Spontaneous uterine rupture and hemoperitoneum in the first trimester

First-trimester uterine rupture: a case report and systematic review of the literature

OBJECTIVE

This study aimed to present a case of first-trimester uterine rupture and perform a systematic review to identify common presentations, risk factors, and management strategies.

DATA SOURCES

Searches were performed in PubMed, Ovid, and Scopus using a combination of key words related to "uterine rupture," "first trimester," and "early pregnancy" from database inception to September 30, 2020.

STUDY ELIGIBILITY CRITERIA

English language descriptions of uterine rupture at ≤14 weeks of gestation were included, and cases involving pregnancy termination and ectopic pregnancy were excluded.

METHODS

Outcomes for the systematic review included maternal demographics, description of uterine rupture, and specifics of uterine rupture diagnosis and management. Data were extracted to custom-made reporting forms. Median values were calculated for continuous variables, and percentages were calculated for categorical variables. The risk of bias was assessed using the Joanna Briggs Institute critical appraisal checklist for case reports and case series.

RESULTS

Overall, 61 cases of first-trimester uterine rupture were identified, including our novel case. First-trimester uterine ruptures occurred at a median gestation of 11 weeks. Most patients (59/61 [97%]) had abdominal pain as a presenting symptom, and previous uterine surgery was prevalent (44/61 [62%]), usually low transverse cesarean delivery (32/61 [52%]). The diagnosis of uterine rupture was generally made after surgical exploration (37/61 [61%]), with rupture noted in the fundus in 26 of 61 cases (43%) and in the lower segment in 27 of 61 cases (44%). Primary repair of the defect was possible in 40 of 61 cases (66%), whereas hysterectomy was performed in 18 of 61 cases (30%). Continuing pregnancy was possible in 4 of 61 cases (7%).

CONCLUSION

Uterine rupture is an uncommon occurrence but should be considered in patients with an acute abdomen in early pregnancy, especially in women with previous uterine surgery. Surgical exploration is typically needed to confirm the diagnosis and for management. Hysterectomy is not always necessary; primary uterine repair is sufficient in more than two-thirds of the cases to achieve hemostasis. Continuing pregnancy, although uncommon, is also possible.

Spontaneous partial uterine laceration in primigravida at 16 weeks of gestation: A case report

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Uterine laceration is extremely rare and little known, however it sometimes causes massive intraperitoneal bleeding and has poor prognosis.

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Inner myometrial laceration may be caused by intrapartum physical stress, whereas uterine laceration in relatively early pregnancy might be occurred by tissue inadaptable for uterine enlargement.

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To diagnosis uterine laceration in early pregnancy is quite difficult because of the absence of specific clinical findings.

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Not only uterine rupture but also uterine laceration should be considered, and exploratory laparotomy should be performed appropriately when hemoperitoneum is strongly suspected.

Introduction

Although uterine rupture is well discussed, uterine laceration and partial myometrial laceration are little known. A previous report hypothesized that the stress of labor was associated with uterine laceration.

Presentation of case

We present a rare case of uterine laceration in a patient in the second trimester. A 34-year-old primigravida woman at 16 weeks’ gestation without a history of uterine surgery complained of sudden low abdominal pain. Ultrasonography showed fetal death and intraperitoneal free fluid. A laparotomy was performed, and partial uterine laceration in the posterior wall along with active bleeding was confirmed.

Discussion

The etiology of uterine laceration in early pregnancy might be different from both classical uterine rupture and previously published uterine laceration. We hypothesized that tissue inadaptable for uterine enlargement, such as that owing to endometriosis and subtle injury by surgical approach, may be associated with the onset mechanism.

Conclusion

The diagnosis of uterine laceration in early pregnancy is quite difficult because of the absence of specific clinical findings. However, it sometimes causes massive intraperitoneal bleeding and has poor prognosis. Therefore, when uterine laceration is suspected as a cause of hemoperitoneum in a pregnant women, clinicians should perfume exploratory laparotomy appropriately.

First Trimester Uterine Rupture: A Case Report and Literature Review

The aim is to report a case of spontaneous uterine rupture in the first trimester of pregnancy and to review the literature on the topic.

METHODS

A literature search was performed using PubMed and Scopus. Relevant English articles were identified without any time or study limitations. The data were aggregated, and a summary statistic was calculated.

RESULTS

A 35-year-old gravida 5, para 2 was admitted at our department because of fainting and abdominal pain. The woman had a first-trimester twin pregnancy and a history of two previous cesarean sections (CSs). Suspecting a uterine rupture, an emergency laparotomy was performed. The two sacs were completely removed, and the uterine rupture site was closed with a double-layer suture. The patient was discharged from hospital four days later in good condition. On the basis of this experience, a total of 76 case reports were extracted from PubMed and included in the review. Fifty-three patients out of 76 (69.74%) underwent previous surgery on the uterus. Most women (67.92%) had a CS, and in this group a cesarean scar pregnancy (CSP) or a placenta accreta spectrum (PAS) disorder was found to be the etiology in 77.78% of cases. Furthermore, 35.85% of the women had hysterectomy after uterine rupture. Twenty-three patients out of 76 (30.26%) had an unscarred uterus. Of this group, most women presented a uterine anomaly (43.48%). Moreover, 17.39% of these women had a hysterectomy.

CONCLUSION

According to the literature, the current pandemic use of CS explains most cases of first-trimester uterine rupture.

Maternal and neonatal outcomes in morbidly adherent placenta: a developing country experience

BACKGROUND

Morbid adherent placenta, a severe pregnancy complication, is associated with massive obstetrical haemorrhage and high maternal mortality. Antenatal diagnosis and meticulous multidisciplinary planning at delivery is crucial for optimal outcome. We aim to identify the maternal and neonatal outcome in women with morbid adherent placenta.

METHOD

It was a retrospective evaluation of cases of clinically suspected and/or histologically confirmed morbid adherent placenta over a 1-year period.

RESULTS

The incidence of morbid adherent placenta was 1 per 306 deliveries. Previous Caesarean section with placenta praevia was the commonest risk factor. Among all, 71.4% had no antenatal care. Of all, 38.9% women needed transfer to critical care. There were five (23.8%) maternal deaths. Of the 21 neonates, four were stillborn, nine needed NICU transfer and eight had an Apgar score of 9 at 5 min of birth.

CONCLUSION

Morbid adherent placenta is associated with poor maternal and neonatal outcome.

First trimester spontaneous uterine rupture in a young woman with uterine anomaly

Spontaneous uterine rupture is a life-threatening obstetrical emergency carrying a high risk for the mother and the fetus. Spontaneous uterine rupture in early pregnancy is very rare complication and it occurs usually in scarred uterus. Uterine anomalies are one of the reasons for spontaneous unscarred uterine rupture in early pregnancy. Obstetricians must consider this diagnosis when a pregnant patient presented with acute abdomen in early pregnancy. We present a case of spontaneous uterine rupture at 12 weeks of gestation in 24-year-old multigravida who had uterine anomaly presenting as an acute abdomen. Our preoperative diagnosis was ectopic pregnancy. Emergency laparotomy confirmed a spontaneous uterine rupture. Uterine anomaly is a risk factor for spontaneous uterine rupture in the early pregnancy. Clinical signs of uterine rupture in early pregnancy are nonspecific and must be distinguished from acute abdominal emergencies.

Misoprostol for treatment of early pregnancy failure in women with previous uterine surgery

OBJECTIVE

Misoprostol use in early pregnancy may incur a risk of uterine rupture in women with previous uterine surgery.

STUDY DESIGN

We analyzed 488 women who received misoprostol 800 microg vaginally in a study that evaluated medical and surgical management of early pregnancy failure. Subjects received a repeat misoprostol dose if expulsion was not confirmed 2 days after treatment. We compared efficacy, acceptability, and safety in subjects with a history (n = 78 women) or absence (n = 410 women) of uterine surgery, defined as cesarean delivery or myomectomy.

RESULTS

Expulsion rates after a single misoprostol dose (69% vs 72%; P = .64) and overall success at 30 days (82% vs 85%; P = .50) were comparable. Pain, bleeding, complications, and acceptability did not differ. No uterine ruptures occurred (95% CI, 0, 3.8%).

CONCLUSION

Misoprostol treatment for early pregnancy failure had similar success, acceptability, and complications in women with and without previous uterine surgery.

Blood in the belly: CT findings of hemoperitoneum

Hemoperitoneum may occur in various emergent conditions. In the trauma setting, evidence of intraperitoneal blood depicted at computed tomography (CT) should lead the radiologist to conduct a careful search of images for the injured visceral organ (the liver or spleen). Specific CT signs, such as a sentinel clot or extravasation of intravascular contrast material, may indicate the source of bleeding and help direct management. In addition, the configuration of accumulated blood may help identify the injured organ; for example, triangular fluid collections are observed in the mesentery most often in the setting of bowel or mesenteric injury. Less commonly, hemoperitoneum may have a nontraumatic origin. Iatrogenic hemoperitoneum may occur as a complication of surgery or other interventional procedures in the abdominal cavity or as a result of anticoagulation therapy. Hemoperitoneum also may be seen in the setting of blood dyscrasias such as hemophilia and polycythemia vera. Tumor-associated hemorrhage, which most often occurs in hepatocellular carcinoma, hepatic adenoma, or vascular metastatic disease, also may produce hemoperitoneum. Other potential causes of nontraumatic hemoperitoneum are gynecologic conditions such as hemorrhage or rupture of an ovarian cyst and rupture of the gestational sac in ectopic pregnancy, and hepatic hematoma in syndromic hemolysis with elevated liver enzymes and low platelet count (HELLP syndrome). Vascular lesions (visceral artery aneurysms and pseudoaneurysms) that occur in systemic vascular diseases such as Ehlers-Danlos syndrome or in pancreatitis are another less common source of hemoperitoneum.