Author Information
Desai D*, Prasad M**, Gupta AS***.
(*Second Year Resident, *Assistant Professor, ***Professor, Department of Obstetrics and Gynecology, Seth G S Medical College & K.E.M. Hospital, Mumbai, India)
Abstract
We come across several cases of previous cesarean sections. The risk of scar dehiscence and uterine rupture in subsequent pregnancies is known. But in modern times, uterine rupture in an unscarred uterus is a rare phenomenon. The successful management and its favorable outcome of a patient who had a previous posterior uterine wall rupture, is presented here.
Introduction
Previous posterior uterine wall rupture with subsequent conception is a high risk pregnancy. A fine balance to achieve adequate fetal maturity, timely delivery to circumvent an antepartum uterine rupture and achieve a favorable maternal and fetal outcome with minimal morbidities and no mortalities is a challenge to the obstetrician. Here we present a rare case of previous posterior uterine wall rupture of unknown etiology and its successful pregnancy outcome.
Case Report
A 26 year old gravida two, para one with no living issue, registered at 13 weeks of gestation at our center, as no medical center around her place of residence was willing to manage her high risk pregnancy. Her previous pregnancy records were reviewed. Intraoperative posterior uterine wall rupture was documented in those records. In that pregnancy, she had registered at 26 weeks and had 5 antenatal follow up visits. It was an induced labor for postdatism. Labor induction had failed and as labor had not progressed cesarean section was done. Labor record, duration of labor prior to cesarean section and methods of induction or labor augmentation were not mentioned in that document. The record also mentioned that during that cesarean section a posterior wall uterine rupture was found and it was sutured. The baby was stillborn. Details regarding how the baby was delivered, whether fetus was lying intraperitoneally, extent of uterine injury, whether a uterine incision was required, and suture materials used to repair the posterior rent were not mentioned. It was not possible to obtain records and more clarifications from her previous treating doctor. One unit blood transfusion was required, and there were no other postoperative problems.
In this pregnancy, she followed up regularly. She was admitted at 24 weeks as she was at a very high risk of rupture of previous posterior wall uterine scar of unknown dimensions and site. Scar strength and integrity also could not be predicted and she was also not a local resident. All high risks and associated morbidities were explained to her and her husband. Hemoglobin was 11.5 gm% with normal leucocyte count. Her platelet count was 1.8 lakh /cu mm and normal blood sugar values. Urine examination was within normal limits and serum TSH was 4.9 IU/ml. She was started on tablet levothyroxine 50 µgm once a day in view of gestational hypothyroidism.
An ultrasound suggestive of single live intrauterine pregnancy of 18 weeks 4 days was available; placenta was anterior not low lying, non adherent. No malformations were seen in the fetus, liquor was adequate. Injectable steroids were given at 26 weeks for fetal lung maturity in anticipation of the need to deliver her prematurely. At around 31 weeks, gestational thrombocytopenia was diagnosed (platelet count was 90000/cu mm) and she was started on multivitamin injection once a day as per hematologists’ advise. Daily monitoring of platelet count was done. It increased to 1.2 lakh/ cu mm in a week. She was scheduled for lower segment cesarean section (LSCS) at 32 weeks after confirming availability of adequate blood and platelets. LSCS was done under spinal anesthesia.
Intraoperatively, there were no adhesions present between bladder and anterior lower segment. Sharp dissection was done to separate bladder, and there was no obvious previous anterior uterine scar seen. A female fetus weighing 2.3 kg was delivered, who cried immediately and had Apgar score of 9/10. She was admitted in the neonatal intensive care unit (NICU) as she had a grunt and was a premature neonate. After expulsion of placenta, uterine cavity was inspected. There was no evidence of scarring, thinning or focal sub decidual hemorrhages in the posterior wall. The uterus was not eventrated and the uterine closure was done in two layers with polyglactin No. 1 suture material. Lastly, after ensuring no evidence of adhesions in pouch of Douglas and near rectosigmoid region, posterior uterine wall was inspected. There was a well healed irregular, broad, midline, vertical, ragged previous rupture scar seen extending from just below the fundus to just above the cervix at the level of insertion of uterosacral ligaments. It was thick, intact in its entire length. Bilateral fallopian tubes and ovaries appeared normal.
Figure 1. Image showing posterior surface with arrow pointing at the scar.
Postoperative period was uneventful and she was discharged on day 5. Suture removal was done and wound was healthy. Healthy neonate was discharged from the NICU on day 15 of birth. She was counseled against future pregnancies and various contraceptive choices were discussed with her.
Discussion
Uterine rupture is a rare occurrence. In a 6 year period of study by Revicky et al in the UK, there were only 12 cases of uterine rupture noted, with a rate of 1 in 3000 deliveries.[1] However, in a 5 year study series conducted in Ethiopia by Berhe et al, the rate was 1 in 110 deliveries.[2] A similar study done by Ashimi et al in Northern Nigeria reported it to be 15 per 1000 deliveries.[3] In India, the rate is reported to be around 1 in 360, and as concluded by Singh et al, uterine rupture continues to be a harsh reality.[4, 5] These statistics clearly highlight the disproportionate occurrence of uterine rupture in the developing world. A cross- sectional study in Chattisgarh, India studied the factors associated with rupture uterus. It is more common in scarred uterus, multiparous women, unbooked pregnancies and induced labor. Obstructed labor, injudicious use of oxytocics, prior history of suction evacuation, poor intrapartum management and lack of referral facilities were all factors associated with uterine rupture .[5]
This association with induced labor has been confirmed by Chibber et al in a 25 year review of cases. Interestingly 48% of the cases were in patients with no prior uterine scar.[6] In our case also an unscarred uterus had ruptured during an induced labor. As reported by Chibber, when uterine rupture occurs, it occurs in the lower segment in 78 % and near the fundus in 22%. Rathod et al have reported that common site of rupture is the anterior wall.[4,6] According to retrospective analysis done in Nigeria, it was found that lateral wall tear is more common around 39% in unscarred uterus.[7] However, posterior uterine wall rupture (as in our case) has not been mentioned as a common location. Perinatal mortality is high when uterine rupture occurs. In the study by Rathod et al, the perinatal mortality was as high as 90%. In our case too, the previous pregnancy resulted in a stillbirth. A case series of 27 women with previous uterine rupture also demonstrated good maternal-fetal outcomes, in which there was only one case of repeat uterine rupture. [8]
Previous history of uterine rupture is considered a contraindication for VBAC (Evidence level “D”).[9] However, no specific recommendation regarding the timing of the planned cesarean section is mentioned. Our patient was fortunate, as the placenta had not implanted on the rupture site as that would have probably weakened the scar or could have resulted in an adherent placenta. Our patient underwent planned LSCS at 32 weeks of gestation. This gestational age was chosen based on multiple factors, wherein a balance was reached between chances of scar giving way and prematurity. The decision was based on the fact that estimated baby weight was more than 2 kg, fetal lung maturity had been relatively ensured by antenatal steroid administration and our NICU statistics had a good survival outcome at this gestational age. Our decision to deliver at 32 weeks was validated by the fact that the mother went home with a live born neonate of reasonable maturity and without the tragedy of a uterine rupture.
Conclusion
Posterior uterine wall ruptures, that too involving almost the entire length of the posterior wall are not common. It is not possible to predict the recurrence of rupture and loss of fetal or maternal life, or the uterus. Women without living children despite proper counseling risk their lives by getting pregnant. This will result in obstetricians having to face the challenge of managing such patients with the aim of ensuring a good maternal and fetal outcome without a repeat rupture. The route of delivery will undoubtedly have to be abdominal. The main challenge is the timing of the delivery so that a reasonably mature neonate is delivered out before the upper segment or unknown site uterine scars have to prove their integrity.
References
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- Berhe Y, Gidey H, Wall LL. Uterine rupture in Mekelle, northern Ethiopia, between 2009 and 2013. Int J Gynaecol Obstet. 2015;130 (2):153–6.
- Ashimi AO, Omole-Ohonsi A, Uqwa AE, Amole TG. A prospective surveillance of ruptured uterus in a rural tertiary health facility in northwest Nigeria. J Matern Fetal Neonatal Med. 2014; 27 (16):1684–7.
- Rathod S, Samal SK, Swain S. A Three Year Clinicopathological Study of Cases of Rupture Uterus. J Clin Diagn Res. 2015; 9(11):QC04-6.
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- Al Qahtani NH, Al Hajeri F. Pregnancy outcome and fertility after complete uterine rupture: a report of 20 pregnancies and a review of literature. Arch Gynecol Obstet. 2011; 284 (5):1123–6.
- Green-top Guideline No. 45 Birth after previous caesarean birth. Royal college of Obstetricians and Gynecologists. October 2015.
Desai D*, Prasad M**, Gupta AS. Pregnancy Outcome In Previous Posterior Uterine Rupture. JPGO 2016. Volume 3 No. 12. Available from: http://www.jpgo.org/2016/12/pregnancy-outcome-in-previous-posterior.html