**, Khadkikar R***. Chauhan
(* Fourth Year Resident, ** Additional Professor, *** Assistant Professor. Department of Obstetrics and Gynecology, Seth GS Medical College & KEM Hospital, Mumbai, India)
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.
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, pregnancy in a rudimentary horn of a malformed uterus, previous myomectomy, previous cesarean section scars, previous hysterolaparoscopy injury[3,4] and previous dilatation and curettage.
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.
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.
- 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.
Pranali Ahale P,
Khadkikar R. Rupture Of Uterus Remote From Term. JPGO 2015. Volume 2 No.
2. Available from: http://www.jpgo.org/2015/02/rupture-of-uterus-remote-from-term.html Chauhan AR