Silent Spontaneous Uterine Rupture at 36 Weeks of Gestation
J. Y. Woo,1L. Tate,1S. Roth,2andA.C.Eke
1Department of Obstetrics and Gynecology, Michigan State University/Sparrow Hospital, Lansing, MI 48912, USA
2Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Michigan State University/Sparrow Hospital,
Lansing, MI 48912, USA
Correspondence should be addressed to A. C. Eke; firstname.lastname@example.org
Received May ; Revised August ; Accepted August
Academic Editor: Giampiero Capobianco
Copyright © J. Y. Woo et al. is is an open access article distributed under the Creative Commons Attribution License, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Introduction. Silent spontaneous rupture of the uterus before term, with extrusion of an intact amniotic sac and delivery of a healthy
neonate, with no maternal or neonatal morbidity or mortality is very rare. Very few cases have been reported in literature. Case
Presentation. We report a case of silent spontaneous uterine rupture, found during a scheduled repeat cesarean section at weeks
of gestation. Patient had history of two prior classical cesarean sections. She underwent cesarean section, with delivery of a healthy
male infant. She had a good postoperative recovery and was discharged on postoperative day . Conclusion. Silent spontaneous
rupture of the uterus before term with extrusion of an intact amniotic sac is rare. A high index of suspicion and good imaging
during pregnancy are important in making this diagnosis.
Spontaneous uterine rupture is an uncommon but potentially
life-threatening obstetrical emergency for both mother and
fetus. It occurs mostly during labor in the context of a
previous uterine scar. Generally, uterine rupture refers to a
complete separation of all uterine layers, including the uterine
serosa, and this usually occurs most commonly in the setting
of classical cesarean section . Classical cesarean delivery
entails a vertical incision involving the upper contractile
portion of the uterus. In contemporary medicine, this type
of incision is oen reserved for preterm breech delivery or
when lower uterine incision is deemed unfeasible or unsafe
. e reported frequency of classical cesarean delivery
is .% by the Eunice Kennedy Shriver National Institute
of Child Health and Human Development Maternal Fetal
Medicine Unit Network (NICHD MFMU) involving ,
births over a -year period . e incidence of uterine
rupture varies depending on the type and location of the
prior uterine incision. e American College of Obstetricians
& Gynecologists (ACOG) Practice Bulletin reports a uterine
rupture risk of . to . percent for women with prior
cesarean undergoing trial of labor . However, the overall
rate for uterine rupture with previous classical cesarean
ranges from . to percent as cited in the literature [–].
Severe maternal complications secondary to uterine rup-
ture include hemorrhage, blood transfusion, and hysterec-
maternal death; even though rare, it occurs in approximately
in uterine ruptures . While asymptomatic uterine
dehiscence rarely results in adverse fetal outcome, complete
uterine rupture with extrusion of placenta or the fetus can be
catastrophic. e risk of perinatal death aer uterine rupture
was found to be .% in a population-based cohort study
in Netherlands , with perinatal mortality reported as
ranging from % to % in less developed countries .
Silent uterine rupture can be very dicult to diagnose, as
the clinical features of uterine rupture, including abdominal
pain, vaginal bleeding, maternal hypovolemic shock, or hem-
orrhage, may be absent. Multiple studies have tried to develop
prediction models for uterine rupture, including sonographic
evaluation of uterine scar, but none has proven to be reliable
especially for previous classical cesarean sections [,].
2. Case Presentation
We report a case of spontaneous uterine rupture, found
during a scheduled repeat classical cesarean section at
weeks of gestation with delivery of a healthy male infant.
Hindawi Publishing Corporation
Case Reports in Obstetrics and Gynecology
Volume 2015, Article ID 596826, 3 pages
F : Silent uterine rupture, with extruded amniotic sac.
tions in and . She also had multiple renal and uterine
reconstructive surgeries and revisions in the years preceding
her pregnancies due to congenital anomalies, including a
duplicated le ureter. Her pregnancy was complicated by
pyelonephritis and hydronephrosis with nephrostomy tube
placement and multiple episodes of urinary tract infections
that were treated. Antenatal testing including multiple bio-
physical proles was done prior to delivery for diculty
in monitoring fetus with nonstress tests; no abnormal nd-
ings were observed. No fetal heart rate abnormalities were
seen immediate before delivery. Patient had one episode of
abdominal discomfort two days prior to scheduled delivery
date, which resolved aer taking one dose of Norco. She
did not experience any uterine contractions prior to deliv-
Upon entering the abdominal cavity via a vertical skin
incision, a complete uterine rupture was seen at the prior
classical incisional scar with the amniotic sac protruding into
the abdomen (Figure ). Fetal parts were palpable through
the protruding membrane. No active bleeding was noted, and
the uterine scar appeared to be brotic at both edges. e
fetus was found in oblique presentation and was delivered
aer amniotomy in normal fashion. Neonate’s APGAR at
g. Inspection of the uterus revealed that the uterine scar
rotated uterus. e posterior lower uterine segment was very
thin and was ballooning outwards. Dense adhesion was noted
between the bladder and anterior lower uterine segment.
Uterus was repaired with multilayer closure. Tubal ligation
was performed as planned. Remainder of the surgery was
completed in the usual fashion.
Patient’s recovery course was uncomplicated. She had
normal amount of vaginal bleeding postpartum. Postoper-
ative hemoglobin was . g/dL. Patient and newborn were
discharged home in good condition on postoperative day .
Uterine rupture is a serious complication of pregnancy and
can cause signicant maternal and perinatal morbidity, with
most cases occurring in the setting of classical cesarean
section. Trial of labor aer cesarean (TOLAC) has been
associated with higher incidence of uterine rupture ;
however, in the case presented, patient had no signs of labor
prior to delivery. She was asymptomatic, denying vaginal
bleeding and abdominal pains prior to delivery. She experi-
enced minimal abdominal discomfort (not pain) days prior
to delivery, which, in hindsight, may be when she ruptured
her uterus. Clinical features of uterine rupture may include
abdominal pain, vaginal bleeding, maternal hypovolemic
uterine rupture may occur without any precipitating signs or
symptoms. Our patient’s history of multiple pelvic surgeries
can also cause unspecic and unclear symptoms.
It can be very dicult to predict individuals who would
rupture their uteruses in pregnancy. Recent studies have
attempted to develop predictive models for uterine rupture.
Bujold  and colleagues developed such indexes using
antepartum and intrapartum factors. However, both models
were neither sensitive nor specic enough for clinical use
(sensitivity of % with false positive rate of %). Grobman
and colleagues also developed a model to estimate specic
risk of uterine rupture during trial of labor. However, the
empiric probability risk of rupture derived from a wide %
CI ranging from . to .%, making this model neither
accurate nor discriminating .
Ultrasonography has been studied to predict uterine
rupture. Bujold and colleagues conductedaprospective
cohort study of women with previous cesarean under-
going trial of labor. eir analysis determined that optimal
cuto is a lower uterine thickness of <. mm, with the rate
of uterine rupture being .% for this group. e limitation
of this study includes the fact that most women with a lower
uterine thickness <. mm did not undergo trial of labor.
is might suggest an established practice pattern which
might limit future studies using ultrasound to predict uterine
rupture. For our case, the patient had multiple ultrasound
studies done for growth and biophysical proles. However,
none were specically looking for the lower uterine segment.
Due to her history of classical incision, measuring the lower
uterine segment might not have been adequate to evaluate
uterine thickness anyway. Review of all ultrasound images in
our patient revealed no abnormality.
perinatal death rate of . per trials of labors . e
lower rate of perinatal death might be due to rapid recogni-
tion of and response to potential uterine ruptures.
Case Reports in Obstetrics and Gynecology
is case report emphasizes that uterine rupture can occur
without symptoms in pregnancy. A high index of suspicion
and proper imaging are therefore needed in making this
Written informed consent was obtained from the patient for
publication of this case report and accompanying images.
Conflict of Interests
e authors declare that they have no conict of interests.
Prenatal care of this patient was done by S. Roth, A. C. Eke,
assisted and analyzed the case and conducted the literature
search and review for analysis. J. Y. Woo prepared the rst
dra of the report. A. C. Eke supervised and guided on the
development of the paper. All authors read and approved the
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