Spontaneous Rupture of the Non Gravid Uterus: A Case Report

Uterine rupture can cause serious morbidity and mortality to the women. A complete uterine rupture is a diagnosis made when all three layers of the uterus are separated, while uterine dehiscence is a similar condition in which there is incomplete division of the uterus that does not penetrate all three layers of the uterus. Uterine dehiscence is most often an occult finding in asymptomatic patients. Mostly the uterine rupture is seen in gravid females however it has been reported in non gravid patients as well. Spontaneous uterine rupture is extremely rare to be seen in non gravid patients, but should be included in the differential diagnosis of acute abdomen and shock in a non pregnant woman of any age due to its catastrophic consequences. In non gravid uterus the most common cause of the uterine rupture is pelvic trauma, uterine myomas, infection or uterine carcinoma. We hereby report a case of 44 years old female with previous 4 caesarean sections who came on12th day of her cycle with heavy bleeding, lower abdominal pain and anaemia. She was found to have small fibroids which were blamed for the menorrhagia and she was admitted for the conservative management. She collapsed on day 2 of admission suddenly and after stabilization of the patient her exploratory laparotomy was done and uterine rupture was detected on the right side of the previous scar. The uterus was repaired as the patient refused for hysterectomy. Her post op recovery was uneventful. Her first periods after the surgery was normal with average amount of blood loss. Key words: Uterine rupture, haemorrhage, non -gravid, caesarean, hysterectomy, laparotomy.

Risk Factors Associated with Uterine Rupture and Dehiscence: A Cross-Sectional Canadian Study

Objective To compare maternal and perinatal risk factors associated with complete uterine rupture and uterine dehiscence. Methods Cross-sectional study of patients with uterine rupture/dehiscence from January 1998 to December 2017 (30 years) admitted at the Labor and Delivery Unit of a tertiary teaching hospital in Canada. Results There were 174 (0.1%) cases of uterine disruption (29 ruptures and 145 cases of dehiscence) out of 169,356 deliveries. There were associations between dehiscence and multiparity (odds ratio [OR]: 3.2; p = 0.02), elevated maternal body mass index (BMI; OR: 3.4; p = 0.02), attempt of vaginal birth after a cesarian section (OR: 2.9; p = 0.05) and 5-minute low Apgar score (OR: 5.9; p < 0.001). Uterine rupture was associated with preterm deliveries (36.5 ± 4.9 versus 38.2 ± 2.9; p = 0.006), postpartum hemorrhage (OR: 13.9; p < 0.001), hysterectomy (OR: 23.0; p = 0.002), and stillbirth (OR: 8.2; p < 0.001). There were no associations between uterine rupture and maternal age, gestational age, onset of labor, spontaneous or artificial rupture of membranes, use of oxytocin, type of uterine incision, and birthweight. Conclusion This large cohort demonstrated that there are different risk factors associated with either uterine rupture or dehiscence. Uterine rupture still represents a great threat to fetal-maternal health and, differently from the common belief, uterine dehiscence can also compromise perinatal outcomes.

Intraoperative surgical difficulties encountered during repeat caesarean section in a tertiary care centre in Northeast India

Background: Caesarean section is the commonest obstetric operative procedure worldwide. The potential perioperative problems in repeat caesarean section include adhesions, increased blood loss, prolonged operative time, injuries to adjacent structures, hysterectomy etc. These increase with increase in caesarean section number.Methods: Hospital based observational study, conducted at Dept. of Obstetrics and Gynaecology, Assam Medical College, from July 2019 to June 2020 with the aim to study intraoperative difficulties encountered during repeat caesarean section. Cases were grouped into two main groups based on number of prior caesarean sections. A detailed history, clinical and intraoperative findings of all pregnant women undergoing repeat caesarean section were noted. Results were tabulated and analysed.Results: Out of 400 women with prior caesarean section who underwent repeat caesarean. 321 had 1 prior caesarean and rest had 2. Among the cases cephalopelvic disproportion was the commonest (43.25%) indication and obstructed labour was the least common (0.25%). Common complications were adhesions (38.25%), thinned lower uterine segment (27%), advance bladder (19.50%), uterine dehiscence (14.75%), excess blood loss (12.75%), extension of uterine incision (8.25%), uterine rupture (1%), placenta accrete (0.75%), and bladder injury (0.5%). Intraoperative complications like adhesions, uterine dehiscence, delivery and operating time were significantly higher in women with 2 prior caesarean section compared to 1 prior caesarean section (p<0.001).Conclusions: Women with caesarean scar are at high risk in subsequent pregnancies particularly in a country like India where antenatal care is often neglected. Best technique to reduce multiple potential complications of repeat caesarean section is to reduce the rates of primary and repeat caesarean sections whenever possible.

Maternal Morbidity with Repeated Cesarean Deliveries

Objective This study aimed to estimate the association between adverse maternal outcomes and the number of repeated cesarean deliveries (CDs) in a single obstetrical practice. Study Design Retrospective cohort study of all CDs between 2005 and 2020 in a single maternal fetal medicine practice. We used electronic records to get baseline characteristics and pregnancy/surgical outcomes based on the number of prior CDs. We performed two subgroup analyses for women with and without placenta previa. Chi-square for trend and one-way analysis of variance (ANOVA) were used. Results A total of 3,582 women underwent CD and met inclusion criteria. Of these women, 1,852 (51.7%) underwent their first cesarean, 950 (26.5%) their second, 382 (10.7%) their third, 191 (5.3%) their fourth, 117 (3.3%) their fifth, and 84 (2.3%) their sixth or higher CDs. The incidence of adverse outcomes (placenta accreta, uterine window, uterine rupture, hysterectomy, blood transfusion, cystotomy, bowel injury, need for a ventilator postpartum, intensive care unit admission, wound complications, thrombosis, reoperation, and maternal death) increased with additional CDs. However, the absolute rates remained low. In women without a placenta previa, the likelihood of adverse outcome did not differ across groups. In women with a placenta previa, adverse outcomes increased with increasing CDs. However, the incidence of placenta previa did not increase with increasing CDs (<5% in each group). The incidence of a uterine dehiscence increased significantly with additional CDs: first, 0.2%; second, 2.0%; third, 6.6%; fourth, 10.3%; fifth, 5.8%; and sixth or higher, 10.4% (p < 0.001). Conclusion Maternal morbidity increases with CDs, but the absolute risks remain low. For women without placenta previa, increasing CDs is not associated with maternal morbidity. For women with placenta previa, risks are highest, but the incidence of placenta previa does not increase with successive CDs. The likelihood of uterine dehiscence increases significantly with increasing CDs which should be considered when deciding about timing of delivery in this population. Key Points

Complications of Caesarean delivery part 1: Early complications

Introduction With the rise in Caesarean deliveries, complications related to the procedure are increasingly encountered. Sonography has an indispensable role in the assessment of these complications and is often the first-line investigation of choice. Topic Description: Part 1 of this pictorial review summarises the early complications unique to and associated with Caesarean deliveries. Discussion Acute haemorrhagic complications include retained products of conception, subfascial and bladder flap haematomas and, rarely, postpartum uterine dehiscence or rupture and iatrogenic vascular complications. Infective complications include puerperal and wound infections. Key sonographic features of these conditions are illustrated. Pitfalls, mimics, limitations and indications for cross-sectional imaging are discussed. Conclusion Sound knowledge of the sonographic features of common early complications of Caesarean delivery will facilitate accurate diagnosis, timely management and improved patient outcomes.

Complications of Caesarean delivery part 2: Non-pregnant and pregnancy-related complications

Introduction With the rise in Caesarean deliveries, complications related to the procedure are increasingly encountered. Sonography has an indispensable role in the assessment of these complications and is often the first-line investigation of choice. Topic description: Part 2 of this pictorial review summarises the non-pregnant and pregnancy-related complications of Caesarean deliveries. Discussion Non-pregnant complications include Caesarean scar defects, scar endometriosis and malpositioned intrauterine devices. Complications related to future gestations include scar ectopic pregnancy, abnormal placentation and intrapartum uterine dehiscence or rupture. Key sonographic features of these conditions are illustrated. Pitfalls, mimics, limitations and indications for cross-sectional imaging are discussed. Conclusion Sound knowledge of the sonographic features of common non-pregnant and pregnancy-related complications of Caesarean delivery will facilitate accurate diagnosis, timely management and improved patient outcomes.

Accurate prenatal discrimination of placenta accreta spectrum from uterine dehiscence is necessary to ensure optimal management

Uterine scar dehiscence with underlying placenta is often misdiagnosed as placenta accreta spectrum both prenatally and intraoperatively due to the absence of myometrial tissue in the area. Misdiagnosis generates obstetric anxiety and results in overtreatment which carries a risk of iatrogenic injury. We present a case of the antenatal diagnosis of uterine dehiscence in a 36-year-old woman with a history of two caesarean deliveries and a low-lying placenta. We further describe the sonographic features useful for differentiating this condition from placenta accreta spectrum in instances where the placenta lies under an area of full thickness uterine scar dehiscence.

Conservative surgical management of immediate post-caesarean uterine dehiscence and pelvis abscess due to proteus mirabilis infection: a rare complication of puerperal endomyometritis

Cesarean delivery is the most commonly performed major abdominal operation in women with prevalence ranging from 12% in public sectors to 28% in private sectors in India (DLHS-3 survey). Parallel to this, the complications of surgery are increased. Among these complications, uterine dehiscence and pelvic hematoma with abscess collection is rare but serious complication which might end in hysterectomy. We hereby describe the conservative surgical management of a case of infected uterine incisional necrosis and dehiscence after primary cesarean delivery. We encountered a 25-years-old woman presenting to our emergency department (ED) with severe suprapubic pain and high-grade fever. She had an emergency cesarean delivery performed 14 days prior to presentation due to non-reassuring fetal heart rate. At the ED, ultrasonography revealed collection with septation around uterus with communication into uterine cavity. CT scan of pelvis was ordered and showed an intraperitoneal collection anterior to the uterus at the level of the uterine cesarean scar. Exploratory laparotomy showed a uterine rupture at the previous incision site. We performed resection of necrotic edges, peritoneal lavage, approximation of uterine edges with separate interrupted sutures, placement of a suction drain in the cul-de-sac. During postoperative follow up, patient was stable with no symptoms or signs of uterine/pelvic infection. Conservative management by drainage and resection of necrotic edges in addition to intravenous antibiotics may be considered as an option before resorting to hysterectomy in selected young patients.