Asymptomatic uterine rupture after two spontaneous vaginal deliveries following prior cesarean section

We present the case of an almost asymptomatic uterine rupture after two consecutive vaginal deliveries after a prior cesarean delivery (first child). Uterine rupture is rare even after a prior cesarean delivery, permitting a trial of labor after a cesarean delivery in spite of the increased risk of uterine rupture. Vaginal birth after previous cesarean delivery, however, demands a cautious approach. Appropriate recommendations have been published by the ACOG and the 'AG fOr fetomaternale Medizin' (a branch of the German Society of Obstetrics and Gynaecology). In our case diagnosis was made by an vaginal ultrasound examination 7.5 weeks after an uncomplicated vaginal delivery. An additional MRI examination did not result in substantial extra information. For that reason it will be indicated only in exceptional cases. To answer the question whether a vaginal ultrasound examination should routinely be offered after an uncomplicated vaginal delivery with a prior cesarean delivery in the history to preclude uterine rupture further studies are necessary.     

Maternal and fetal signs and symptoms associated with uterine rupture in women with prior cesarean delivery

Objective: To describe the association between maternal and fetal physical signs and symptoms (signs/symptoms) and childbirth outcomes in women with prior cesarean delivery (CD).

Methods: Cases of uterine rupture at a single institution were reviewed to examine risk factors for experiencing signs/symptoms and poor childbirth outcomes.

Results: Among 21?014 deliveries, 3252 (15.5%) had prior CD, and 75 (2.3%) had uterine rupture. Of these, 66 (88.0%) labored. Among those who labored, 51 (77.3%) demonstrated signs/symptoms prior to delivery. Signs/symptoms included vaginal bleeding, abdominal pain, fetal bradycardia and decreased fetal heart rate (FHR) variability. Laboring patients with signs/symptoms were seven times more likely than those without them to have poor maternal/neonatal outcome (27/51 [52.9%] versus 2/15 [13.3%], OR?=?7.31 [95% CI 1.34–52.43], p?=?0.0155). In multivariate analysis, risk factors for poor fetal outcome were cervical ripening (OR 4.99 [95% CI 0.86–28.99, p?=?0.0735) and prolonged FHR deceleration/bradycardia (OR 2.78 [95% CI 0.86–9.10], p?=?0.0905). Fetal tachycardia was a risk factor for poor maternal outcome (OR 8.10 [95% CI 1.40–46.84], p?=?0.0195).

Conclusions: Among laboring women with uterine rupture, 77% demonstrated maternal or fetal signs/symptoms before delivery. The presence of at least one sign/symptom identified nearly all laboring patients (27/29 [93.1%]) with poor outcomes.     

Rate of uterine rupture during a trial of labor in women with one or two prior cesarean deliveries.

OBJECTIVE: We sought to determine whether there is a difference in the rate of symptomatic uterine rupture after a trial of labor in women who have had 1 versus 2 prior cesarean deliveries. STUDY DESIGN: The medical records of all women with a history of either 1 or 2 prior cesarean deliveries who elected to undergo a trial of labor during a 12-year period (July 1984-June 1996) at the Brigham and Women's Hospital were reviewed. Rates of uterine rupture were compared for these 2 groups. Potential confounding variables were controlled by using logistic regression analyses. RESULTS: Women with 1 prior cesarean delivery (n = 3757) had a rate of uterine rupture of 0.8%, whereas women with 2 prior cesarean deliveries (n = 134) had a rate of uterine rupture of 3.7% (P =.001). In a logistic regression analysis that was controlled for maternal age, use of epidural analgesia, oxytocin induction, oxytocin augmentation, the use of prostaglandin E(2) gel, birth weight, gestational age, type of prior hysterotomy, year of trial of labor, and prior vaginal delivery, the odds ratio for uterine rupture in those patients with 2 prior cesarean deliveries was 4.8 (95% confidence interval, 1.8-13. 2) CONCLUSIONS: Women with a history of 2 prior cesarean deliveries have an almost 5-fold greater risk of uterine rupture than those with only 1 prior cesarean delivery.     

妊娠中晚期完全性子宫破裂临床分析

目的:探讨妊娠中晚期完全性子宫破裂的临床特点、治疗情况及母儿预后。方法:回顾分析2014年1月至2018年9月华中科技大学附属同济医院收治的妊娠中晚期完全性子宫破裂15例的病例资料。结果:妊娠中晚期完全性子宫破裂患者15例,平均孕周32~(+4)周(23~(+1)～39周)。15例患者均有腹部手术史或宫腔操作史,其中子宫底或宫角部破裂7例,子宫体部破裂6例,原剖宫产瘢痕处破裂2例。14例患者行剖宫产+子宫破裂修补术(其中3例行子宫动脉结扎),术后恢复良好;1例患者入院时已发生失血性休克,多器官功能衰竭,抢救无效死亡。胎婴结局中死亡8例,新生儿重度窒息3例,轻度窒息3例,出生时状态良好1例。结论:瘢痕子宫是子宫破裂的主要危险因素,但除剖宫产手术史外,肌瘤剔除史、异位妊娠史及宫腔操作史也与子宫破裂相关。有效识别高危孕妇,定期产检监测,快速识别可疑症状,紧急剖宫产有利于提高母儿预后。     

Uterine rupture during second trimester abortion with misoprostol

BACKGROUND: Data are limited regarding the use of misoprostol in the midtrimester, therefore few cases with uterine rupture during the second trimester with a previous uterine scar have been reported in the literature. CASE REPORT: A 23-year-old woman with a prior low transverse cesarean section presented at 26 weeks' gestation for pregnancy termination for a fetal abnormality. She was given 200 microg misoprostol intravaginally every 3 h until regular contractions began. After the fourth dose, she had vaginal bleeding and severe contractions. She aborted completely 2 h later after the last dose. Uterine rupture was diagnosed at the previous cesarean section scar by manual vaginal examination. She underwent emergency laparotomy and the uterus was repaired. CONCLUSION: Misoprostol use in the second trimester in a woman with a uterine scar can trigger severe contractions that can lead to uterine rupture.     

Risk of uterine rupture with a trial of labor in women with multiple and single prior cesarean delivery

OBJECTIVE: To determine whether the risk for uterine rupture is increased in women attempting vaginal birth after multiple cesarean deliveries. METHODS: We conducted a prospective multicenter observational study of women with prior cesarean delivery undergoing trial of labor and elective repeat operation. Maternal and perinatal outcomes were compared among women attempting vaginal birth after multiple cesarean deliveries and those with a single prior cesarean delivery. We also compared outcomes for women with multiple prior cesarean deliveries undergoing trial of labor with those electing repeat cesarean delivery. RESULTS: Uterine rupture occurred in 9 of 975 (0.9%) women with multiple prior cesarean compared with 115 of 16,915 (0.7%) women with a single prior operation (P = .37). Multivariable analysis confirmed that multiple prior cesarean delivery was not associated with an increased risk for uterine rupture. The rates of hysterectomy (0.6% versus 0.2%, P = .023) and transfusion (3.2% versus 1.6%, P < .001) were increased in women with multiple prior cesarean deliveries compared with women with a single prior cesarean delivery attempting trial of labor. Similarly, a composite of maternal morbidity was increased in women with multiple prior cesarean deliveries undergoing trial of labor compared with those having elective repeat cesarean delivery (odds ratio 1.41, 95% confidence interval 1.02-1.93). CONCLUSION: A history of multiple cesarean deliveries is not associated with an increased rate of uterine rupture in women attempting vaginal birth compared with those with a single prior operation. Maternal morbidity is increased with trial of labor after multiple cesarean deliveries, compared with elective repeat cesarean delivery, but the absolute risk for complications is small. Vaginal birth after multiple cesarean deliveries should remain an option for eligible women. LEVEL OF EVIDENCE: II-2.     

Bladder rupture associated with uterine rupture. A report of two cases occurring during vaginal birth after cesarean

BACKGROUND: Uterine rupture occurs in < 1% of patients undergoing a trial of labor after cesarean section. Associated injury to adjacent organs within the maternal pelvis has likewise been very rarely reported. CASE: Two cases of posterior bladder wall rupture occurred in association with rupture of low transverse uterine incisions. CONCLUSION: Bladder rupture may be associated with uterine rupture during attempted vaginal birth after cesarean. The potential for bladder injury should be included in the patient's antepartum counseling.     

Changes in uterine size after vaginal delivery and cesarean section determined by vaginal sonography in the puerperium

There have been few reports on postpartum changes in the uterus during the three months after delivery. The aim of this study was to evaluate uterine morphological changes in women after vaginal delivery (n=262–351) and in women after cesarean section (n=64–82) and to evaluate the relation between breast-feeding and parity, and uterine involution at 1 and 3 months postpartum measured by vaginal ultrasonography. There were no significant differences in parity between the vaginal delivery group and the cesarean section group. The length of the uterus at one month (7.93±1.16 cm, mean±SD) and, three months (7.03± 1.19 cm) and the width of the uterus at three months (3.83±0.94 cm) after delivery in the cesarean section group were greater than in the transvaginal group (7.64±1.03 cm, 6.65±0.99 cm, 3.57±0.62 cm, respectively). Increasing maternal parity was associated slightly with larger uterine size at one month post partum. The length of the uterus of women with a breast-feeding rate of 80% or more per day was 6.35±0.85 cm, and shorter than in women with a rate of 20% or less 7.03±1.04 cm, at three months after delivery. The width of the uterine body of women with a breast-feeding rate of 80% or more per day was 3.32±0.45 cm, and shorter than in women with a rate of 20% or less 3.87±0.66 cm, at 3 months after delivery. Stepwise regression and multiple regression analysis among parity, the history of cesarean section, the breast-feeding rate at one and three months after the delivery, and the restoration of the menses at three months after the delivery showed that the uterine size at one month after the delivery was related to the cesarean section and that the uterine size at three months after delivery was mostly related to the rate of breast-feeding. These results indicated that uterine involution was related to delivery mode at one and three months postpartum, feeding mode at three months postpartum, the menses restoration, and parity. The rate of breast-feeding was mostly related to the uterine size at three months postpartum. Received: April 1998 / Accepted: 26 March 1999     

Misoprostol for second trimester pregnancy termination in women with prior caesarean section

OBJECTIVE: To examine whether a previous caesarean section increases the risk for complications in women undergoing a mid-trimester pregnancy termination by labour induction. DESIGN: Retrospective analysis of case records between 1997 and 2002. SETTING: Fetal Medicine Unit of a large teaching hospital. POPULATION: One hundred and eight women with a previous caesarean section (study group) and 216 women without such a history (controls), who underwent a second trimester termination of pregnancy. METHODS: All the terminations were performed between 17 and 24 weeks of gestation by using 400 mug of oral administration of misoprostol in combination with 400 mug of intravaginal misoprostol. The same dose of intravaginal misoprostol was repeated every 6 hours for a maximum of five doses. MAIN OUTCOME MEASURES: Severe haemorrhage requiring blood transfusion, post-abortal infection, retained placenta and uterine rupture. RESULT: Complications occurred in 16 out of 108 women of the study group (15%) and in 26 out of 216 of the controls (12%), with only one ruptured uterus in the control group. CONCLUSION: We found no evidence that a previous caesarean delivery affects the incidence of complications when women with such a history undergo a mid-trimester pregnancy termination with misoprostol.     

Uterine rupture during induced or augmented labor in gravid women with one prior cesarean delivery.

OBJECTIVE: Our purpose was to examine the risk of uterine rupture during induction or augmentation of labor in gravid women with 1 prior cesarean delivery. STUDY DESIGN: The medical records of all gravid women with history of cesarean delivery who attempted a trial of labor during a 12-year period at a single center were reviewed. The current analysis was limited to women at term with 1 prior cesarean delivery and no other deliveries. The rate of uterine rupture in gravid women within that group undergoing induction was compared with that in spontaneously laboring women. The association of oxytocin induction, oxytocin augmentation, and use of prostaglandin E(2) gel with uterine rupture was determined. Logistic regression analysis was used to examine these associations, with control for confounding factors. RESULTS: Of 2774 women in the analysis, 2214 had spontaneous onset of labor and 560 women had labor induced with oxytocin or prostaglandin E(2) gel. The overall rate of rupture among all patients with induction of labor was 2.3%, in comparison with 0.7% among women with spontaneous labor (P =.001). Among 1072 patients receiving oxytocin augmentation, the rate of uterine rupture was 1.0%, in comparison with 0.4% in nonaugmented, spontaneously laboring patients (P =.1). In a logistic regression model with control for birth weight, use of epidural, duration of labor, maternal age, year of delivery, and years since last birth, induction with oxytocin was associated with a 4.6-fold increased risk of uterine rupture compared with no oxytocin use (95% confidence interval, 1.5-14.1). In that model, augmentation with oxytocin was associated with an odds ratio of 2.3 (95% confidence interval, 0.8-7.0), and use of prostaglandin E(2) gel was associated with an odds ratio of 3.2 (95% confidence interval, 0.9-10.9). These differences were not statistically significant. CONCLUSION: Induction of labor with oxytocin is associated with an increased rate of uterine rupture in gravid women with 1 prior uterine scar in comparison with the rate in spontaneously laboring women. Although the rate of uterine rupture was not statistically increased during oxytocin augmentation, use of oxytocin in such cases should proceed with caution.     

Perinatal outcome following prior delivery in the late second or early third trimester

Forty pregnancies in 37 women who were previously delivered of a live-born fetus between 20 and 32 weeks' gestation are reported here. Fourteen pregnancies were treated with cervical cerclage between 14 and 16 weeks. Twenty-six pregnancies were initially managed conservatively, but three of these patients had a McDonald cerclage placed between 18 and 23 weeks because of significant change in cervical effacement or dilatation. The risk of preterm delivery was 36% (5 of 14) in the cerclage group and 38% (10 of 26) in those patients managed conservatively. The perinatal survival rates were 93% (13 of 14) and 88% (23 of 26), respectively. These results are encouraging when it is considered that only 14% (9 of 64) of prior gestations (exclusive of spontaneous abortions and elective terminations) were carried to term and the perinatal survival rate was 28% (18 of 64). Although this study was nonrandom, these results also support the selective use of cervical cerclage on the basis of past history and physical examination.