Author Information
Sharma G*, Samant PY**, Parulekar SV***
(* Third Year Resident, ** Additional Professor, *** Professor and Head of Department
Department of Obstetrics and Gynaecology, Seth G.S. Medical College and K.E.M Hospital, Mumbai, India.)
Abstract
Spontaneous
rupture of uterus in a primigravida prior to onset of labor is extremely rare.
The uterus needs to be conserved in such cases, if possible. The future
obstetric outcome is influenced by quality of the scar We report hysterographic findings in a case
of spontaneous chronic upper segment rupture in 26 year old primigravida with
30 weeks of gestation.
Introduction
Poor
healing of a uterine scar may be associated with complications in future
pregnancies like scar pregnancy, morbidly adherent placenta, scar dehiscence or
rupture.[1] The healing may
be related to the site of the rupture (upper segment versus lower segment), the
type of rupture (acute versus chronic), the type of suture material, and/or the
suturing technique. A defective scar increases the risk of recurrent rupture.
Though the value of a hysterography in assessment of the integrity of uterine
lower segment scars is unproved, it may be useful in assessment of upper
segment scars in between pregnancies. An unusual case of healing of such an
injury is presented.
Case
Report
A 30 year
old woman, married for 12 years, primigravida presented with 7.5 months of
amenorrhea and complaints of watery vaginal discharge and pain in abdomen for
10 days. She had undergone diagnostic hysteroscopy and laparoscopy one year ago
for evaluation of infertility. Operative details of the procedure were not
available. On examination her vital parameters were normal. She had severe
pallor. There was no tenderness, guarding or rigidity on abdominal examination.
Uterine fundal height was of 30 weeks of gestation. The fetus was in left
acromioanterior oblique lie. Clear amniotic fluid was seen to be draining from
the cervix which was uneffaced and closed, Her hemoglobin was 6.2 g/dL, white
cell count and C reactive protein levels normal. Ultrasonography showed a
viable fetus of 25 weeks of gestation and estimated weight of 700 g in an
oblique lie. It had an encephalocoele. Amniotic fluid index was zero. There was
no evidence of peritoneal fluid collection. Four units of packed cells were
transfused to correct the anemia. White cell count and C reactive protein
levels were estimated every day. In view of prolonged rupture of membranes, an
oblique lie, and rising levels of C reactive protein, a hysterotomy was
performed under spinal anesthesia. A live female fetus weighing 650 g was
delivered through a lower segment transverse incision. A small portion of the
placenta was delivered out of the uterine incision. A 5 cm diameter defect was
noted in the left fundal area of the uterus. The placenta and membranes were seen
extruding from the defect. The uterine wall was thinned around the defect, and
its edges were fibrotic and not bleeding. The sigmoid, transverse colon and a
loop of small bowel were adherent to the posterior wall of the uterus below the
defect. The placenta was adherent to the sigmoid colon. The adhesions between
the uterus and bowel were released with the assistance of surgeons. A small
part of the placenta was left attached to the sigmoid colon because it could
not be separated safely. Small serosal tears in the sigmoid colon were
repaired. The uterine rent was repaired with a continuous suture of
polygalactin no. 1 excluding the decidua. The primary uterine incision was
closed similarly. The patient was transfused with 4 units of packed cells and 4
units of fresh frozen plasma. She made an uneventful recovery.
The couple
was counseled regarding the future risk of rupture of uterus at scar site and
increased risk of maternal and perinatal morbidity and mortality. However the
couple was keen on having another pregnancy. So a hysterography was performed
after 6 months to assess healing of the scar. It showed multiple pockets of the
dye in the myometrium at the site of the scar, and an intravasation of the dye
(figure 1). There was no defect in the myometrium at the scar site.
Figure 1.
Hysterogram: there are multiple pockets of the dye in the myometrium (solid
arrows) and venous intravasation of the dye (hollow arrow).
Discussion
The
incidence of uterine rupture increases in a case of scarred uterus depending on
the type and site of incision or injury. There is a 32% risk of uterine rupture
in a patient with prior upper segment rupture in comparison to 6% risk in a
patient with lower segment rupture.[2,3] Rupture of unscarred uterus
is associated with higher parity, prolonged labor, obstetric maneuvers
(internal podalic version, manual removal of placenta, and instrumental
delivery), inherent weakness of myometrium, disorders of collagen matrix
(Ehler’s Danlos type IV), uterine anomalies, and placental abruption.[4] A
spontaneous rupture of the uterus in a nulliparous woman is unusual, but may be
seen if there has been uterine injury or surgery in the past. Hysterography can
be used to evaluate integrity of scar. It may show invasion of the myometrium
by the scar, pockets of the dye in the myometrium, and intravasation of the
dye. The differential diagnoses of this appearance include prominent cervical
glands, result of past myomectomy or curettage, uterine diverticula, and focal
adenomyosis.[5,6]
In the
case presented, the rupture of the uterus might have been due to uterine injury
at the time of hysteroscopy and laparoscopy. It had been a slow rupture, so
that the placenta got extruded and implanted on the sigmoid colon nearby. That
also explained why she did not have features of internal hemorrhage and a
hemoperitoneum at laparotomy. Multiple pockets of the dye in the myometrium at
the site of the scar indicate ingrowth of the endometium into the myometrium as
in adenomyosis, related to deficient endometrium locally. Venous intravasation
was due to deficient endometrium. The thinning of the uterine wall locally and
the radiographic appearance of the scar indicate a high risk of a rupture of
the uterus in a future pregnancy, possibly at an even earlier gestational age.
References
- Naji O, Abdallah Y, Bij De Vaate AJ, Smith A, et al. Standardized approach for imaging and measuring Cesarean section scars using ultrasonography. Ultrasound Obstet Gynecol 2012;39:252–259.
- Reyes-Ceja L; Cabrera R; Insfran E; Herrera-Lasso F. Pregnancy Following Previous Uterine Rupture: Study of 19 Patients. Obstetrics & Gynecology 1969;34:387-389.
- Ritchie EH: Pregnancy after rupture of the pregnant uterus: A report of 36 pregnancies and a study of cases reported since 1932. J Obstet Gynaecol Br Commonw 1971;78:642-648.
- Turner M.J: Uterine rupture. Best Pract Res Clin Obstet Gynaecol 2002;16:69-79.
- Ahmadi F, Torbati L, Akhbari F, Shahrzad G. Appearance of uterine scar due to previous caesarean section on hysterosalpingography: various shapes, locations and sizes. Iranian Journal of Radiology. 2013;10:103-10.
- Fabres C, Aviles G, De La Jara C, et al. The cesarean delivery scar pouch: clinical implications and diagnostic correlation between transvaginal sonography and hysteroscopy. J Ultrasound Med 2003;22:695-700
Citation
Sharma G, Samant PY,
Parulekar SV. Hysterographic
Assessment of Repair of Uterine Chronic Rupture. JPGO
2014 Volume 1 Number 1 Available from: http://jpgyob.blogspot.in/2014/01/hysterographic-assessment-of-repair-of.html