Author
Information
Ahale P*, Chauhan
AR
(* Fourth Year Resident, ** Additional Professor, *** Assistant Professor. Department of
Obstetrics and Gynecology, Seth GS Medical College & KEM Hospital, Mumbai, India)
Abstract
Uterine rupture is classified as either complete when all
layers of the uterine wall are separated, or incomplete when the uterine muscle
is separated but the visceral peritoneum is intact (uterine dehiscence). Morbidity
and mortality rates are high when rupture is complete. The greatest risk factor
for either form of rupture is prior cesarean delivery. We report a case of a
primigravida with 24 weeks’ pregnancy with rupture of the uterine fundus, with
past history of hysteroscopic injury, most probably uterine perforation, which
was repaired in order to conserve the uterus.
Introduction
Rupture
of uterus during labor is a common event. Overall incidence of uterine rupture
is 1 in 1146 pregnancies (0.07%)
and mostly they occur following
previous cesarean section involving the
lower segment. Spontaneous uterine rupture in
the second trimester is very rare. Previous reported cases show that second
trimester uterine rupture is associated with invasive choriocarcinoma, placenta
increta or percreta,[1] pregnancy in a rudimentary horn of a malformed uterus,[2] previous
myomectomy, previous cesarean section
scars, previous hysterolaparoscopy injury[3,4] and previous
dilatation and curettage.
Case
Report
A 34 year old
primigravida, married for 8 years, was referred with 24 weeks of pregnancy and
uterine rupture . The patient was a known case of primary
infertility who had undergone diagnostic hysteroscopy and laparoscopy one year ago
in a private hospital; she had been verbally told that there was a uterine
perforation during hysteroscopy; however, no documentation of the same was
available. She conceived within five
months of the procedure and had an uneventful first trimester.
She was admitted in the
same private hospital for the last 3 days in view of threatened preterm labor,
for which she was given isoxuprine intravenous infusion for one day and
corticosteroids for lung maturity. However, her pain intensified over 2 to 3
days and she developed gradual abdominal distension. She was referred to our
tertiary care center with ultrasound showing a 2 cm rent in the uterine fundus
and a large fluid collection with internal echoes superior to the rent, outside
the uterine cavity with moderate hemoperitoneum. The fetus was seen in cephalic
presentation with severe bradycardia. The
amniotic fluid index was
zero.
Figure 1. Ultrasound showing
hemoperitoneum.
On examination, the
patient was
in hypovolemic shock; her general condition was poor, with a low volume pulse
of 110/min and blood pressure of 80/60 mm Hg. Abdominal examination revealed
tense abdominal distension up to 36 weeks’ uterine size. Uterine contour was
absent. There was no vaginal bleeding and the cervix was closed. Emergency
exploratory laparotomy was performed. Approximately 1000 ml of blood
with clots
was
removed. Uterine rupture at the fundus measuring approximately 7 x 7 cm,
extending from 2 cm above right cornua, to approximately 1 cm above left cornua
was seen,
with part of amniotic sac and placenta expelled out through the ruptured site. A
690 g stillborn female fetus
with placenta and membranes was removed from uterus through
the
ruptured site. Repair of ruptured uterus was done in 2 layers with No. 1 polyglactin. The tubes and ovaries were
normal. She was transfused with two units of whole blood. Post operative course
was uneventful and she was discharged after thorough counseling about avoidance of
conception and possibility of pregnancy through surrogacy in the future.
Figure 2. Repaired fundal rupture.
Discussion
Rupture
uterus is not uncommon following previous cesarean section. Most of these occur
during labor. Surgeries in which uterine scarring occurs on upper segment like
hysterotomy, upper segment cesarean section, myomectomy, previously
repaired uterine rupture, surgeries done for mullerian anomalies like
metroplasty, and LSCS with upward, J shaped
or inverted T-shaped extension are more prone to uterine rupture even before labor starts, unlike the lower
segment scars which are likely to rupture only during labor.
The
initial signs and symptoms of uterine rupture are nonspecific making the
diagnosis difficult; this can cause delay in definitive therapy. Fetal morbidity and mortality increase due to
fetal anoxia occurring as a result of catastrophic hemorrhage
and uterine spasm.
The
premonitory signs and symptoms of uterine rupture are inconsistent, and the
short time for instituting action makes uterine rupture a much feared event for
medical practitioners. The signs and symptoms largely depend on the time of
onset, site, and severity of the uterine rupture. Rupture at the site of a
previous uterine scar is less dramatic because of relatively reduced
vascularity.
In
our case, there was a rupture involving fundal region at 24 weeks’ of pregnancy
with a history of diagnostic hysteroscopy and laparoscopy done 1 year
back for primary infertility.
There
might have been injury to fundal region during hysteroscopy which might have
weakened the myometrium and resulted in rupture in this pregnancy. The decision
for repair rather than hysterectomy was taken to maintain the menstrual
function.
In
contrast to many reports in which rupture of uterus during second trimester was
diagnosed in previously scarred uterus, our patient had no history of previous
cesarean section. However, advanced maternal age and history of hysteroscopic
injury may have been the cause in this patient.
References
- De Roux SJ, Prendergast NC, Adsay NV. Spontaneous uterine rupture with fatal hemoperitonium due to placenta accrete percreta: a case report and review of the literature. Int J Gynecol Pathol. 1999;18(1):82-6.
- Ayoubi JM, Fanchin R, Lesourd F, et al. Rupture of a uterine horn after laparoscopic salpingectomy. A case report. J Reprod Med 2003;48(4):290-2.
- Dubuisson JB, Fauconnier A, Deffarges JV, et al. Pregnancy outcome and deliveries following laparoscopic myomectomy. Hum Reprod. 2000;15(4):869-73.
- Matsue K, Shimoya K, Shinakai T, et al. Uterine rupture of caesarean scar related to spontaneous abortion in the first trimester. J Obstet Gynecol Res 2004;30(1):34-6.
Citation
Pranali Ahale P, Chauhan AR