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Silent Spontaneous Uterine Rupture at 36 Weeks of Gestation

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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 36 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 3. 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.
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Case Report
Silent Spontaneous Uterine Rupture at 36 Weeks of Gestation
J. Y. Woo,1L. Tate,1S. Roth,2andA.C.Eke
1
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; ahizeekend@yahoo.ca
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.
1. Introduction
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 oen 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-
tomy.emostseverecomplicationofuterineruptureis
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 aer 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 dicult 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
http://dx.doi.org/10.1155/2015/596826
CaseReportsinObstetricsandGynecology
F : Silent uterine rupture, with extruded amniotic sac.
epatienthadhistoryoftwopriorclassicalcesareansec-
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 proles was done prior to delivery for diculty
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 aer taking one dose of Norco. She
did not experience any uterine contractions prior to deliv-
ery.
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
aer amniotomy in normal fashion. Neonate’s APGAR at 
andminuteswereand,respectively.Birthweightwas
 g. Inspection of the uterus revealed that the uterine scar
ruptureoccurredleofmidlineduetoaseverelyrightward
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 .
3. Discussion
Uterine rupture is a serious complication of pregnancy and
can cause signicant maternal and perinatal morbidity, with
most cases occurring in the setting of classical cesarean
section. Trial of labor aer 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
shock,orhemorrhage.Fromourcase,welearnedthat
uterine rupture may occur without any precipitating signs or
symptoms. Our patient’s history of multiple pelvic surgeries
can also cause unspecic and unclear symptoms.
It can be very dicult 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 specic enough for clinical use
(sensitivity of % with false positive rate of %). Grobman
and colleagues also developed a model to estimate specic
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 proles. However,
none were specically 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.
Despitepreviouslyquotedhighrateofperinatalmortality,
studiesdoneintheUnitedStatesrevealedmuchlower
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
4. Conclusion
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
diagnosis.
Consent
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 conict of interests.
Authors’ Contribution
Prenatal care of this patient was done by S. Roth, A. C. Eke,
andJ.Y.Woo.ecesareansectionwasdonebyS.Roth,J.Y.
Woo,andL.Tate.J.Y.Woo,S.Roth,L.Tate,andA.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
nal paper.
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... Furthermore, obstructive dystocia, obstetric operation injury, improper use of drugs to promote uterine contractions, multiple pregnancies and uterine malformations are also linked to a high risk of spontaneous rupture. A previous study reported that the use of prostaglandin during labor is associated with a greater risk of uterine rupture (10). Another study, by Kotoulová et al., also reported that Cushing syndrome can lead to spontaneous rupture during pregnancy (11). ...
... Reaching an accurate pre-operative diagnosis was a particular challenge in our case. The clinical features of typical uterine rupture include severe abdominal pain, vaginal bleeding, maternal low blood volume shock and massive hemorrhage (10). Once a uterus ruptures, the flow of amniotic fluid and blood are expected to cause acute abdominal tearing pain with tenderness and rebound tenderness. ...
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The spontaneous rupture of an unscarred uterus at 28 gestational weeks is an extremely rare event, particularly when associated with an intact amniotic sac extrusion and fetal leg entrapment, which has not been previously reported. A 27-year-old primigravid woman was referred to our department, due to perpetual abdominal pain, at 28 weeks and 5 days of gestation. The patient, G3p0, had previously undergone two induced abortions. At the time of admission, abdominal ultrasonography suggested a defect in the left uterine horn. An emergency laparotomy was subsequently performed and revealed an intact amniotic sac extrusion and fetal leg entrapment. Considering the risk of placental abruption, and the possibility of a secondary rupture if the gestation was not terminated, an emergency Cesarean section was recommended. Uterine rupture may be suspected whenever a patient complains of durative abdominal pain at 28 weeks and 5 days of gestation, even in the absence of an intra-abdominal hemorrhage or vaginal bleeding.
... The frequently reported complications of laparoscopic surgery generally arise due to failure to adequately suture myometrial defects, poor hemostasis with subsequent hematoma formation or excessive use of monopolar or bipolar electrosurgery, and hence devascularization of the myometrium, which can interfere with myometrial wound healing and increase the risk of rupture [6]. Uterine rupture refers to a complete separation of all the uterine layers [7] and of the overlying visceral peritoneum and is often associated with clinically significant paroxysmal pain, uterine bleeding, fetal distress, and even protrusion or expulsion of the fetus and/or placenta into the abdominal cavity. It entails the need for prompt cesarean delivery, uterine repair, or hysterectomy. ...
... Meticulous closure of the myometrial bed following myomectomy can be difficult via laparoscopy and could therefore interfere with the integrity of the scar [3]. Uterine rupture during pregnancy seems to occur more frequently as a consequence of laparoscopic than laparotomic myomectomy [2][3][4][5][6][7][8][9][10][11][12][13][14][15][16], although this finding is extremely limited because it depends on few reported cases (such as our submitted cases) and has provoked debate in the recent literature. After abdominal myomectomies the scars are of similar thickness to normal myometrium, whereas after laparoscopic procedures they are strained, more contracted, and thinner than normal myometrium. ...
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We describe two cases of uterine rupture in pregnancy after laparoscopic myomectomy and analyze all the aetiological factors involved in this circumstance according to the recent literature, focusing above all on the surgical procedures and the characteristics of the excised myomas. The two cases of uterine rupture in pregnancy following laparoscopic myomectomy occurred at 36 and 18 weeks of gestation, respectively. Both women had undergone laparoscopic multiple myomectomy and uterine rupture occurred along the isthmic myomectomy scars, despite the fact that compliance with all the recent technical surgical recommendations for the previous laparoscopic multiple myomectomy had been fully observed. In our cases we identified the isthmic localization, size of the excised myomas (≥4 cm), and individual characteristics of the healing process as possible risk factors for “a real complication.” Larger studies and robust case-control analyses are needed to draw reliable conclusions; special care should be paid when performing laparoscopic myomectomy in women planning a later pregnancy.
... However, with enhancement in contemporary obstetric services, cases of uterine rupture following previously unscarred uterus are declining [6]. Uterine rupture classically refers to a complete separation of all the uterine layers and of the overlying visceral peritoneum and is often associated with clinically significant paroxysmal pain, uterine bleeding, fetal distress, and even protrusion or expulsion of the fetus and/or placenta into the abdominal cavity [7], but when the peritoneum is still intact, it is referred to as incomplete rupture. ...
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... Uterine rupture is an obstetric complication that causes significant maternal and foetal morbidity and mortality [1]. Silent uterine rupture is very difficult to diagnose, as the clinical features of uterine rupture, including abdominal pain, vaginal bleeding, maternal hypovolemic shock, or haemorrhage may be absent [2]. We present the spontaneous rupture of the posterior wall of the uterus at 36 weeks of gestation; the uterine rupture was found during the operation. ...
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To assess incidence of uterine rupture in scarred and unscarred uteri and its maternal and fetal complications in a nationwide design. Population-based cohort study. All 98 maternity units in The Netherlands. All women delivering in The Netherlands between August 2004 and August 2006 (n = 371,021). Women with uterine rupture were prospectively collected using a web-based notification system. Data from all pregnant women in The Netherlands during the study period were obtained from Dutch population-based registers. Results were stratified by uterine scar. Population-based incidences, severe maternal and neonatal morbidity and mortality, relative and absolute risk estimates. There were 210 cases of uterine rupture (5.9 per 10,000 pregnancies). Of these women, 183 (87.1%) had a uterine scar, incidences being 5.1 and 0.8 per 10,000 in women with and without uterine scar. No maternal deaths and 18 cases of perinatal death (8.7%) occurred. The overall absolute risk of uterine rupture was 1 in 1709. In univariate analysis, women with a prior caesarean, epidural anaesthesia, induction of labour (irrespective of agents used), pre- or post-term pregnancy, overweight, non-Western ethnic background and advanced age had an elevated risk of uterine rupture. The overall relative risk of induction of labour was 3.6 (95% confidence interval 2.7-4.8). The population-based incidence of uterine rupture in The Netherlands is comparable with other Western countries. Although much attention is paid to scar rupture associated with uterotonic agents, 13% of ruptures occurred in unscarred uteri and 72% occurred during spontaneous labour.
Article
To evaluate the accuracy of antenatal sonographic measurement of lower uterine segment (LUS) thickness in the prediction of risk of uterine rupture during a trial of labor (TOL) in women with a previous Cesarean section (CS). PubMed and EMBASE were searched to identify articles published on the subject of sonographic LUS measurement and occurrence of a uterine defect after delivery. Four independent researchers performed identification of papers and data extraction. Selected studies were scored on methodological quality, and sensitivity and specificity of measurement of LUS thickness in the prediction of a uterine defect were calculated. We performed bivariate meta-analysis to estimate summary receiver–operating characteristics (sROC) curves. We included 21 studies with a total of 2776 analyzed patients. The quality of included studies was good, although comparison was difficult because of heterogeneity. The estimated sROC curves showed that measurement of LUS thickness seems promising in the prediction of occurrence of uterine defects (dehiscence and rupture) in the uterine wall. The pooled sensitivity and specificity of myometrial LUS thickness for cut-offs between 0.6 and 2.0 mm was 0.76 (95% CI, 0.60–0.87) and 0.92 (95% CI, 0.82–0.97); cut-offs between 2.1 and 4.0 mm reached a sensitivity and specificity of 0.94 (95% CI, 0.81–0.98) and 0.64 (95% CI, 0.26–0.90). The pooled sensitivity and specificity of full LUS thickness for cut-offs between 2.0 and 3.0 mm was 0.61 (95% CI, 0.42–0.77) and 0.91 (95% CI, 0.80–0.96); cut-offs between 3.1 and 5.1 mm reached a sensitivity and specificity of 0.96 (95% CI, 0.89–0.98) and 0.63 (95% CI, 0.30–0.87). This meta-analysis provides support for the use of antenatal LUS measurements in the prediction of a uterine defect during TOL. Clinical applicability should be assessed in prospective observational studies using a standardized method of measurement. Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd.
Article
Uterine rupture is an obstetrical emergency that can be catastrophic for the mother and fetus. Previous uterine surgery, including previous cesarean delivery or myomectomy, is an established risk factor, although the exact magnitude of the associated risk remains uncertain. We reviewed the literature related to uterine rupture after previous cesarean delivery with classical incision or myomectomy in an attempt to quantify outcomes associated with various management strategies. Although cesarean delivery with a classical incision is relatively uncommon (representing 0.3%-0.4% of deliveries), it presents a significant risk of rupture in subsequent pregnancies (1%-12% on the basis of published reports). Available data suggest that scheduled cesarean at 36-37 weeks optimizes both maternal and fetal outcomes in these cases. Patients with previous myomectomy are more frequently encountered in the obstetrical population. The risk of uterine rupture in subsequent pregnancies in these women is substantially lower than those with a history of previous classical incision (0.5%-0.7% on the basis of published reports). Although less common, given the potentially devastating consequences of uterine rupture, scheduled delivery at 38 weeks is suggested in those women requiring cesarean delivery. Despite the lack of well-controlled studies, preferred management strategies can be gleaned from previously published data to optimize maternal and fetal outcomes in women with these risk factors.
Article
To identify risk factors associated with uterine rupture among term pregnancies attempting a vaginal birth after a previous cesarean. A case-control study was done of 348 uterine ruptures in Massachusetts between 1991 and 1998, initially screened by ICD-9 code and confirmed by medical record review, with 424 control women with a trial of labor randomly selected proportional to cases on year of delivery. Multivariable regression was used to estimate odds ratios and 95% confidence intervals. Successful previous vaginal birth decreased risk for uterine rupture, and gestation > 40 weeks and macrosomia increased risk. Oxytocin for induction increased risk, with a slightly lower effect when used for augmentation. Prostaglandin use in conjunction with oxytocin did not have an additive uterine rupture risk. Women using epidural analgesia have an increased uterine rupture risk. Certain labor management practices increase the risk for uterine rupture 2-3 times, although the absolute increase is small from a baseline uterine rupture rate of 0.5% to 1.0-1.5%. The association between epidural analgesia and uterine rupture deserves further study.
Article
Uterine rupture is the most serious complication for women undergoing trial of labor (TOL) after prior cesarean delivery. While rates of uterine rupture vary significantly according to a variety of clinically associated risk factors, the absolute risk for this complication ranges between 0.5 and 4 percent. Previous vaginal delivery and prior successful vaginal birth after cesarean delivery confer the lowest risk of rupture on women attempting TOL. In contrast, multiple prior cesareans, short interpregnancy interval, single layer uterine closure, prior preterm cesarean, labor induction and augmentation have all been suggested in some studies as factors which may increase the rate of uterine rupture. While considering these risk factors is important in counseling women regarding childbirth following cesarean delivery, the infrequency of uterine rupture coupled with relatively weak associations for most risk factors has prevented the development of an accurate prediction tool for uterine rupture. Preliminary studies suggest that sonographic evaluation of the uterine scar may hold some promise for identifying women at risk.
Article
The purpose of this study was to establish the validity of sonographic evaluation of lower uterine segment (LUS) thickness for complete uterine rupture. A prospective cohort study of women with previous cesarean delivery was conducted. LUS thickness (full thickness and myometrial thickness only) was measured between 35 and 38 weeks gestation, and the thinnest measurement was considered to be the dependent variable. Receiver operating curve analyses and logistic regression were used. Two hundred thirty-six women were included in the study. Nine uterine scar defects (3 cases of complete rupture during a trial of labor and 6 cases of dehiscence) were reported. Receiver operating curve analyses showed that full thickness of <2.3 mm was the optimal cutoff for the prediction of uterine rupture (3/33 vs 0/92; P = .02). Full thickness was also identified as an independent predictor of uterine scar defect (odds ratio, 4.66; 95% confidence interval, 1.04-20.91) Full LUS thickness of <2.3 mm is associated with a higher risk of complete uterine rupture.
Article
The cesarean birth rate has continued to climb despite efforts to counteract it. A major reason for this rise is the practice of elective repeat cesarean. We conducted a meta-analysis that included 31 studies with a total of 11,417 trials of labor to evaluate the association between birth route after a cesarean and morbidity and mortality for the mother and infant. Summary odds ratios were calculated. Maternal febrile morbidity was significantly lower after a trial of labor than after an elective repeat cesarean. The intended birth route made no difference in the rates of uterine dehiscence or rupture. The use of oxytocin, presence of a recurrent indication for the previous cesarean, and presence of an unknown uterine scar were also unassociated with dehiscence or rupture. After excluding antepartum deaths, fetuses weighing less than 750 g, and congenital anomalies incompatible with life, we found no difference in perinatal death rates. The proportion of 5-minute Apgar scores of 6 or lower was higher after a trial of labor, but we were unable to exclude very low birth weight fetuses or those with congenital anomalies from this analysis. Our findings argue for trials of labor for more women after a cesarean birth.