Placenta percreta-induced uterine rupture diagnosed by laparoscopy in the first trimester

Spontaneous uterine rupture is lethal in pregnant women. Placenta percreta-induced spontaneous uterine rupture in the first trimester is extremely rare and difficult to diagnose. A 35-year-old pregnant woman, with a history of 2 vaginal deliveries and 2 spontaneous abortions treated by dilatation and curettage, was admitted to the emergency department because of sudden severe abdominal pain; the gestational age as calculated by sonography was 14 weeks. Diagnostic laparoscopy was considered for surgical abdomen and fluid collection that was noted in sonography. During laparoscopy, uterine rupture with massive bleeding was detected; therefore, total abdominal hysterectomy was performed. The patient was discharged without any complications. Pathological analysis of the uterine specimen revealed placenta percreta to be the cause of the rupture. Uterine rupture should be considered in the differential diagnosis in all pregnant women who present with acute abdomen, show fluid collection in the peritoneal cavity. In addition, we recommend laparoscopy for the investigation of acute abdomen with unclear diagnosis in the first trimester of pregnancy.     

Placenta praevia percreta

Placenta percreta and praevia are rare and life-threatening causes of massive maternal haemorrhage. The incidence of concurrent placenta percreta and praevia has increased over recent years with the rising number of caesarean sections. Placenta praevia, defined as the ‘implantation of the placenta in the lower uterine cavity, completely or partially covering the internal os’, is the major risk factor for placenta accreta spectrum (PAS) in women with prior caesarean section. PAS is the abnormal adhesion of the placenta to the uterine wall and consists of three types; placenta accreta, increta and percreta. Placenta percreta represents only 5% of cases of PAS but has the highest maternal morbidity and mortality of the three types and involves invasion of the placenta through the entirety of the myometrium, potentially into neighbouring organs. We present a case of placenta praevia percreta and review the macroscopic and microscopic findings pertinent to making the diagnosis.     

Spontaneous bilateral cornual uterine dehiscence early in the second trimester after bilateral laparoscopic salpingectomy and in-vitro fertilization: case report.

A bilateral cornual uterine dehiscence is reported, which occurred 14 weeks after in-vitro fertilization (IVF) in a patient having a medical history of previous bilateral salpingectomy via laparoscopy. Uterine rupture is a rare obstetric complication usually occurring during the third trimester of pregnancy within a uterus which has previously undergone an operation. Ectopic pregnancy is a well known complication of IVF. Post-salpingectomy cornual localization with rupture has also been published. Possible causes are discussed and the attention of the counselling physician is directed to the necessary awareness of such a complication in this high risk population. The reported case is an extreme rarity: a similar case has not been previously published in the literature.     

Uterine dehiscence in a nullipara,diagnosed by MRI,following use of unipolar electrocautery during laparoscopic myomectomy: Case report

Uterine scar dehiscence following laparoscopic myomectomy (LM) is a rare event. We present a case of an magnetic resonance imaging-diagnosed uterine dehiscence in a primigravid patient at 29 weeks gestation, following a laparoscopic subserosal myomectomy, performed using unipolar electrocoagulation. Pregnant patients with a history of prior surgery where unipolar electrocoagulation is used on the uterus should be closely followed throughout pregnancy and uterine dehiscence or rupture should be part of the differential diagnosis when they present with abdominal pain.     

Placenta percreta in week 10 of pregnancy with consecutive hysterectomy: case report

Placenta percreta in early pregnancy is rare and has been documented in only a few cases. We report on a patient with abdominal pain in week 10 of pregnancy. Sonography revealed a defective embryonic development and the absence of a border line between trophoblast and myometrium, as well as invasive growth in the region of isthmocervical transition, so curettage was performed. Heavy bleeding at this stage made a hysterectomy necessary. Histological examination revealed a placenta percreta. Because of possible complications, the therapy of choice for a placenta percreta is a hysterectomy, as was performed in this case.     

Uterine rupture following hysteroscopic lysis of synechiae due to tuberculosis and uterine perforation

A patient with genital tuberculosis who conceived with in-vitrofertilization and embryo transfer following hysteroscopic synechiolysiscomplicated by a fundal uterine perforation subsequently presentedwith uterine rupture at 36 weeks gestation. Immediate Caesareansection and repair of the ruptured uterus were performed. Womenwith a history of uterine perforation should be counselled regardingthe risk of uterine rupture during their subsequent pregnancies.     

Fertility-sparing surgery, with subsequent pregnancy, in persistent gestational trophoblastic neoplasia: case report

Gestational trophoblastic neoplasia (GTN) is primarily a disease of women of reproductive age. In most instances, it is cured by surgical evacuation of the uterus, with persistent disease being very sensitive to chemotherapy. Hysterectomy, recommended for persistent chemotherapy-resistant uterine disease, may be unacceptable to the woman who wishes to maintain her fertility. Uterine resection of localized disease, with uterine reconstruction, may be a viable alternative. A case is presented of a woman with persistent uterine GTN, treated with localized uterine resection and reconstruction, followed by two successful pregnancies and deliveries. The literature is reviewed and potential pregnancy complications of this management, particularly uterine rupture, are discussed.     

疤痕子宫孕妇晚期妊娠阴道分娩临床结局分析

目的探讨孕晚期疤痕子宫孕妇经阴道分娩的影响因素并分析其可行性。方法回顾性分析80例孕晚期疤痕子宫孕妇经阴道分娩的临床资料,将其分为疤痕子宫自然临产组（n=38）、疤痕子宫计划分娩组（n=42）,并设定对照组（n=50）。比较3组间的分娩结局如产后出血量、胎盘胎膜滞留率、是否存在子宫破裂、急产率及钳产率等情况。结果自然临产组有9例（23.68%）孕妇以钳产术缩短第二产程终止妊娠,而计划分娩组则有8例（19.05%）,均高于对照组3例（6.00%）,两两比较差异有统计学意义（P〈0.01）。自然临产组孕妇钳产率又稍高于计划分娩组,但两组比较差异无统计学意义（P〉0.05）。自然临产组总产程〈3h者有9人（23.68%）,急产率高于计划分娩组（2.38%）及对照组（10.00%）,差异有统计学意义（P〈0.01）。3组孕妇产后出血量、胎盘胎膜滞留率以及非计生引产胎儿评分比较,差异均无统计学意义（P〉0.05）。3组均无子宫破裂及新生儿重度窒息等不良事件发生。结论疤痕子宫并非阴道试产的绝对禁忌,产前超声检查子宫下段疤痕区域的良好连续性及低位钳产术是其阴道试产的有利因素。     

Control and assessment of the uterus and cervix during pregnancy and labour

Preterm labour and resultant preterm birth are the most important problems in perinatology. Countless efforts have failed to establish a single effective treatment of preterm labour, partly because the mechanisms regulating the uterus and cervix during pregnancy are not well understood. New knowledge is needed to inhibit early progression of labour (uterine contractility and cervical ripening), and adequate quantitative tools to evaluate the uterus and cervix during pregnancy are lacking. In this review, we outline studies showing that the uterus (myometrium) and cervix pass through a conditioning step in preparation for labour. This step is not easily identifiable with present methods to assess the uterus or cervix. In the uterus, this seemingly irreversible step consists of changes in the electrical properties to make muscle more excitable and responsive to produce forceful contractions. In the cervix, the step consists of softening of the connective tissue components. Progesterone appears to have a dominant role in controlling both the uterus and cervix, as antiprogestins induce early, preterm conditioning leading to preterm labour. Apparently, nitric oxide (NO) also controls conditioning of the uterus and cervix. In the uterus, NO, in concert with progesterone, inhibits uterine contractility. At term, NO production by the uterus and placenta are decreased and allow labour to progress. In contrast, NO in the cervix increases at the end of pregnancy and it may be the final pathway for stimulating cervical ripening by activation of metalloenzymes. The progress of labour can be assessed non-invasively using electromyographic (EMG) signals from the uterus (the driving force for contractility) recorded from the abdominal surface. Uterine EMG bursts detected in this manner characterize uterine contractile events during human and animal pregnancy. A low uterine EMG activity, measured transabdominally throughout most of pregnancy, rises dramatically during labour. EMG activity also increases substantially during preterm labour in humans and rats. This method may be used one day to predict impending preterm labour and identify control steps and treatments. A quantitative method also assesses the cervix, using an optical device which measures collagen fluorescence in the cervix. The collascope estimates cervical collagen content from a fluorescent signal generated when collagen cross-links are illuminated with excitation light of about 340 nm. The system has proved useful in rats and humans at various stages of pregnancy, and indicates that cervical softening occurs progressively in the last one-third of pregnancy. In rats, collascope readings correlate with resistance measurements made in the isolated cervix, which may help to assess cervical function during pregnancy, and indicate control and treatments.     

Posterior uterine wall rupture during labour

Vaginal births after Caesarean section (VBAC) are well-accepted procedures when pregnant women do not have any contra-indications. The possibilities of the uterine dehisence and rupture during VBAC should always be considered. This occurrence is usually related to the previous scar tissue and subsequent risk is acceptable. Nevertheless, rupture that occurs in presumably normal tissue areas of the uterus instead of in scar tissue areas with resultant perinatal death is extremely rare. We present a 31 year old woman who had posterior uterine rupture when she tried VBAC at 38 weeks gestation. During the course of VBAC, she had a smooth labour course without use of any augmentation medication, but her condition was complicated with uterine rupture without any premonitory signal. It resulted in maternal shock and sequentially the death of the newborn 7 days after delivery. By reviewing this case report, we should keep in mind that prompt response to every woman during labour is of paramount importance to avoid repeating the occurrence of uterine rupture, partly because uterine rupture could occur without prominent signals and partly because subsequent dangers seem to be those created by acts of omission. Finally, the benefits and safety of VBAC have not been undermined because this patient is an isolated and extremely rare case.     

Primary peritoneal pregnancy implanted on the uterosacral ligament: a case report

Peritoneal pregnancies are classified as primary and secondary. Primary implantation on the peritoneum is extremely rare in extrauterine pregnancy and is a potentially life-threatening variation of ectopic pregnancy within the peritoneal cavity, representing a grave risk to maternal health. Secondary abdominal pregnancies are by far the most common and result from tubal abortion or rupture, or less often, after uterine rupture with subsequent implantation within abdomen. Early diagnosis and appropriate surgical management, regardless of stage of gestation, appear to be important in achieving good results. We report a case of primary peritoneal pregnancy in a 28-year-old woman, who had severe lower abdominal pain one day before laparotomy for a preoperative diagnosis of ectopic pregnancy. The conceptus was implanted on the left uterosacral ligament. A fresh embryo of approximately 8 weeks' gestation was found in the conceptus.     

A large amniocele with protruded umbilical cord diagnosed by 3D ultrasound

An amniocele is a herniation of the amniotic sac through a uterine defect. Uterine rupture during pregnancy may develop as a result of a pre-existing injury, uterine anomaly, or unscarred uterus. A 30-year-old patient, with a history of 2 vaginal deliveries, presented an amniocele complicated by left fundal perforation and was evaluated with 3-dimensional ultrasound at 23 weeks. Because of worsening lower abdominal pain and vaginal bleeding, she underwent exploratory laparotomy. Herein, we report a uterine rupture with amniocele.     

Laparoscopic management of rudimentary horn pregnancy

A unicornuate uterus with rudimentary horn is a rare Mullerian abnormality. This uterine anomaly may cause many gynaecological and obstetric complications, including infertility, recurrent abortions, preterm deliveries and rupture of the uterus, especially when the pregnancy implants in the rudimentary horn. To date, laparotomy has been the treatment of choice when resection of a rudimentary horn was indicated. We report on the case of a woman who benefited from laparoscopic surgery of a rudimentary horn pregnancy. Laparoscopy, in these exceptional cases, is the most accurate diagnostic tool that carries significant advantages in effective surgical management, thereby avoiding laparotomy.      

A case of herniated gravid uterus through a laparotomy scar

A 36-year-old manual worker presented in her second pregnancy at 34 weeks of gestation with an unusual bulge of her abdomen. The lower abdominal bulge turned out to be her gravid uterus herniated through an anterior abdominal wall incisional hernia which is a rare but serious obstetric situation with complications such as premature labour, intrauterine growth retardation, strangulation, intrauterine death and rupture of the lower uterine segment been reported. We had a successful outcome by conservative treatment till 38 weeks of gestation followed by an elective lower segment Caesarean section with hernia repair. Incisional hernia is a frequent complication of abdominal wall closure and the management of pregnancy with a large incisional hernia with gravid uterus in its sac is challenging.     

急诊子宫切除术在产科大出血中的应用及评价

目的探讨产科急诊子宫切除术在抢救产科大出血中的应用价值。方法采用回顾性资料分析方法,对我院2000年10月至2004年3月期间收治的8例因产科急诊行子宫切除术患者的临床资料进行分析。结果8例均为经保守治疗不能控制的产科大出血患者,其中弥散性血管内凝血(DIC)2例,子宫胎盘卒中3例(1例合并DIC),宫缩乏力2例(1例为双胎妊娠),子宫破裂、子宫畸形(并胎盘植入)各1例。出血量1600～3500ml,平均2380ml。8例患者均行子宫切除术后痊愈出院。相关因素分析显示,孕产次、多胎妊娠、分娩方式等因素与产科急诊子宫切除术相关。结论产科急诊子宫切除术是治疗急性产科大出血的有效措施之一。     

Ectopic pregnancies in Caesarean section scars: the 8 year experience of one medical centre

BACKGROUND: Our aim was to supplement the mostly individual case reports on the rarely occurring and life-threatening condition of ectopic pregnancy developing in a Caesarean section scar. METHODS AND RESULTS: Eight of all the patients treated in our department between 1995 and 2002 had been diagnosed for ectopic pregnancy that developed in a Caesarean section scar. They comprised this case series group. Four of them underwent methotrexate treatment; one had expectant management, one transcervical aspiration of the gestational sac and two by open surgery. All the non-surgically treated women had an uneventful outcome. One underwent a term Caesarean hysterectomy and the other first trimester hysterotomy and excision of the pregnancy located in the scarred uterus. Analysis of all these women's obstetric history revealed that five of them (63%) had been previously operated because of breech presentation, one had a cervical pregnancy and one had placenta previa. Four of them (50%) had multiple (> or = 2) Caesarean sections. CONCLUSIONS: The women at risk for pregnancy in a Caesarean section scar appear to be those with a history of placental pathology, ectopic pregnancy, multiple Caesarean sections and Caesarean breech delivery. Heightened awareness of this possibility and early diagnosis by means of transvaginal sonography can improve outcome and minimize the need for emergency extended surgery.     

Preeclampsia Is Associated with Widespread Apoptosis of Placental Cytotrophoblasts within the Uterine Wall

Preeclampsia is a serious pregnancy complication diagnosed by signs of widespread maternal endothelial dysfunction. In normal pregnancy, a subpopulation of placental cytotrophoblast stem cells executes an unusual differentiation program that leads to invasion of the uterus and its vasculature. This process attaches the conceptus to the uterine wall and starts the flow of maternal blood to the placenta. Preeclampsia is associated with abnormal cytotrophoblast differentiation, shallow invasion, and decreased blood flow to the placenta. To determine whether abnormal differentiation and/or hypoxia leads to cytotrophoblast apoptosis, we used the TUNEL (terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling) method to label DNA strand breaks in tissue sections of the placenta and the uterine wall to which it attaches. Control samples (n = 9) showed almost no apoptosis, but in samples from patients with preeclampsia, 15-50% of the cytotrophoblasts that invaded the uterine wall were labeled (8/9 samples). These same cells failed to stain for Bcl-2, a survival factor normally expressed by trophoblasts in both the placenta and the uterine wall. Our results show that preeclampsia is associated with widespread apoptosis of cytotrophoblasts that invade the uterus. The magnitude of programmed cell death in this population may account for the sudden onset of symptoms in some patients, as well as the associated coagulopathies.     

CASE REPORT: Diethylstilbestrol-induced Mullerian abnormalities, septate uterus, genital tuberculosis and twin pregnancy with term delivery after in-vitro fertilization

We report a case of a twin pregnancy at term obtained afterfive multiple embryo transfers in a patient who presented diethylstilbestrol(DES)-associated cervical and uterine structural abnormalities,a septate uterus and bilateral tuberculous salpingitis. Thesuitability of in-vitro fertiliza tion/embryo transfer in DES-exposedwomen is discussed.     

Spontaneous rupture of the liver following a normal pregnancy and delivery

Liver haematoma and rupture is a rare but potentially devastating complication of pregnancy. The majority of cases are associated with severe preeclampsia. We report a case of spontaneous hepatic rupture in a 39-year old woman following a normal pregnancy and delivery. Shoulder tip pain and serum haemoglobin of 6.8 prompted immediate imaging with computed tomography. A large subcapsular haematoma involving the right lobe of the liver was identified and managed conservatively. This diagnosis should be considered in the patient who presents with pain in the upper part of the abdomen and signs of haemorrhagic shock, even in the case of an uncomplicated pregnancy.     

Uterine remodelling during pregnancy and pseudopregnancy in the brushtail possum (Trichosurus vulpecula; Phalangeridae)

The formation of a placenta is critical for successful mammalian pregnancy and requires remodelling of the uterine epithelium. In eutherian mammals, remodelling involves specific morphological changes that often correlate with the mode of embryonic attachment. Given the differences between marsupial and eutherian placentae, formation of a marsupial placenta may involve patterns of uterine remodelling that are different from those in eutherians. Here we present a detailed morphological study of the uterus of the brushtail possum (Trichosurus vulpecula; Phalangeridae) throughout pregnancy, using both scanning and transmission electron microscopy, to identify whether uterine changes in marsupials correlate with mode of embryonic attachment as they do in eutherian mammals. The uterine remodelling of T. vulpecula is similar to that of eutherian mammals with the same mode of embryonic attachment (non‐invasive, epitheliochorial placentation). The morphological similarities include development of large apical projections, and a decrease in the diffusion distance for haemotrophes around the period of embryonic attachment. Importantly, remodelling of the uterus in T. vulpecula during pregnancy differs from that of a marsupial species with non‐invasive attachment (Macropus eugenii; Macropodidae) but is similar to that of a marsupial with invasive attachment (Monodelphis domestica; Didelphidae). We conclude that modes of embryonic attachment may not be typified by a particular suite of uterine changes in marsupials, as is the case for eutherian mammals, and that uterine remodelling may instead reflect phylogenetic relationships between marsupial lineages.