohort study.

SETTING

Women with vEDS due to pathogenic/likely pathogenic (P/LP) COL3A1 variants are at increased risk for arterial dissection and pregnancy-related complications during pregnancy and delivery.

POPULATION

Women with a P/LP COL3A1 variant were included from 2019 until 2021.

METHODS

Genetic and clinical data was collected through retrospective analysis.

MAIN OUTCOME MEASURES

Description of the genotype and pregnancy-related outcomes.

RESULTS

We collected information about 121 pregnancies of 43 women with vEDS, including nine women with a haploinsufficient variant. Neither uterine rupture nor life-threatening or fatal vascular events occurred in the perinatal period. The miscarriage rate was 19% (23/121) and 19.1% of the live births were preterm (18/94). Miscarriages were significantly more frequent in women with a glycine substitution in COL3A1 compared to other COL3A1 variant types (19/23, 82.6%, p = 0.018). Thirty-four women had a vaginal birth (79.1%), including 1/7 with known vEDS. Eight deliveries were complicated by severe perineal tears, and six by postpartum haemorrhage.

CONCLUSIONS

No pregnancy-related deaths, arterial dissections or uterine ruptures occurred in our cohort. Since no life-threatening events occurred during pregnancy and delivery, discouragement of pregnancy in all women with vEDS in current guidelines might be too strict. Based on these data, we propose a shared decision-making process.

Management of spontaneous liver hemorrhage in vascular Ehlers Danlos syndrome: A case report

INTRODUCTION

Vascular Ehlers Danlos syndrome (vEDS) is a heritable connective tissue disorder characterized by vascular, solid organ, and hollow viscus fragility. Herein we report a patient with vEDS who presented with a large spontaneous subcapsular liver hemorrhage. This case highlights the challenges associated with managing vEDS patients and discusses approaches to optimize their care.

PRESENTATION OF CASE

A 33-year-old woman presented to the emergency department with acute onset abdominal pain. Computed Tomography Angiogram (CTA) revealed a large subcapsular hemorrhage with active extravasation. Interventional Radiology (IR) performed a hepatic artery angiogram which revealed no blush thus embolization was not performed. The closure device pulled through the arterial wall and an expanding groin hematoma was noted despite manual compression. The patient was brought emergently to the Operating room (OR) for left groin exploration where the arterial injury was identified and repaired. Her post-operative course was complicated by pulmonary embolism (PE) and a left groin infection requiring return to the OR.

DISCUSSION

In the rarely reported cases of hepatic hemorrhage with vEDS, the patients have more commonly presented with multiorgan involvement or died during their hospital admission. These patients have extremely friable tissues and pose additional risk of complications for any invasive procedure.

CONCLUSION

The case described is the second reported instance of a patient with vEDS who survived their acute hospital course after presenting with a spontaneous hepatic hemorrhage. Key management considerations include preservation of the liver capsule to allow for spontaneous hematoma resorption and cutdown access in the OR for angiography.

Vascular Ehlers-Danlos syndrome and pregnancy: A systematic review

BACKGROUND

Vascular Ehlers-Danlos syndrome (vEDS) is a hereditary connective tissue disorder associated with an elevated risk of vascular, uterine and digestive complications. Managing pregnancy in this context can be a challenge.

OBJECTIVES

To systematically review the literature data on the complications in pregnancy associated with vEDS.

SEARCH STRATEGY

We searched the Pubmed Medline and Embase databases for articles using the following terms "vascular Ehlers-Danlos syndrome" or "vEDS" AND "pregnancy".

SELECTION CRITERIA

Women with vEDS.

DATA COLLECTION AND ANALYSIS

We searched the PubMed® MEDLINE® database for publications evaluating obstetric outcomes in women with vEDS.

MAIN RESULTS

A total of 121 publications were screened, with six (accounting for 412 pregnancies) included in our review. Of the women included in this sample, 30% were infertile. The miscarriage rate was 13.8% (57/412) and 8.8% of the live births were premature. Obstetric anal sphincter injuries occurred in 11.3% (23/203) of the deliveries. The maternal mortality rate per pregnancy was 5.7%.

CONCLUSIONS

Women with vEDS present an elevated risk of uterine rupture, vascular events, digestive events and death during pregnancy. Women appear to be most at risk during the peripartum period; to avoid expulsive efforts, a caesarean section should be scheduled at 37 weeks of gestation.

Spontaneous Rupture of Unscarred Uterus in a Term Primagravida with Lethal Skeletal Dysplasia Fetus (Thanatophoric dysplasia). A Case Report and Review of the Literature

Background and Importance

 Spontaneous uterine rupture, especially in an unscarred uterus, is a rare pregnancy complication that can cause severe morbidity and mortality in both the mother and the fetus. The vast majority of uterine ruptures occur in the presence of a previous uterine scar, most commonly from a previous cesarean delivery. To our knowledge, here we reported the first case of spontaneous rupture of unscarred uterus in a term primigravida secondary to lethal skeletal dysplasia fetus (Type 1 Thanatophoric dysplasia) faced by a practicing clinician in an underdeveloped country (Somalia) with a successful outcome.

Case Presentation

 The patient was 24 yrs. Old Primagravida, at 40 weeks gestation by LMP, presented with abdominal pain and active vaginal bleeding; she did not receive antenatal care during pregnancy; after initial abdominal ultrasonography and vaginal examination, laparotomy was performed due to high suspicion of uterine rupture. After dead fresh fetal extraction, the uterine defect was repaired successfully, and the patient was discharged home in good condition after several days.

Conclusion

 Through this case, we would like to highlight the urgent need to focus on and recognize the importance of receiving antenatal care in the community so that the burden of thousands of lives lost each year can be reduced.