Preterm premature rupture of membrane and twin-to-twin transfusion syndrome before 20 weeks: a favourable outcome

We describe a monochorionic twin gestation with a severe twin-to-twin transfusion syndrome associated with a preterm premature rupture of membranes at 20 weeks of gestation in the polyhydramniotic sac. The pregnancy was managed expectantly and outcome was favourable for the 2 neonates. We discuss how these two severe pathologies seem to counteract each other by compensations of their symptoms.     

Repair of Uterine Rupture in Twin Gestation after Laparoscopic Cornual Resection

Spontaneous uterine rupture in the course of pregnancy is a rare event that usually occurs in a scarred uterus. The event occurs mostly during the intrapartum period and is potentially catastrophic for both mother and fetus. We report a case of 2-cm cornual rupture in a pregnant woman at 13 weeks twin gestation with previous history of cornual pregnancy successfully managed via laparoscopy. Sudden onset of abdominal pain and vaginal bleeding was noted first. Physical examination revealed stable vital signs, lower abdominal tenderness, and mild rebounding pain. Pelvic ultrasonography revealed twin pregnancy at 13 weeks with extrauterine saccular structure 6 cm in diameter located on the left fundus and contiguous with an intrauterine oligohydramnics twin. Exploratory laparotomy was promptly performed, and a small rupture about 2 cm in diameter was observed on the upper portion of the left fundus, the site of a previous laparoscopic cornual resection scar. A protruding amniotic sac of about 6 cm diameter and containing some part of the umbilical cord was seen. The uterine rupture site was repaired directly after aspiration of amniotic fluid from the protruding sac. After surgery, the patient received antibiotics, 17-OH-progesterone for potential rupture of membranes and prematurity. Tocolysis with Ritodrine for irregular uterine contractions was given at 22 weeks gestation. Steroids were given at 24 weeks gestation. The pregnancy ended with a successful delivery by cesarean section because of uncontrollable uterine contractions at 30 5/7 weeks gestation. In conclusion, although termination of pregnancy would normally be recommended when uterine rupture occurs, a different approach to management may now be accepted.     

Uterine rupture of cesarean scar related to spontaneous abortion in the first trimester

We report the case of a 31-year-old Japanese female diagnosed by transvaginal ultrasonography to have a spontaneous uterine rupture in the first trimester. Her condition was complicated by diabetes mellitus type 1. Her previous pregnancy had resulted in an emergency cesarean section by transverse incision of the lower uterine segment with single-layer suture at 37(+4) weeks of gestation. Transvaginal ultrasonography displayed both a gestational sac located in the anterior lower uterine segment and a defect in the uterine wall located at the site of the previous cesarean delivery scar. Pelvic magnetic resonance imaging showed that the uterine muscle layer was discontinuous and the gestational sac was almost outside the uterine cavity, accompanied by mild hemorrhaging within the endometrial cavity. The defect in the lower uterine wall was round in shape and was 3 cm in diameter. Since uterine ruptures can occur during all gestational periods, it is important to pay attention to the uterine wall where any cesarean incision was previously made.     

Pregnancy outcome after laparoscopic electromyolysis

Laparoscopic myolysis, a procedure designed to shrink uterine myomas by coagulating their blood supply, is an alternative to myomectomy or hysterectomy in women who do not contemplate childbearing. Three patients conceived within 3 months after myolysis against the surgeon's advice. In two of these women the uterus ruptured at 32 and 39 weeks' gestation, respectively, associated with death of the 32-week fetus. The third patient had an uneventful elective cesarean section at 39 weeks' gestation. Until the risk of uterine rupture after myolysis has been accurately compared with that after myomectomy, women should not undergo myolysis if they wish to conceive. Should pregnancy occur after myolysis, caution and intensive surveillance of mother and fetus must be applied, and cesarean section should be performed at earliest signs and symptoms of uterine rupture and at term before onset of labor.     

Clinically silent polymicrobial amnionitis and intrauterine fetal death associated with a Cu-7 intrauterine contraceptive device

This article presents a case of silent polymicrobial amnionitis with subsequent intrauterine fetal death in a 34-year old woman who conceived with a Cu-7 IUD in place. There were no apparent pregnancy complications or symptoms of uterine infection during early pregnancy. At 16 weeks gestation, the patient underwent amniocentesis for cytogenetic studies. 5 different microorganisms--Corynebacterium, Staphylococcus warneri, Staphylococcus epidermidis, Streptococcus mitis, and Ureaplasma urealyticum--were isolated from the amniotic fluid. 2 week later, intrauterine fetal death was detected. U. urealyticum was at this point isolated from the cervix and placental and fetal tissues. This organism, which has been associated with chorioamnionitis, spontaneous abortion, and neonatal death, is suspected to have contributed to the fetal death in this case. U. urealyticum can invade the amniotic sac with fetal membranes intact and persist for 8 weeks without overt effects. This case illustrates the risks associated with nonremoval of an IUD after contraceptive failure.     

Spontaneous uterine rupture with amniotic sac protrusion at 28 weeks subsequent to previous hysteroscopic metroplasty

BACKGROUND: Hysteroscopic metroplasty improves pregnancy outcome in case of uterine septum. Uterine rupture during a pregnancy following this procedure may occur. CASE: A patient with a history of hysteroscopic resection of a uterine septum complicated by fundal perforation, presented at 28 weeks a spontaneous uterine rupture with amniotic sac protrusion through the uterine wall disruption. CONCLUSION: Uterine rupture during pregnancy following a hysteroscopic metroplasty may occur even though it appears to be a very uncommon event. Patients who have had this procedure should be aware of this potential risk in case of future pregnancies. How to avoid such complication is still unclear.     

Caesarean scar pregnancy: hysterotomy is rapid and safe management option

Caesarean scar pregnancy (CSP) is implantation of the gestational sac within the hysterotomy scar. Ultrasound is the main diagnostic tool. Early diagnosis and termination of pregnancy is crucial to avoid the risk of uterine rupture. The termination modalities available are dilatation and curettage, methotrexate therapy, hysteroscopy, uterine artery embolization and laparotomy. We present a case of undisturbed CSP which presented at 6 weeks + 6 days gestation. Our management was termination of pregnancy by exploratory laparotomy and hysterotomy for excision of the mass. The postoperative period was uneventful and there was rapid decline of beta human chorionic gonadotrophin to the normal level.     

Pregnancy in primigravida complicated by premature rupture of membranes in 15th week of pregnancy with successful delivery outcome of the mature newborn--case report and review of the literature

Premature rupture of membranes and amniotic fluid leakage is a very serious complication of pregnancy. In most cases it causes the premature contractile activity of uterine muscle and premature labour. It is a very rare situation when after premature rupture of membranes at less than 20 weeks of gestation it is possible to carry pregnancy to term with a successful delivery outcome of healthy mature infant. In the study we analysed the course of pregnancy in 28 years old primigravida with PROM from 15th week of pregnancy with a successful delivery outcome of mature newborn in 37th week of gestation. Our analysis revealed that in certain cases of premature rupture of membranes it is possible to successfully prolong the duration of pregnancy till the foetus matures. It seems necessary to improve the management which allows to prolongate the duration of pregnancy in premature rupture of membranes.     

Delayed interval delivery of a second twin

We report a case of diamniotic dichorionic pregnancy at 21 weeks and 5 days of gestation with threatened preterm labor with cervical modification and protrusion into vagina of the amniotic sac of twin one. After 4 days there was a rupture of membrane of the protruding sac and delivery of the first twin. We decided to retain the other one to allow improvement in the outcome for the second twin. The patient was treated with tocolytics, antibiotics and continuously monitored. After 18 days there was increasing uterine contractility and we decided to perform the cesarean section and delivered the second twin.     

The efficacy of intraamniotic steroids for induction of labor.

Labor induction in humans by the injection of 18 mg of betamethasone (Celestone) into the amniotic sac was investigated in a group of 19 pregnant women. Eight of the cases were high-risk pregnancies of 36-39 weeks' gestation, and 11 were normal pregnancies of 40-42 weeks' gestation. A group of 19 women at similar stages of pregnancy served as a control group. The criterion for the efficacy of the technique was the onset of labor or rupture of the membranes within 72 hours of the injection. Contrary to other reports, it was concluded that the technique is ineffective since no significant difference was found between the experimental and control groups.     

Spontaneous uterine rupture at thirty-three weeks subsequent to previous superficial laparoscopic myomectomy

Obstetric uterine rupture has previously been reported after the laparoscopic removal of deep intramural myomas, but never has it been reported to follow the removal of superficial myomas. A 39-year-old primigravid woman with a history of a superficial subserous laparoscopic myomectomy was seen for acute abdominal symptoms at 33 weeks of gestation. Emergency cesarean laparotomy confirmed a spontaneous rupture of the uterine fundus with extrusion of the intact fetal sac into the upper abdomen. This is the first reported case of obstetric uterine rupture subsequent to the removal of a superficial myoma by laparoscopic techniques.(Am J Obstet Gynecol 1997;177:1547-9.)     

Spontaneous uterine rupture at a non-cesarean section scar site caused by placenta percreta in the early second trimester of gestation: A case report

ObjectivesRisk factors for placenta percreta are placenta previa and prior cesarean delivery. Placenta percreta–induced ruptures at non-cesarean sites are very rare, particularly in the early second trimester.Case reportA 30-year-old woman with a prior cesarean delivery was brought to our emergency department at 17 weeks' gestation for sudden-onset consciousness loss and generalized convulsions. Hypovolemic shock was identified. Computed tomography scans suggested uterine rupture and massive ascites, r/o hemoperitoneum. Emergency exploratory laparotomy revealed a ruptured hole over the left uterine fundus with protruding placental tissue; placenta percreta was impressed. An intact intrauterine sac was dissected and removed. The placenta was removed and hysterorrhaphy was completed.ConclusionPlacenta percreta is dangerous and is rarely seen in the early second trimester. Uterine rupture should always be kept in mind in pregnant woman with acute abdomen associated with hypovolemic shock, even in those of early pregnancy without scarred uterus. Routine sonographic examination of placentation, even in early second trimester, should be emphasized.     

The frequency and clinical significance of intra-amniotic inflammation in twin pregnancies with preterm labor and intact membranes

Objective: The objective of this study is to evaluate the frequency and clinical significance of intra-amniotic inflammation in twin pregnancies with preterm labor and intact membranes.

Study design: Amniotic fluid (AF) was retrieved from both sacs in 90 twin gestations with preterm labor and intact membranes (gestational age between 20 and 34 6/7 weeks). Preterm labor was defined as the presence of painful regular uterine contractions, with a frequency of at least 2 every 10?min, requiring hospitalization. Fluid was cultured and assayed for matrix metalloproteinase-8. Intra-amniotic inflammation was defined as an AF matrix metalloproteinase-8 concentration >23?ng/mL.

Results: The prevalence of intra-amniotic inflammation for at least 1 amniotic sac was 39% (35/90), while that of proven intra-amniotic infection for at least one amniotic sac was 10% (9/90). Intra-amniotic inflammation without proven microbial invasion of the amniotic cavity was found in 29% (26/90) of the cases. Intra-amniotic inflammation was present in both amniotic sacs for 22 cases, in the presenting amniotic sac for 12 cases, and in the non-presenting amniotic sac for one case. Women with intra-amniotic inflammation observed in at least one amniotic sac and a negative AF culture for microorganisms had a significantly higher rate of adverse pregnancy outcome than those with a negative AF culture and without intra-amniotic inflammation (lower gestational age at birth, shorter amniocentesis-to-delivery interval, and significant neonatal morbidity). Importantly, there was no significant difference in pregnancy outcome between women with intra-amniotic inflammation and a negative AF culture and those with a positive AF culture.

Conclusion: Intra-amniotic inflammation is present in 39% of twin pregnancies with preterm labor and intact membranes and is a risk factor for impending preterm delivery and adverse outcome, regardless of the presence or absence of bacteria detected using cultivation techniques.     

Doppler flow velocimetry assisted diagnosis of an intrauterine synechia during pregnancy

The differential diagnosis of reflective intrauterine membranes during pregnancy includes amniotic bands of fetal origin or membranes of combined maternal-fetal origin. While the former have been associated with fetal transverse reduction defects or the lethal amniotic band syndrome, the latter are usually benign and consist of a preexisting uterine septation or synechia around which the fetal membranes fold or become enveloped. We present an unusual case in which a patient was noted at 19 weeks' gestation to have an intrauterine membrane of undetermined origin, appearing to contain a pulsating vessel. Color Doppler imaging and Doppler flow velocimetry clearly depicted a pulse synchronous with the maternal heart rate, defining the membrane as amniotic membranes surrounding a preexisting uterine synechia and not a true amniotic band. The pregnancy was otherwise uneventful and the patient delivered a healthy neonate at elective repeat cesarean at which time the presence of the uterine synechia was confirmed.     

PROLONGED PREGNANCY AND THE BIOPHYSICAL PROFILE A Birthing Center Perspective

A triage system for antepartum surveillance of postdates pregnancy is studied in a busy, indigent care service with limited resources for in-hospital delivery. One hundred seventy-eight pregnancies (13.2% of the total population) were thought to be at least 42 weeks' gestation by clinical criteria, and 128 of these underwent at least one complete biophysical profile within seven days of delivery. We find no statistically significant difference in the incidence of meconium staining, fetal distress in labor, or low Apgar scores when either the high or low scoring groups are compared, or when compared with the 50 patients who delivered without a biophysical evaluation. Specific components of the testing schema, however, namely oligohydramnios and spontaneous decelerations on the nonstress test, are highly associated with adverse perinatal events. Of the total population thought to be postmature clinically, only 60 infants (33.9%) were actually beyond 42 weeks' gestation by Dubowitz scoring. We conclude that a modified biophysical assessment as described is easily performed in a nontertiary care setting where a CNM-MD team approach is applied and may help to differentiate patients who require expeditious termination of pregnancy in-hospital from those who can be managed expectantly in the birthing center.     

Amniotic band syndrome following septostomy in management of twin-twin transfusion syndrome: a case report.

Septostomy, a rupture of the diamniotic membrane separating monozygotic twins essentially creating a monoamniotic gestation, is a potential therapeutic modality for twin-twin transfusion syndrome (TTTS). This may be associated with complications including cord entanglement or complete rupture of the membranes. We report a case of severe amniotic band syndrome with cord amputation after septostomy. A 33-year-old woman with a Mo-Di twin pregnancy was diagnosed with TTTS at 18 weeks of gestation. Septostomy as well as amnioreduction were performed at 24 weeks of gestation. A repeat cesarean delivery was performed at 31 weeks resulting in a live recipient baby of 1340 g and a dead donor with amniotic band syndrome. The donor showed pieces of membrane tightening both legs. The right thigh became entangled in the bands connecting to the umbilical cord of the live fetus. The umbilical cord of the dead twin was completely amputated, whereas the umbilical cord of the live infant was also entrapped within the amniotic band resulting in small diameter and some degree of stricture. This is the first report of a rare but serious complication following septostomy.     

剖宫产术后再次妊娠子宫破裂10例临床分析

目的 探讨剖宫产术后再次妊娠子宫破裂的临床特点及预防。方法 对1990年1月至2013年12月北京协和医院收治的10例剖宫产术后再次妊娠子宫破裂的病例进行回顾分析。结果 10例子宫破裂的患者中,不完全破裂6例,完全破裂4例。完全破裂的患者平均分娩孕周（27+6±9+4）周,此次分娩距前次剖宫产时间均≥21个月;入院时均未足月,主诉全部伴有下腹部疼痛。子宫不完全破裂的患者平均分娩孕周（36+4±5+2）周,此次分娩距前次剖宫产时间均≥12个月;大部分为足月,多数不伴有腹部疼痛。结论 剖宫产术后再次妊娠是子宫破裂的高危因素。对于有剖宫产史再次妊娠的患者,整个孕期都要提高警惕,加强孕期管理和监护。     

Premature rupture of the membranes in a single twin gestational sac. A case report

Premature rupture of the membranes was diagnosed with ultrasound and subsequent injection of dye into the upper sac of a 15-week twin gestation. Because of a history of prolonged infertility, conservative treatment (including bed rest, antibiotics and intravaginal povidone-iodine pessaries) was given. Four weeks later the leakage of amniotic fluid stopped, and at 32 gestational weeks the patient delivered healthy twins by cesarean section. No sign of chorioamnionitis was noted clinically or histologically. It seems that in this unusual case the lower sac was acting as a tampon and at some stage prevented further escape of amniotic fluid as well as ascending infection.     

Interleukin-18 in cervical mucus and amniotic fluid: relationship to microbial invasion of the amniotic fluid,intra-amniotic inflammation and preterm delivery

Objective To evaluate the relationship between interleukin (IL)-18 in cervical mucus and amniotic fluid and microbial invasion of amniotic fluid, preterm delivery and intra-amniotic inflammation in women in preterm labour, with preterm prelabour rupture of membranes and at term.
Design A prospective follow up study.
Setting Sahlgrenska University Hospital, Göteborg, Sweden.
Sample Women with singleton pregnancies (  <34 weeks  ) presenting with preterm labour (   n = 87  ) or preterm prelabour rupture of membranes (   n = 47  ) and women, not in labour, at term (   n = 28  ).
Methods Amniotic fluid was retrieved transabdominally. Cervical mucus was taken from the uterine cervix of women in preterm labour and at term. IL-18 was analysed with enzyme-linked immunosorbent assay.
Main outcome measures IL-18 in relation to microbial invasion of the amniotic fluid, delivery within seven days or  <34 weeks  of gestation and intra-amniotic inflammation.
Results The levels of IL-18 in cervical mucus and amniotic fluid were higher in women with preterm labour than in those not in labour at term. In the preterm labour group, significant associations were found between elevated IL-18 in amniotic fluid and microbial invasion of the amniotic fluid, as well as between delivery within seven days or  <34 weeks  of gestation and intra-amniotic inflammation. Delivery was delayed longer in the preterm prelabour rupture of membranes subgroup with  IL-18 ≥1.0 ng/mL than in that with IL-18 <1.0 ng/mL  .
Conclusions In the preterm labour group, high IL-18 in amniotic fluid (but not in the cervix) was associated with microbial invasion of the amniotic fluid, intra-amniotic inflammation and prompt delivery. On the other hand, elevated IL-18 in preterm prelabour rupture of the membranes group correlated with a longer interval to delivery.