Spontaneous uterine rupture at 28 weeks: A case report

Spontaneous Uterine rupture is associated with massive intra-peritoneal bleed which can be fatal if not recognized. We report a case of 32 year old multigravida at 28 weeks of gestation with history of liver cysts, previous caesarean and uterine curettage, who presented with acute abdominal pain and tenderness; ultrasound revealed placenta percreta. CT abdomen showed haemoperitoneum. The patient underwent emergency caesarean hysterectomy due to uterine rupture at the cornual site.

[Complete uterine ruptures]

BACKGROUND

Uterine rupture is one of the most severe Obstetric complications by high morbidity and maternal and fetal mortality.

OBJECTIVES

To review cases of uterine rupture occurred for the last five years. Release the incidence, the risk factors and maternal and fetal complications, both immediate and long term.

METHODS

Retrospective cohort study including all patients who completed their gestation in the University Hospital Complex of Ourense (Spain) between 2008 and March 2013. Review all medical records of patients diagnosed with uterine rupture during this period. Statistical analysis was performed using the statistical package Epidat 3.0.

RESULTS

We found an overall incidence of uterine rupture of 0.078 %. In patients with a previous cesarean delivery incidence rises to 0.31%.

CONCLUSION

Uterine rupture is an uncommon but with high maternal fetal morbidity. The main risk factor is a trial of labor after a previous cesarean delivery.

Ruptured uterus and bowel injury from manual removal of placenta: a case report

BACKGROUND

Retained placenta is a significant cause of maternal mortality and morbidity throughout the developing world. 'Though, intestinal injury may arise as a complication of induced abortion following instrumentation through the genital tract, the involvement of the large bowel in complicated manual removal of placenta is a very rare occurrence

CASE REPORT

We present the case of a 28 year-old Para 3+0, 3 alive woman who had attempted manual removal of placenta in a basic emergency obstetric care facility that resulted in lower uterine segment rupture with evisceration of bowels through the laceration outside the introitus. She subsequently had right hemi- colectomy with ileo-transverse anastomosis and repair of uterine rupture with bilateral tubal ligation.

CONCLUSION

This case highlights the risk of exposing parturients to inexperienced attendants at delivery and emphasises the need for intensification of manpower training to attain the 5th MDG enunciated by the United Nations.

The pattern of labor preceding uterine rupture

OBJECTIVE

We sought to characterize the labor of women attempting trial of labor after cesarean (TOLAC) who experience uterine rupture.

STUDY DESIGN

We conducted a secondary analysis of a nested case-control study of women attempting TOLAC. Women experiencing uterine rupture (cases) were compared to 2 reference groups: successful TOLAC and failed TOLAC. Interval-censored regression was used to estimate the median time to progress 1 cm in dilation and the total time from 4-10 cm.

RESULTS

A total of 115 cases were compared to 341 successful TOLAC and 120 failed TOLAC. The time to progress 1 cm was similar between groups until 7-cm dilation. After 7 cm, cases of uterine rupture required longer to progress than successful TOLAC (median [95th percentile] time from 7-8 cm: 0.38 [1.91] vs 0.16 [0.79] hours; from 8-9 cm: 0.28 [1.10] vs 0.10 [0.39] hours). Women with a uterine rupture had labor curves similar to those with a failed TOLAC.

CONCLUSION

Women with labor dystocia in the active phase of labor should be closely monitored for uterine rupture in TOLAC.

Isolated impairment of posterior pituitary function secondary to severe postpartum haemorrhage due to uterine rupture

Cranial diabetes insipidus (DI) due to postpartum haemorrhage is an extremely rare clinical event. We describe herein isolated posterior pituitary insufficiency in a 26-year-old woman who had undergone subtotal hysterectomy for severe postpartum haemorrhage because of uterine rupture. The patient experienced polyuria within 6 h postoperatively. DI was suggested by the elevated urine volumes and low urine specific gravity. The diagnosis of DI was confirmed by water deprivation test and vasopressin stimulation test. The anterior pituitary function was within normal limits. A high clinical suspicion is certainly required for the diagnosis of DI in the immediate postpartum period. To rapidly initiate appropriate therapy, the possibility of DI should always be kept in mind while evaluating patients who have polyuria and polydipsia after severe postpartum bleeding. Delay or failure to treat this condition might result in hypovolemic shock.

[Life threatening postpartal haemorrhage after rupture of the vagina, uterine cervix, caesarean section or hysterectomy]

The authors discuss 10 cases--seven after vaginal and cervical rupture, 2 after Caesarean section and 1 after hysterectomy. Six of them died--5 after rupture of the vagina and cervix and one after Caesarean section. The lethal issue was avoidable in all cases because it was a result of untimely done or not done at all hysterectomy and other interventions, e.g., ligation of the hypogastric arteries, as well as of faulty surgical performance. Basic principles of surgical behavior in such cases are postulated.

First trimester uterine rupture and scar pregnancy

Uterine rupture during the first trimester of pregnancy is an extremely rare, but life-threatening cause of intraperitoneal hemorrhage. Up to the knowledge of the authors all reports of first trimester uterine ruptures are related to scar dehiscences following previous cesarean sections or occurred in unscarred uteri of multiparous women. In cases of multiparity silent ruptures cannot be precluded, so that the uterus might be scarred during the following pregnancy. In early pregnancy of approximately 4-5 weeks, vaginal ultrasonography may clearly verify a scar pregnancy, but sonographical diagnostic findings may change with the pregnancy progress. In all cases of reported first trimester ruptures in pregnancies with previous cesarean sections or in pregnancies of multiparous women reported in literature, dating scans were performed too late for to preclude pregnancies in the scar. We postulate our hypotheses, that all first trimester uterine ruptures are caused by scar implantation of the trophoblast.

Pathologie und Klinik der Uterusrupturen in der Universitäts-Frauenklinik Hamburg-Eppendorf in den Jahren 1968 bis 1982

This report deals with 26 cases of uterine rupture seen in Hamburg-Eppendorf in the gynaecological hospital of the University during the years 1968 to 1982. The frequency of such rupture was 0.1% in relation to the total number of deliveries. Approximately 92% of the cases were due to a previous Caesarean section. There was no maternal death, although the maternal complication rate was high. The corrected perinatal mortality rate in relation to a rupture of the uterus was 3.8% during the period under review.

Intrapartum predictors of uterine rupture

This case-controlled study reviewed 26 cases of uterine rupture at an academic medical center. Controls were selected in a 2:1 design by reviewing the immediate successful vaginal birth after cesarean delivery (VBAC) before and after each case of uterine rupture. At less than 2 hours before delivery or acute uterine rupture, mild and severe variable decelerations, persistent abdominal pain, and hyperstimulation were more common in cases of uterine rupture as compared to controls and had statistically significant positive likelihood ratios (LR). Mild and severe variable fetal heart rate decelerations, especially in the presence of persistent abdominal pain, may predict uterine rupture in patients attempting VBAC.

Frequency, predisposing factors and fetomaternal outcome in uterine rupture

OBJECTIVE

To determine the frequency and to analyze the predisposing factors, maternal and fetal outcome of uterine rupture.

DESIGN

Cross-sectional study.

PLACE AND DURATION OF STUDY

The Department of Gynaecology and Obstetrics, Jinnah Postgraduate Medical Centre, Karachi from February 1997 to January 2000.

PATIENTS AND METHODS

All cases of ruptured uterus, who were either admitted with or who developed this complication in the hospital, were included in the study. Demographic data, details regarding the most probable predisposing factor, type of rupture, the management and maternal and fetal outcome were taken into consideration for analysis.

RESULTS

During three years, total number of deliveries was 18668, and there were 103 cases of uterine rupture (0.55%). Out of these, only 13 (12.62%) patients were booked. Most of the patients presented between the ages of 26-30 years (42.71%). Majority of ruptures occurred in para 2-4 (44.66%). Fifty-five cases (53.39%) had a previous caesarean section scar. In 68 (66.01%) cases, the tear was located in lower uterine segment. In 93 (90.29%) cases, anterior uterine wall was involved. Rupture was complete in 79 (76.69%) cases. Repair of uterus was done in 79 (76.69%) cases. Hysterectomy was performed in 24 (23.30%) cases. There were 8 (7.76% or 77.66/1000) maternal deaths and 85 (81.73% or 825 / 1000) perinatal deaths.

CONCLUSION

This study confirms high frequency of such serious preventable obstetrical problem which can lead to high fetomaternal mortality. Rupture of caesarean section scar was the most common cause of uterine rupture found in this series.

Obstetric Uterine Rupture of the Unscarred Uterus: A Twenty-Year Clinical Analysis

BACKGROUND

Rupture of the unscarred uterus is a rare and potentially catastrophic event. We retrospectively reviewed the records of patients with this condition to analyze their obstetric and gynecologic history and evaluate maternal and perinatal morbidity and mortality.

METHODS

A total of 11 cases of rupture of the unscarred gravid uterus were managed at Mackay Memorial Hospital from January 1984 to September 2003. Data extracted from the records included the use of uterine stimulants, instrumental delivery, and prior abortion by instrumentation, clinical features, treatment, and maternal and fetal morbidity and mortality.

RESULTS

The incidence of unscarred uterine rupture is 0.009% during the 20-year study period. The most common contributing factors were prior abortion by instrumentation and the use of uterotonic agents, in three cases respectively. Fetal distress occurred in six cases and postpartum hemorrhage in two. There was no maternal death, but in two cases, there was intrauterine fetal demise or perinatal death.

CONCLUSION

Though unexpected in a woman with an unscarred uterus, rupture should be considered as a possible cause of fetal distress or unusual pain or hypotension in the mother.

Fetal Heart Rate Changes Associated With Uterine Rupture

OBJECTIVE

To identify fetal heart rate characteristics of patients with uterine rupture compared with successful vaginal birth after cesarean (VBAC) controls.

METHODS

This is a case-control study. Obstetric records of patients at the University of Washington Medical Center and Swedish Medical Center were reviewed for cases of uterine rupture. Entry criteria included operative confirmation of the diagnosis, gestational age beyond 24 weeks, presence of one or more prior low transverse uterine incisions, and availability of fetal heart tracings. Each case was matched with 3 controls randomly selected from a pool of successful VBAC deliveries at the same institution within 1 year. Three blinded independent examiners then examined fetal heart tracings. Each tracing was rated for the presence of fetal tachycardia, mild or moderate variable decelerations, severe variable decelerations, late decelerations, prolonged decelerations, fetal bradycardia, and loss of uterine tone in both the first and second stages of labor separately.

RESULTS

Of the 48 uterine ruptures identified, 36 met inclusion criteria. These were matched with 100 controls. Cases showed significantly increased rates of fetal bradycardia than controls in the first stage (P <.01) and second stage (P <.01). No significant differences were noted in rates of mild or severe variable decelerations, late decelerations, prolonged decelerations, fetal tachycardia, or loss of uterine tone.

CONCLUSION

Fetal bradycardia in the first and second stage is the only finding to differentiate uterine ruptures from successful VBAC patients.

LEVEL OF EVIDENCE

II-2

Pyometra. What is its clinical significance?

OBJECTIVE

To evaluate the clinical outcomes of pyometra.

STUDY DESIGN

Retrospective study conducted between 1993 and 1999 in two regional hospitals.

RESULTS

Pyometra represented 0.038% of gynecologic admissions. Of the 27 women with pyometra, 6 (22.2%) cases were associated with malignancy, 1 (3.7%) was associated with genital tract abnormality, and 20 (74.1%) were idiopathic. Patients with idiopathic pyometra tended to be older and had a higher incidence of concurrent medical conditions. Five (18.5%) women experienced spontaneous perforation of pyometra. A preoperative diagnosis was correctly made in 17 of 22 (77.3%) patients without spontaneous perforation. Most women were treated with dilatation of the cervix and drainage. Nine women (33.3%) had persistent or recurrent pyometra; three of them were asymptomatic.

CONCLUSION

Pyometra is an uncommon condition, but the incidence of associated malignancy is considerable, and the risk of spontaneous perforation is higher than previously thought. Dilatation and drainage is the treatment of choice, and regular monitoring after initial treatment is warranted to detect persistent and recurrent disease.

Characteristics of fetal heart rate tracings prior to uterine rupture

OBJECTIVE

To identify the fetal heart rate patterns that occurred in a 2-h period of time preceding uterine rupture.

METHODS

The fetal monitor strips and the medical records of patients with a confirmed diagnosis of uterine rupture were reviewed. These patients delivered at the University of Michigan Hospital from January 1, 1985 to December 31, 1999 and were >or =28 weeks gestational age. Asymptomatic uterine scar dehiscences were excluded. The weeks of gestation, the number of cesarean sections, the surgical findings, and the maternal complications were obtained from the review of the maternal records. The fetal monitor strips for the 2 h preceding the uterine rupture were analyzed, and the fetal heart rate patterns were classified.

RESULTS

During the study period, there were 11 patients identified with uterine rupture. Seven of the 11 (64%) had operative or post-operative complications. There were no maternal deaths. Review of the eight fetal heart rate tracings available revealed 7/8 (87.5%) with recurrent late decelerations and 4/8 (50%) with terminal bradycardia. All four of the patients with fetal bradycardia were preceded by recurrent late decelerations (100%).

CONCLUSIONS

The most common fetal heart rate abnormalities that occurred prior to uterine rupture were recurrent late decelerations and bradycardia. The appearance of recurrent late decelerations may be an early sign of impending uterine rupture.

Third consecutive complete posterior uterine rupture. A case report

BACKGROUND

Management of pregnancy in a woman who has had a ruptured uterus on more than one occasion presents a great clinical and ethical challenge to the obstetrician.

CASE

This appears to be the first report on complete uterine ruptures in three consecutive pregnancies.

CONCLUSION

Prolonged hospital admission, intensive antenatal surveillance, antenatal steroid administration and elective premature delivery may give the best chance for a good outcome in these pregnancies. However, despite all these efforts, there is still a high risk of an unfavorable outcome.

Maternal and neonatal outcomes after uterine rupture in labor

OBJECTIVE

There is significant controversy about the risks related to attempted vaginal birth after cesarean and the implications for informed consent of the patient. Recent data suggest that women who deliver in hospitals with high attempted vaginal birth after cesarean rates are more likely to experience successful vaginal birth after cesarean, as well as uterine ruptures. We conducted a study to evaluate maternal and neonatal morbidity and mortality after uterine rupture at a tertiary care center.

STUDY DESIGN

We performed a retrospective chart review of cases of uterine rupture from 1976 to 1998. All women who had a history of uterine rupture were identified with International Classification of Diseases, Ninth Revision, identifiers with hospital discharge data cross-referenced with a separate obstetric database. We abstracted demographic information, fetal heart rate patterns, maternal pain and bleeding patterns, umbilical cord gas values, and Apgar scores from the medical record. Outcome variables were uterine rupture events and major and minor maternal and neonatal complications.

RESULTS

During the study period there were 38,027 deliveries. The attempted vaginal birth after cesarean rate was 61.3%, of which 65.3% were successful. We identified 21 cases of uterine rupture or scar dehiscence. Seventeen women had prior cesarean deliveries (10 with primary low transverse cesarean delivery, 3 with unknown scars, 1 with classic cesarean delivery, 2 with two prior cesarean deliveries, and 1 with four prior cesarean deliveries). Of the 4 women who had no history of previous uterine surgery, one had a bicornuate uterus whereas the others had no factors increasing the risk for uterine rupture. We confirmed uterine rupture and scar dehiscence in 19 women. Specific details were not available for 2 patients. Uterine rupture or scar dehiscence was clinically suspected in 16 women with 3 cases identified at delivery or after delivery. Sixteen women had symptoms of increased abdominal pain, vaginal bleeding, or altered hemodynamic status. There were 2 patients who required hysterectomies and 3 women who received blood transfusions; there were no maternal deaths related to uterine rupture. The fetal heart rate pattern in 13 cases showed bradycardia and repetitive variable or late decelerations. Thirteen neonates had umbilical artery pH >7.0. Two cases of fetal or neonatal death occurred, one in a 23-week-old fetus whose mother had presented to an outlying hospital and the second in a 25-week-old fetus with Potter's syndrome. All live-born infants were without evidence of neurologic abnormalities at the time of discharge.

CONCLUSION

Our data confirm the relatively small risk of uterine rupture during vaginal birth after cesarean that has been demonstrated in previous studies. In an institution that has in-house obstetric, anesthesia, and surgical staff in which close monitoring of fetal and maternal well-being is available, uterine rupture does not result in major maternal morbidity and mortality or in neonatal mortality.

Dystocia among women with symptomatic uterine rupture

OBJECTIVE

The purpose of this study was to analyze cervical dilatation patterns among women with uterine rupture by means of a mathematic model and to use the results to determine optimal intervention criteria.

STUDY DESIGN

This was a case-control review that compared a case patient group of 19 women with uterine rupture during labor with control groups with either no previous cesarean deliveries, vaginal birth after cesarean delivery, or failure of attempted vaginal birth after cesarean delivery. The mathematic model quantified dilatation and adjusted for conditions specific to each patient. Case patients were compared with matched control subjects by means of paired t tests, analysis of variance, odds ratios, and conditional logistic regression.

RESULTS

Dystocia was present in 31.6% to 47.4% of patients with uterine rupture, versus 2.6% to 13.2% of the control group with no previous cesarean deliveries (P< or =.001). The incidence of an arrest disorder among patients with uterine rupture was similar to that seen in the control group with failure of attempted vaginal birth after cesarean delivery. However, the interval from diagnosis to rupture or cesarean delivery was 5.5 +/- 3.3 hours among case patients with uterine rupture and 1.5 +/- 1.3 hours in the control group with failure of attempted vaginal birth after cesarean delivery.

CONCLUSION

When cervical dilatation was lower than the 10th percentile and was arrested for > or =2 hours, cesarean delivery would have prevented 42.1% of the cases of uterine rupture and resulted in excess 2.6% and 7.9% cesarean delivery rates among women with no previous cesarean deliveries and women with vaginal birth after cesarean delivery, respectively.

The effect of uterine rupture on fetal heart rate patterns

The high success rate of vaginal birth after cesarean section (VBAC) and its low association with complications has led to VBACs being attempted at all types of facilities, including birth centers. It must be kept in mind that unpredictable uterine rupture can occur and that uterine rupture necessitates emergency intervention. The only reported predictable feature of fetal heart rate patterns in response to uterine rupture is the sudden onset of fetal bradycardia. Fetal patterns are presented to illustrate this finding.

Uterine activity patterns in uterine rupture: a case-control study

OBJECTIVE

To determine whether uterine activity patterns are associated with intrapartum uterine rupture.

METHODS

Because of the infrequency of uterine rupture, a case-control design was implemented. Cases were women who sustained uterine ruptures during a trial of labor, resulting in a neurologically impaired neonate. Controls were women who had a successful vaginal birth after cesarean (VBAC) or vaginal delivery with no history of uterine scar. The uterine activity patterns of cases were compared with those of each control group for number of contractions per hour, uterine tetany (contraction longer than 90 seconds), and uterine hyperstimulation (five or more contractions in a 10-minute period).

RESULTS

The final study population consisted of 18 rupture patients, 35 VBAC patients, and 33 spontaneous vaginal delivery patients. Women in the rupture group had fewer contractions per hour (15.8+/-7.3) than VBAC (19.7+/-5.5) (P < .05) or spontaneous delivery group (19.4+/-6.6) (P < .10). VBAC patients were five times as likely to have 16 or more contractions per hour than were rupture patients, 95% confidence interval [CI] 1.3, 21.3, P < .02). Patients who had spontaneous delivery were 3.5 times more likely to have 16 or more contractions per hour than were rupture patients (95% CI 0.9, 14.1, P = .08). The rupture group had equal or less uterine tetany than did the controls.

CONCLUSION

Uterine activity patterns and oxytocin use do not appear to be associated with the occurrence of intrapartum uterine rupture.

Spontaneous rupture of the unscarred uterus

OBJECTIVE

By presentation of cases of spontaneous (nontraumatic) ruptures of previously intact uteri, we sought to emphasize important aspects of this rare and dangerous event.

STUDY DESIGN

Two case presentations of oxytocin-associated unscarred uterine rupture and review of pertinent literature are used to study risk factors and accompanying clinical characteristics.

RESULTS

Both spontaneous ruptures of previous unscarred uteri were associated with low-dose oxytocin augmentation, bradycardia, and uterine hyperstimulation monitor patterns and occurred at the onset of the second stage of labor.

CONCLUSION

Because of its rarity, further investigation of spontaneous uterine rupture will depend on case presentations where the associated events listed are noted and uterine hyperstimulation, fetal bradycardia, and second-stage onset are proved or disproved as valid clinical associations.

The prediction of "controlled" uterine rupture by the use of intrauterine pressure catheters

OBJECTIVE

To determine whether uterine activity, assessed by either fluid-filled or solid pressure catheters, changes with uterine incision at cesarean delivery.

METHODS

Uterine activity was recorded continuously during low transverse cesarean delivery in ten parturients using fluid-filled pressure catheters and in ten women with solid pressure catheters. Visual analyses were performed of the last 30 minutes of uterine recording before uterine incision and of the period after incision; the analyses were then compared within and between the catheter groups for mean uterine tone and contraction amplitude, frequency, and duration. Oxytocin use, anesthesia method, mean gestational age, birth weight, length of labor, duration of monitoring, and uterine incision-to-delivery time were compared between the groups.

RESULTS

All obstetric end points were similar in both catheter groups except for a higher mean birth weight in the solid-catheter group. The mean (+/- standard deviation) duration of post-incision monitoring was 4.7 +/- 0.94 minutes. After uterine incision, mean tone and contraction amplitude were unchanged, whereas mean contraction frequency and duration decreased significantly.

CONCLUSIONS

Though intrauterine monitoring was brief, this model allows a unique view of "controlled" uterine rupture. Spontaneous uterine rupture may evolve more gradually; however, neither catheter type would be likely to aid its early recognition.

Trauma in pregnancy: uterine rupture

Trauma during pregnancy is a unique situation. Understanding injury patterns, anatomic and physiologic changes, and the initial approach to resuscitation is essential for all emergency nurses. Maternal resuscitation is the only means of fetal resuscitation. Meticulous attention must be given to the ABC's, with some minor modifications. Cervical spine immobilization is done in conjunction with positioning on the left side. Oxygen is used liberally, but may not benefit the fetus if hypovolemia exists. IV access and aggressive fluid resuscitation should proceed quickly. Diagnostic testing, including radiologic evaluation, is performed as necessary--the mother's life must not be jeopardized on the basis of fetal risk. Continuous fetal monitoring should be instituted, even with seemingly minor injuries. In the rare event of maternal arrest, a postmortem cesarean section may be lifesaving for the infant. Policies should be formulated jointly by ED, obstetric, and neonatal staffs in advance to speed this difficult decision-making process. The keys to survival, for both mother and infant, are an organized approach to resuscitation and teamwork among all professionals.

Diagnostic potential of cardiotocography (CTG) for silent uterine rupture

We report on 3 patients with silent rupture of previous uterine scars. Despite continuous monitoring by cardiotocography, diagnosis was not made until the time of surgery. The cesarean section was indicated by the obstetrical-clinical examination, while CTG offered no evidence of uterine rupture.

Uterine rupture secondary to a malignant mixed mesodermal (mullerian) tumor: a case report

A case of uterine rupture resulting from tumor penetration of the myometrium in a patient with malignant mixed mesodermal tumor is described; the first in the literature known to the authors. Notable features include rapid progression of disease, hemoperitoneum, and diffuse intraoperative bleeding controlled by radiographic embolization.

[Uterine rupture in sheep]

A number of cases of uterine rupture in sheep occurring in the field are reported. Ruptures of the uterus in sheep which could not be sutured were not found to carry a bad prognosis in every case.

Asymptomatic rupture of the uterus: a case report

Rupture of the gravid uterus is a serious obstetric emergency that threatens maternal and fetal life. In certain cases the classic clinical picture may be absent. Most asymptomatic ruptures are in the lower segment and of minor extent or are really dehiscences of scars. This paper presents a case of massive spontaneous rupture involving the entire corpus diagnosed at elective postpartum sterilization. This unusual event stimulated a review of the causes and clinical presentations of uterine rupture.

Rupture of the uterus with DIC

Rupture of the uterus is an uncommon obstetric emergency that usually occurs after 36 weeks gestation in a woman with a previous cesarean section. Complete rupture of the uterus with extrusion of the fetus into the peritoneal cavity is associated with high fetal mortality and with hypovolemic shock in the mother. Incomplete ruptures are less catastrophic and are often found incidentally at routine elective cesarean section. Management of uterine rupture consists of prompt recognition, rapid replacement of maternal blood volume, and early laparotomy and hysterectomy or, in selected cases, uterine repair. Disseminated intravascular coagulation has been reported in association with such obstetrical emergencies as abruptio placentae, intrauterine fetal demise, septic abortion, and amniotic fluid embolism. We report a case in which there was clinical and laboratory evidence of DIC in a patient with uterine rupture. The patient was successfully managed with prompt hysterectomy and replacement of coagulation factors.

Plane penetration of uterine muscle by intrauterine shields

A finite element approach is used to predict stress and deformation states of uterine muscle tissue under plane strain indentation by a flexible shield. Realistic, one-dimensional "punch" elements at the shield edges assure that muscle shear stresses remain bounded within experimentally measured values. For typical tissue, bearing pressure, deformation flow fields and edge slip stresses leading to tissue damage are calculated. Penetration depth to shield width ratios are up to 3.0. A piecewise linear, elastic approximation to the highly variable, nonlinear mechanical behavior of the tissue is used. Results are applied to the prediction of possible tissue damage by a flexible shield intrauterine contraceptive device, in place and in equilibrium with typical multiparous uteri.

[Notes on the aetiopathogenesis, clinical picture and treatment of rupture of the uterus during labour. Apropos of a case]

The aetiopathogenesis, clinical picture and anatomopathological features of spontaneous rupture of the uterus during labour are examined and reference is made to a personal case in which the ensuing massive haemorrhage necessitated hysterectomy. A pathogenetic interpretation of this serious complication is based on the findings.