Posterior uterine wall rupture during labour

Modified surgical technique in an unusual uterine rupture

Background

Uterine rupture is an extremely rare and unpredictable event for women undergoing trial of labor after cesarean delivery (TOLAC).

Case presentation

We present a patient with a lateral edge uterine rupture after TOLAC and our modified surgical technique for preventing complications of uterine atony.

Conclusion

Further case report studies are required in order to evaluate the effectiveness of our new-modified surgical technique in appropriate selected cases.

Rupture of the posterior cul-de-sac during trial of labour after caesarean section

Rupture of the vaginal wall in unobstructed labour is a rare entity in the developed world. This case report describes rupture of the posterior cul-de-sac in a healthy 34-year-old multiparous woman attempting trial of labour after caesarean section. The woman presented to the labour ward at term with spontaneous onset of contractions. In the second stage of labour, the woman experienced sudden severe abdominal pain, different in character from the contraction pain. Therefore, the baby was delivered by ventouse extraction. As the woman continued to experience severe immobilising abdominal pain during the hospital stay, a CT scan was performed which revealed a haematoma and free fluid at the right side of the uterus. A laparotomy was performed 3 days postdelivery, during which a rupture of the posterior cul-de-sac was found and closed with a continuous suture. The woman was discharged 3 days after laparotomy in good clinical condition.

Spontaneous postpartum rupture of an intact uterus: a case report

Rupture of uterus is an obstetrical complication characterized by a breach in the uterine wall and the overlying serosa. We report an unusual case of spontaneous rupture of an unscarred uterus in a 33-year-old woman, a day after her third successful vaginal delivery. A 33-year-old pregnant woman, gravid 3, para 3, was referred to our department at 39 gestational week because of rupture of membranes. Despite tocolysis administration, her pregnancy was delivered vaginally after 2 days, giving birth to a male neonate of 3,020 g with normal Apgar scores at first and fifth minute. Her uterus was intact and gynecological examination after delivery was normal without any potential signs or symptoms of pathology. However, the day following her labor, patient complained of left iliac fossa pain. Her blood tests revealed a CRP value at 27.6 mg/L, whereas the X-rays revealed an extensive impacted fecal mass in the colon. MRI revealed that the left lower myometrial part of the uterus was depicted abrupt, with simultaneous presence of hemorrhagic stuff. The decision of laparotomy was therefore made in order to further evaluate rupture of uterus and properly treat patient. And subtotal hysterectomy was performed. Postoperative follow-up period was not characterized by any complications and patient was finally discharged 4 days after hysterectomy.

Rupture of a pregnant unscarred uterus in an early secondary trimester: a case report and brief review

Rupture of a pregnant uterus in early pregnancy and an unscarred uterus are extremely rare, and some non-specific symptoms might appear before this occurrence. We report the case of a multiparous woman (gravida 3, para 2) with uterine fundal rupture in her early second trimester (17+ weeks of gestational age), who presented upper abdominal discomfort and vomiting for 3 days, and progressed into sudden acute abdomen and shock. During emergent laparotomy, the entire amniotic sac was found in the peritoneal cavity with a rupture of the uterine fundus. Although we could not confirm that the appearance of upper gastrointestinal symptoms and severe vomiting was associated with uterine rupture in this pregnant woman, abdominal symptoms or signs might be a hint or cause of severe catastrophic pregnancy-related complications.

Posterior uterine rupture causing fetal expulsion into the abdominal cavity: a rare case of neonatal survival

Introduction. Uterine rupture is a potentially catastrophic complication of vaginal birth after caesarean section. We describe the sixth case of posterior uterine rupture, with intact lower segment scar, and the first neonatal survival after expulsion into the abdominal cavity with posterior rupture. Case Presentation. A multiparous woman underwent prostaglandin induction of labour for postmaturity, after one previous caesarean section. Emergency caesarean section for bradycardia revealed a complete posterior uterine rupture, with fetal and placental expulsion. Upon delivery, the baby required inflation breaths only. The patient required a subtotal hysterectomy but returned home on day 5 postnatally with her healthy baby. Discussion. Vaginal birth after caesarean section constitutes a trial of labour, and the obstetrician must be reactive to labour events. Posterior uterine rupture is extremely rare and may occur without conventional signs. Good maternal and fetal outcome is possible with a prompt, coordinated team response.

Shortening the second stage of labor?

OBJECTIVE

To evaluate the benefits and risks of using uterine fundal pressure in shortening the second stage of labor and on the obstetrical outcome.

MATERIAL AND METHODS

A pilot study comprising 209 primigravidae between 37 and 40 gestational weeks with singleton fetus in cephalic presentation admitted to the delivery suite were considered and were randomly allocated into two groups: I (n=101) and II (n=108), with or without manual fundal pressure, respectively, during the second stage of labor. Main observation measures considered were: duration of the second stage of labor was the primary outcome measure and the secondary outcome measures were severe maternal morbidity/mortality, neonatal trauma, admission to neonatal intensive care unit, and neonatal death.

RESULTS

There were no significant differences in the mean duration of the second stage of labor and secondary outcome measures. Significant adverse findings having no mention in the earlier literature, were noticed which were: one case each of retained placenta and uterine prolapse besides increased evidence of maternal exhaustion and perineal injuries (including one case of complete perineal tear) in the group where fundal pressure was exercised.

CONCLUSION

Application of uterine fundal pressure in a delivering woman was not only ineffective in shortening the second stage of labor but added to the risks during parturition.

Posterior uterine rupture in a woman with a previous Cesarean delivery

A 33-year-old primipara with a previous low transverse Cesarean delivery underwent labor induction at 41 weeks' gestation with a 10-mg dinoprostone vaginal insert. Eleven hours later, with the cervix fully dilated, an emergency Cesarean delivery was performed because of repetitive variable decelerations followed by fetal bradycardia. A posterior uterine wall rupture extending from the fundus to the vagina was repaired in layers. The neonate had an Apgar score of 2 and 4 and expired on the 7th day of life.

Delayed diagnosis of an atypical rupture of an unscarred uterus due to assisted fundal pressure: a case report

Introduction

Although rare, rupture of an unscarred uterus is one of the most dangerous obstetric complications, resulting in maternal and fetal jeopardy.

Case presentation

A 30-year-old grand multiparous Turkish woman without any history of uterine surgery gave birth vaginally at 37 weeks of gestation with fundal pressure applied in the second stage of labor. Transabdominal sonography performed 32 hours after delivery due to postural hypotension and a drop in hemoglobin values in the postpartum period revealed massive intra-abdominal free fluid. On emergency laparotomy, serosal rupture of the uterus on the left posterior side was observed. She underwent a subtotal hysterectomy and did well postoperatively.

Conclusion

Postural hypotension in postpartum patients without any evident vaginal bleeding may be an early sign of possible uterine rupture, even if the vital signs are stable. Early diagnosis is important if maternal morbidity and mortality are to be decreased.

Fetal survival following posterior uterine wall rupture during labour with intact previous caesarean section scar

INTRODUCTION

Posterior wall rupture of the uterus in presence of previous caesarean scar is an extremely rare and unpredictable event.

CASE REPORT

A 26-year old lady in her second pregnancy went into spontaneous labour at 41 weeks gestation. She had emergency caesarean section in her previous pregnancy. She made slow progress in labour to full dilatation without augmentation, but was noted to have fresh vaginal bleeding and breakthrough pain despite an epidural. Uterine scar rupture was suspected and an emergency lower segment caesarean section was carried out. Fresh intraperitoneal bleeding was noted but with an intact previous scar. The baby was delivered in good condition. A vertical posterior uterine wall rupture of the lower segment, 5 cm in length, was found to be bleeding profusely and was successfully repaired.

DISCUSSION

Uterine rupture is a rare but serious complication. Usually the rupture occurs through the previous uterine scar. There are only four reported cases in the literature of posterior uterine rupture in labour through "healthy" uterine tissue in women with previous caesarean section. This is the first instance of fetal survival. The exact mechanism is unknown but likely to be a combination of factors including prostaglandin use, element of obstruction and strong inelastic scar.

CONCLUSION

Strict vigilance is required during labour in women with previous scar. Early recognition of imminent scar rupture should speed delivery and improve the outcome for mother and baby.

Silent Uterine Rupture in an Unscarred Uterus

OBJECTIVE

Uterine rupture is one of the most serious obstetric complications, with an increased risk of maternal and perinatal morbidity, and even mortality.

CASE REPORT

A multiparous woman came to our labor room at 41 weeks of gestation for induction of labor due to being post-term and having a nonreactive nonstress test. She had no history of abdominal or gynecologic surgery. Emergent cesarean section was performed due to prolonged decelerations shown on the fetal monitor. A 12 cm uterine laceration was identified after opening the abdominal cavity. Fortunately, her uterus was preserved and her postoperative condition was stable.

CONCLUSION

To avoid maternal and fetal morbidity, or even mortality, obstetricians should be aware of the possible existence of uterine rupture in an unscarred uterus.

Laparoscopic and vaginal repair of uterine scar dehiscence following cesarean section as detected by ultrasound

INTRODUCTION AND OBJECTIVE

Cesarean section (CS) is the most common operation in obstetrics, with rising incidence in most countries. As a result of this operation late scar dehiscence may occur, which may lead to uterine rupture in a subsequent pregnancy. In this case series we have described sonographic detection of scar dehiscence after CS and feasibility of vaginal or combined laparoscopic and vaginal scar excision and uterine repair.

METHODS

Five consecutive patients underwent vaginal or laparoscopic assisted vaginal approach for repair of suspected scar dehiscence following CS, during a 5 year period. In all cases, transvaginal sonography detected suspicious features of scar dehiscence over the anterior uterine wall. Except of one, all patients had reported recurrent pelvic pain and/or irregular menstrual bleedings. Furthermore all patients planned for a further pregnancy.

RESULTS

Resection of the uterine defect and re-constitution of the uterine wall was successfully achieved in all five patients. There were no intra-operative complications and none of the patients required blood transfusion. The mean operation time was 117 min (27-192). Presence of scar tissue was confirmed on histology in all specimens. Four patients remained free of symptoms with no evidence of recurrent scar dehiscence on sonography over a median follow up of 30 months (3-46). One patient had an uneventful pregnancy 24 months after scar removal and was delivered by repeat CS at 39 weeks' gestation.

CONCLUSION

Patients with a history of CS should undergo transvaginal sonography of the scar region in order to detect latent scar dehiscence in combination with uterine wall thinning prior to planning further pregnancy. In suspected cases, a combined laparoscopic - vaginal or vaginal approach can be employed to repair the defect.