Placenta percreta causing rupture of an unscarred uterus at the end of the first trimester of pregnancy: case report

Reports on placenta percreta in early pregnancy leading to a spontaneous rupture of the uterus are rare. We report a case of this potentially life-threatening complication in the 14th week of pregnancy in an otherwise healthy woman who underwent a manual extraction of the placenta during a previous delivery but who had no history of severe pathology that could have potentially resulted in uterine damage. The occurrence of severe abdominal pain and the presence of a large quantity of free fluid in the abdomen necessitated an emergency laparotomy, revealing a haemoperitoneum due to rupture of the uterus, which was followed by a hysterectomy. This case demonstrates that in patients with a history of placenta accreta and subsequent manual extraction of the placenta, a close investigation of the uterine wall and placentation should be performed in the first trimester in order to anticipate a placenta percreta.     

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.     

First trimester uterine rupture and scar pregnancy

Uterine rupture during the first trimester of pregnancy is an extremely rare, but life-threatening cause of intraperitoneal hemorrhage. Up to the knowledge of the authors all reports of first trimester uterine ruptures are related to scar dehiscences following previous cesarean sections or occured in unscarred uteri of multiparous women. In cases of multiparity silent ruptures cannot be precluded, so that the uterus might be scarred during the following pregnancy. In early pregnancy of approximately 4–5 weeks, vaginal ultrasonography may clearly verify a scar pregnancy, but sonographical diagnostic findings may change with the pregnancy progress. In all cases of reported first trimester ruptures in pregnancies with previous cesarean sections or in pregnancies of multiparous women reported in literature, dating scans were performed too late for to preclude pregnancies in the scar. We postulate our hypotheses, that all first trimester uterine ruptures are caused by scar implantation of the trophoblast.     

Spontaneous rupture of the left external iliac vein

Recently, we have experienced a case of spontaneous rupture of the left iliac vein in a 62-year-old woman, who had been suffering from hemiparesis and chronic constipation. An urgent laparotomy was performed for massive hemoperitoneum without knowing the bleeding point, and laceration on the left external iliac vein was repaired. Spontaneous rupture of the iliac vein is extremely rare. However, it should be included in differential diagnoses of the patient with massive hemoperitoneum who have no known pathology or any evidence of blunt trauma.     

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。     

Tubal curettage: a new conservative treatment for haemorrhagic interstitial pregnancies

Haemorrhagic interstitial pregnancies are commonly treated by cornual resection. This invasive procedure may increase the risk of uterine rupture in subsequent pregnancies. We report here a case of a haemorrhagic interstitial pregnancy, associated with a viable intrauterine pregnancy in a salpingectomized woman, which was treated successfully by curettage of the uterine cornu.     

Fatal splenic rupture in a pregnant woman with hemoglobin C/beta-thalassemia and myeloid metaplasia

Splenic rupture with intraperitoneal hemorrhage is a fatal condition that is rarely encountered during the third trimester of pregnancy; its pathogenetic mechanisms and causes are largely unknown. We report a case of splenic rupture in a pregnant woman that caused the death of the mother and child. The patient was a carrier of double heterozygosis for hemoglobin C/beta-thalassemia. Spleen and liver enlargement due to extramedullary hematopoiesis was found at autopsy. Our data suggest that rare and hidden hematologic disorders should be considered as possible causes of splenic enlargement and rupture during pregnancy.     

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.     

Laparoscopic myomectomy and subsequent pregnancy: results in 54 patients

The laparoscopic approach to myomectomy has raised questions about the risk of uterine rupture in patients who become pregnant following surgery. It has been suggested that the rupture outside labour in pregnancies following laparoscopic myomectomy can be due to the difficulty of suturing or to the presence of a haematoma or to the wide use of radio frequencies. In this paper we describe the pregnancy outcome of 54 patients submitted to laparoscopic myomectomy at our Institution and prospectively followed during subsequent pregnancies. A total of 202 patients underwent laparoscopic myomectomy. A total of 65 pregnancies occurred in 54 patients who became pregnant following surgery. Data were collected about complications of pregnancy, mode of delivery, gestational age at delivery and birthweight of the neonates. No cases of uterine rupture occurred. Twenty-one pregnancies followed an IVF procedure. Nine patients conceived twice and one three times. Four multiple pregnancies occurred. Eight pregnancies resulted in a first trimester miscarriage and another in an interstitial pregnancy requiring laparotomic removal of the cornual gestational sac. Of the remaining 56 pregnancies, 51 (91%) were uneventful. In two cases a cerclage was performed at 16 weeks. In two cases pregnancy-induced hypertension developed. Two pregnancies ended with a preterm labour (26-36 weeks). A Caesarean section was performed in 45 cases (54/57, 80%). In terms of the safety of laparoscopic myomectomy in patients who become pregnant following surgery, our results were encouraging. However, further studies are needed to provide reliable data on the risk factors and the true incidence of uterine rupture.     

Spontaneous splenic rupture in a hemodialysis patient

Spontaneous splenic rupture (SSR) in a patient undergoing hemodialysis has been described as an extremely rare and potentially fatal complication. We report here spontaneous splenic rupture in a 52-year-old woman undergoing regular hemodialysis for end-stage renal disease (ESRD). She complained of colicky abdominal pain in the left upper quadrant area and dizziness when she assumed an upright posture. Her vital signs revealed low blood pressure and tachycardia, which was suggestive of hypovolemic shock. Abdomen CT scan showed splenic hematoma and hemoperitoneum. However, she had no history of any event triggering the splenic rupture. An exploratory laparotomy showed a ruptured spleen and an emergency splenectomy was performed. We suggest that spontaneous spleen rupture may be attributed to uremic coagulopathy and heparin-induced coagulopathy.     

半乳糖凝集素-3在复发性流产子宫蜕膜及绒毛组织中的表达

目的检测复发性流产患者子宫蜕膜及绒毛半乳糖凝集素-3（galectin-3）表达，为进一步探讨不明原因复发性流产提供理论依据。方法对41D例不明原因复发性流产患者及32例正常妊娠行人工流产患者，采用RT—PCR、免疫组织化学链霉素抗生物素蛋白-过氧化酶链接法（sp法）检测其子宫蜕膜及绒毛半乳糖凝集素-3的表达。结果复发性流产者子宫蜕膜及绒毛半乳糖凝集素-3的表达明显低于正常妊娠组。结论半乳糖凝集素-3与妊娠早期绒毛及子宫蜕膜发育相关，其表达降低可能是导致复发性流产的原因之一。     

Pregnancy following laparoscopic myomectomy: preliminary results.

The objective of this study was to assess the outcome of pregnancy in a series of women who underwent laparoscopic myomectomy. A total of 115 women underwent laparoscopic myomectomy for pressure and pain (76.5%), abnormal bleeding (52.2%) and/or infertility (29.6%). Follow up data were obtained either by reviewing the patient's chart or returned questionnaire. Of the 115 women, there were 42 pregnancies in 31 patients. Two women were lost to follow-up. Of the remaining 40 pregnancies, six ended with vaginal delivery at term. Caesareans were performed in 22 cases, including 21 at term and one at 26 weeks gestation. Two pregnancies were associated with a normal delivery, but the mode of delivery is unknown. Eight resulted in first trimester pregnancy loss, one was an ectopic pregnancy, and one patient underwent elective termination. Spontaneous uterine rupture was not noted during pregnancy or at term in any of the cases. Average length of follow-up from the date of surgery was 43 months, with a range of 9-99 months. Our series did not confirm the hypothesis that laparoscopic myomectomy is associated with an increased risk for uterine dehiscence during pregnancy. However, a larger series is needed to make a conclusive judgement.     

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.     

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.     

Spontaneous rupture of splenic artery aneurysm in pregnancy: a case report

Splenic artery aneurysms (SAA) occur predominantly in women, and the majority of them are asymptomatic until rupture. Over half of those that rupture occur during pregnancy. Spontaneously ruptured SAA during pregnancy is always a life-threatening surgical entity for both the mother and the fetus. We report the case of a 29-year-old woman at 34 weeks' gestation with spontaneous rupture of SAA who underwent emergency exploratory laparotomy and splenectomy. This case illustrates the need to consider ruptured SAA as part of important differential diagnosis in haemodynamically unstable pregnant women.     

Splenic pregnancy: a case report and review of the literature

Primary splenic pregnancy is the least common form of extrauterine pregnancy. We report a case of splenic pregnancy occurring in a 29-year-old woman presenting with acute abdomen and hemoperitoneum. Recognition of this rare form of gestation is of critical importance, owing to the risk of exsanguination and death, and should be considered in the differential diagnosis of acute abdomen in women of reproductive age.     

Risk of uterine rupture during labor among women with a prior cesarean delivery.

BACKGROUND: Each year in the United States, approximately 60 percent of women with a prior cesarean delivery who become pregnant again attempt labor. Concern persists that a trial of labor may increase the risk of uterine rupture, an uncommon but serious obstetrical complication. METHODS: We conducted a population-based, retrospective cohort analysis using data from all primiparous women who gave birth to live singleton infants by cesarean section in civilian hospitals in Washington State from 1987 through 1996 and who delivered a second singleton child during the same period (a total of 20,095 women). We assessed the risk of uterine rupture for deliveries with spontaneous onset of labor, those with labor induced by prostaglandins, and those in which labor was induced by other means; these three groups of deliveries were compared with repeated cesarean delivery without labor. RESULTS: Uterine rupture occurred at a rate of 1.6 per 1000 among women with repeated cesarean delivery without labor (11 women), 5.2 per 1000 among women with spontaneous onset of labor (56 women), 7.7 per 1000 among women whose labor was induced without prostaglandins (15 women), and 24.5 per 1000 among women with prostaglandin-induced labor (9 women). As compared with the risk in women with repeated cesarean delivery without labor, uterine rupture was more likely among women with spontaneous onset of labor (relative risk, 3.3; 95 percent confidence interval, 1.8 to 6.0), induction of labor without prostaglandins (relative risk, 4.9; 95 percent confidence interval, 2.4 to 9.7), and induction with prostaglandins (relative risk, 15.6; 95 percent confidence interval, 8.1 to 30.0). CONCLUSIONS: For women with one prior cesarean delivery, the risk of uterine rupture is higher among those whose labor is induced than among those with repeated cesarean delivery without labor. Labor induced with a prostaglandin confers the highest risk.     

Pregnancy outcome and deliveries following laparoscopic myomectomy

Uterine rupture after myomectomy by laparotomy is not a common occurrence. Some case reports of uterine rupture after laparoscopic myomectomy (LM) raise the question of the quality of the uterine scar produced when this technique is performed. In order to assess the outcome of pregnancies and deliveries after LM and to assess the risk of uterine rupture, we performed an observational study. Questionnaires were mailed to all women who had had LM for at least one intramural or subserosal myoma of more than 20 mm diameter and who were aged <45 years. Ninety-eight patients became pregnant at least once after LM, giving a total of 145 pregnancies. Among the 100 patients who had delivery, there were three cases of spontaneous uterine rupture. Because only one of these uterine ruptures occurred on the LM scar, the risk of uterine rupture was 1.0% (95% CI 0.0-5. 5%). Seventy-two patients (72.0%) had trials of labour. Of these, 58 (80.6%) were delivered vaginally. There was no uterine rupture during the trials of labour. Spontaneous uterine rupture seems to be rare after LM. This risk should not deter the use of LM if needed. When performing LM, particular care must be given to the uterine closure.     

A polymorphism in the MTHFD1 gene increases a mother's risk of having an unexplained second trimester pregnancy loss

Low maternal folate or vitamin B12 status has been implicated in numerous pregnancy complications including spontaneous abortion. The primary aim of this study was to test a polymorphism within the trifunctional folate enzyme MTHFD1 (5,10-methylenetetrahydrofolate dehydrogenase, 5,10-methenyltetrahydrofolate cyclohydrolase, 10-formyltetrahydrofolate synthetase) for an association with a mother's risk of having an unexplained second trimester pregnancy loss. We genotyped 125 women who had at least one unexplained spontaneous abortion or intrauterine fetal death between 13 and 26 weeks gestation and 625 control women with no history of prior pregnancy loss. Our study is the first to identify an association between the MTHFD1 1958G-->A (R653Q) polymorphism and the maternal risk of having an unexplained second trimester pregnancy loss. Women who are MTHFD1 1958AA homozygous have a 1.64-fold increased risk of having an unexplained second trimester loss compared to women who are MTHFD1 1958AG or 1958GG [OR 1.64 (1.05-2.57), P = 0.03]. It has been reported that polymorphisms in 5,10-methylenetetrahydrofolate reductase (MTHFR), 677C-->T (A222V), transcobalamin II (TCII), 776C-->G (P259R), are associated with pregnancy loss. Both variants were tested in this study. Neither showed evidence of significantly affecting the maternal risk of having a second trimester pregnancy loss. In conclusion, the MTHFD1 1958AA genotype may be an important maternal risk factor to consider during pregnancy.     

Spontaneous splenic rupture: A rare presentation of dengue fever

Spontaneous rupture of the spleen with hemoperitoneum is a very rare, but serious manifestation of dengue fever (DF). We report a case of a young female who was presented with atraumatic abdominal pain, hypovolemic shock, anemia, ascites and hepatosplenomegaly with a recent history of a febrile illness. Subsequent investigations proved the presence of hemoperitoneum with spontaneous splenic rupture with seropositivity for DF. Early diagnosis and conservative management in this case resulted in a favorable outcome.