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.     

Expectant management of a herniated amniotic sac presenting as silent uterine rupture: a case report and literature review

Foetal membranes bulging into the abdominal cavity is a unique initial manifestation of silent or complete uterine rupture during pregnancy. Since silent uterine rupture has potential risk for complete uterine rupture, which leads to acute life-threatening complications for both the mother and baby, it is difficult to determine whether to manage expectantly or surgically, including repair of the uterine wall or termination of the pregnancy, especially in the early second trimester. We present here a case of a herniated amniotic sac with overstretched uterine wall of the fundus presenting as silent uterine rupture, which was incidentally detected on routine ultrasonography at 18 weeks' gestation in a 38-year-old primigravida with a history of myomectomy for diffuse uterine leiomyomatosis. Magnetic resonance imaging examination revealed that the myometrium thickness was fully maintained at the site of the foetal membranes ballooning. The pregnancy was therefore managed expectantly and continued to successful delivery at 30 weeks' gestation. The precise assessment of the uterine wall may be essential to manage a herniated amniotic sac presenting as silent uterine rupture and to optimise the outcome of the pregnancy. We review all cases of a herniated amniotic sac out of focally overstretched uterine wall before 34 weeks' gestation.     

Sexuality in pregnancy and premature labour

The relation of sexual behaviour during pregnancy to the initiation of labour was investigated in 358 patients of whom 58 were delivered after premature labour and 300 were delivered spontaneously at term. In all patients the mean weekly coital frequency and the frequency of orgasm were investigated by means of a retrospective questionnaire. There was no significant difference in coital or orgasmic frequency between the women who had a premature labour and those who had a spontaneous delivery at term. This was also true when those having premature labour were divided into those starting labour with ruptured membranes and those starting with contractions.     

Sexuality in pregnancy and premature labour

Summary. The relation of sexual behaviour during pregnancy to the initiation of labour was investigated in 358 patients of whom 58 were delivered after premature labour and 300 were delivered spontaneously at term. In all patients the mean weekly coital frequency and the frequency of orgasm were investigated by means of a retrospective questionnaire. There was no significant difference in coital or orgasmic frequency between the women who had a premature labour and those who had a spontaneous delivery at term. This was also true when those having premature labour were divided into those starting labour with ruptured membranes and those starting with contractions.     

Uterine activity during spontaneous labour after previous lower-segment caesarean section

Uterine activity was measured in three groups of labouring women who previously had a caesarean section (CS): group A included women with a previous elective CS before labour or in the early latent phase of labour and no previous vaginal delivery; group B included women with a CS in the active phase of labour and no previous vaginal delivery; group C included women with a CS and a vaginal delivery either before or after the abdominal delivery. The active contraction area profiles in the three groups were compared with those of matched control groups of nulliparae and multiparae without a uterine scar. Group A had a uterine activity profile similar to that in control nulliparae and significantly higher than that in control multiparae. The uterine activity in group B was less than that in matched nulliparae but was similar to that in matched multiparae. Group C had significantly less uterine activity than matched nulliparae but a similar profile to that in the matched multiparae. Progress of labour into the active phase in the previous pregnancy reduces the uterine activity profile in subsequent labour. Women who had had a vaginal delivery either before or after the CS (group C) exhibited uterine activity profiles similar to multiparae, suggesting that an intact scar did not affect the uterine function.     

Uterine activity during spontaneous labour after previous lower-segment caesarean section

Summary. Uterine activity was measured in three groups of labouring women who previously had a caesarean section (CS): group A included women with a previous elective CS before labour or in the early latent phase of labour and no previous vaginal delivery; group B included women with a CS in the active phase of labour and no previous vaginal delivery; group C included women with a CS and a vaginal delivery either before or after the abdominal delivery. The active contraction area profiles in the three groups were compared with those of matched control groups of nulliparae and multiparac without a uterine scar. Group A had a uterine activity profile similar to that in control nulliparae and significantly higher than that in control multiparae. The uterine activity in group B was less than that in matched nulliparae but was similar to that in matched multiparae. Group C had significantly less uterine activity than matched nulliparae but a similar profile to that in the matched multiparae. Progress of labour into the active phase in the previous pregnancy reduces the uterine activity profile in subsequent labour. Women who had had a vaginal delivery either before or after the CS (group C) exhibited uterine activity profiles similar to multiparae, suggesting that an intact scar did not affect the uterine function.     

Fetal causes of the onset of labour. A kybernetic model (author's transl)

The question of initiation of labour is not yet solved. A fetal fixing of the date would be ingenious. On the one hand the fet is endangered by prematurity, on the other hand by placental insufficiency in postmaturity. Fetuses with comparatively lighter placenta remain in average shorter in utero until spontaneous initiation of labour than those with comparatively heavier placenta. This fact leads to the assumption of a relative placental insufficiency as a determining factor of the onset of labour. A further inquiry demonstrates, that babies born after premature termination of pregnancy about the term - either by induction of labour or by primary sectio caesarea - are heavier and longer than those born after spontaneous labour. This leads to the assumption of a prenatal weight loss of the infant before spontaneous initiation of labour. This weight loss is caused by diminution of water content and relative placental insufficiency. This relative placental insufficiency also leads to a diminution of amniotic fluid, which is swallowed by the "hungry" fet in a greater amount. Altogether a diminution of uterine volume is resulting, which is accomplished by a diminution of uterine wall tension. The coordination of uterine activity, which precedes delivery, is combined with the ripening of the cervix. The ripening of the cervix also leads to a retraction of myometrium and thus to a further diminution of uterine wall tension. It is concluded, that a diminution of uterine volume, causes by fetal weight loss and diminution of amniotic fluid, leads to a reduction of uterine wall tension, which is supported by the ripening of the cervix. This reduction of uterine wall tension is the precondition of the increasing coordination of activity, which precedes delivery.     

Successful laparoscopic treatment of a ruptured primary ovarian pregnancy

A 26-year-old woman had classic symptoms of primary ovarian pregnancy. Ultrasound examination disclosed a cystic mass surrounded by a complex mass that was compatible with hematoma in the pouch of Douglas, as well as an intrauterine device (IUD) displaced near the isthmic portion of the uterine cavity. Laparoscopy revealed a ruptured gestational sac in the cul-de-sac that was encapsulated by a hematoma originating from the right ovary. All deep-seated products of conception were excised from the ovary, and the IUD was removed. Treatment was successful and avoided more invasive intervention.     

Physiological implications of the materno-fetal oxygen gradient in human early pregnancy

This study evaluates the role of the fetal fluid cavities on materno-fetal oxygen diffusion in early pregnancy. Oxygen tension (pO2) was recorded using a multiparameter sensor inserted inside the exocoelomic cavity (ECC) or in the amniotic cavity. There was no correlation between coelomic pO(2) and gestational age, but a negative correlation was found between amniotic pO(2) and gestational age. The mean (SEM) pO(2) was 19.5 mm Hg (1.83) in the ECC at 7-11 weeks and 15.4 mm Hg (1.36) in the amniotic cavity at 11-16 weeks. The volume of the ECC changed little between 7 and 10 weeks of gestation, indicating that coelomic pO(2) results from passive oxygen diffusion through the placenta and is an indicator of the overall pO(2) inside the gestational sac during the first trimester. By contrast, the amniotic cavity volume increases exponentially, whereas amniotic pO(2) decreases with gestational age, suggesting that the increase in uterine blood flow is not sufficient to compensate for the rapid increase in amniotic fluid volume during the first half of pregnancy.     

Management of ruptured corpus luteum cyst of pregnancy occurring in a 15-year-old girl by laparoscopic surgery with intraoperative autologous blood transfusion

BACKGROUND: Laparoscopic surgery is a minimally invasive procedure with many advantages. However, laparoscopic treatment of ruptured corpus luteum cyst of pregnancy with massive hemoperitoneum occurring in a young girl has not previously been reported. CASE: A 15-yr-old girl presenting with acute abdomen and hemoperitoneum was referred to our department. A urinary pregnancy test was positive and an ultrasound revealed a gestational sac in the uterine cavity, the preoperative differential diagnosis was narrowed to either intrauterine pregnancy with ruptured corpus luteum cyst or heterotopic pregnancy. Emergency laparoscopic surgery was performed to investigate the cause of hemoperitoneum and a diagnosis of ruptured corpus luteum cyst of pregnancy was established. After retrieving pooled blood in the abdominal cavity for intraoperative autologous blood transfusion, the rupture site with active bleeding was laparoscopically sutured and hemostasis was achieved. At the same time, intrauterine pregnancy was electively terminated at the request of the patient and her family. The postoperative course was uneventful. CONCLUSION: Ruptured corpus luteum cyst of pregnancy manifesting massive hemoperitoneum is a rare but life-threatening disorder that can occur even in a young girl. Ovarian conservative treatment can laparoscopically be performed with intraoperative autologous blood transfusion.     

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.     

Primary omental pregnancy: case report and review of literature

Omental pregnancy is a very rare form of ectopic pregnancy. A 29-year-old woman presented with severe abdominal pain. History of the patient revealed use of combined oral contraceptive pills. There was no gestational sac in the endometrial cavity and no tubal ring in the adnexa, but free peritoneal fluid was detected at ultrasonography. Laparotomy was done according to pre-operative diagnosis of ruptured tubal pregnancy. Bilateral tubes and ovaries were intact; gestational sac was detected attached to the necrotic lower edge of omentum. Although 16 cases of omental pregnancy (mostly secondary) were reported in the literature, herein we describe a primary omental pregnancy without adnexal involvement.     

Comparison of magnetic resonance imaging and ultrasonography in the early diagnosis of interstitial pregnancy

OBJECTIVE: To investigate the usefulness of ultrasonography (USG) and magnetic resonance imaging (MRI) in the early diagnosis of interstitial pregnancy. STUDY DESIGN: Four cases of interstitial pregnancy that showed characteristic ultrasonographic and MRI findings were studied. All cases received cornual resection, and the presence of interstitial pregnancy was confirmed by pathologic examination. RESULTS: Three of four cases had a gestational sac in the uterine cornu or a protruding cornual mass and myometrium between the sac and uterine cavity on both USG and MRI. In the remaining case, preoperative diagnosis was inconclusive because no gestational sac was demonstrated by USG or MRI. Color flow mapping was conducted in three cases and revealed prominent peritrophoblastic blood flow. CONCLUSION: The findings suggest that USG combined with color flow mapping is the first choice in the early diagnosis of interstitial pregnancy. MRI, which is an extremely expensive imaging technology, should be used only if transvaginal USG with color flow mapping is inconclusive in ruling out the diagnosis of interstitial pregnancy.     

Three-dimensional transvaginal sonographic diagnosis of early and asymptomatic interstitial pregnancy

Context The interstitial gestation is a rare form of tubal pregnancy which is associated with high morbidity. The diagnosis of an interstitial gestation can be reached through a bidimensional transvaginal ultrasonography (2D-TVUS), however, sometimes when making use of this technique it is not possible to appropriately evaluate the position of the gestational sac in relation to the uterine cavity. The three-dimensional transvaginal ultrasonography (3D-TVUS) allows accessibility to plans that the bidimensional does not, thus it makes it possible to reach a more accurate diagnosis and it also allows for an appropriate therapeutic planning. Case report We present a case of interstitial gestation diagnosed in the sixth week in an asymptomatic woman, who had a previous diagnosis of primary infertility. The 2D-TVUS revealed the presence of a gestational sac outside of the uterine cavity; moreover the colored Doppler and the power Doppler indicated a thriving vascular ring. The 3D-TVUS in the surface and transparency mode demonstrated that the gestational sac was located in the interstitial region of the uterine tube, and the niche mode accurately evaluated the relationship between the gestational sac and the uterine cavity. The patient was successfully treated with a local injection of methotrexate guided by a transvaginal ultrasonography. The 3D-TVUS was of great importance to confirm the diagnosis, to allow appropriate therapeutic choices and to decrease the morbidity.     

Labour characteristics and uterine activity: misoprostol compared with oxytocin in women at term with prelabour rupture of the membranes

Objective To compare the labour pattern and uterine activity of oral misoprostol with oxytocin for labour induction in women presenting with prelabour rupture of membranes at term.
Design Prospective randomised study.
Setting Department of Obstetrics and Gynaecology, Queen Mary Hospital, Hong Kong.
Participants Eighty women presenting with prelabour rupture of membranes at term.
Methods The women were randomised to receive either 100 μg misoprostol orally every 4 hours to a maximum of three doses, or intravenous oxytocin infusion according to the hospital protocol. Intrauterine pressure transducers were inserted one hour before induction of labour in both groups of women. We compared the pattern of uterine activity, the induction-to-delivery interval, duration of labour, mode of delivery and neonatal outcome between the two groups.
Results Both oxytocin and oral misoprostol caused an increase in uterine activity within one hour of labour induction. Peak uterine activity was reached 6–8 h after oral misoprostol, with persistent effects, and 8–10 h after oxytocin, requiring continuous titration of medication. The duration of labour was significantly reduced in nulliparous women, but not in those who were multiparous in the misoprostol group. The induction-to-delivery interval, the mode of delivery and the perinatal outcome were similar for the two groups.
Conclusion Oral misoprostol caused earlier peak uterine activity, compared with oxytocin (6–8 h vs 8–10 h). Oral misoprostol was not only as effective as oxytocin in inducing labour in women at term with prelabour rupture of the membranes, but it reduced significantly the duration of labour in nulliparous women.     

Factors associated with rapid labour in nulliparae.

The objective of this study was to assess the factors which may influence rapid labour in nulliparae. This is a cohort study of 991 consecutive nulliparae who were admitted in spontaneous labour with a singleton pregnancy and cephalic presentation. The setting was the National Maternity Hospital, Dublin where active management of labour is applied to all nulliparae fitting the above criteria. Rapid labour of 2 hours or less occurred in 82 patients (8.3%). Dilatation of 2 cm of the cervix on admission in labour, gestation of less than 37 weeks, and diminishing birthweight, were more common in rapid labours compared with other labours. Women in rapid labour were not surprisingly less likely to require oxytocin augmentation, or to need operative vaginal delivery or Caesarean section, receive epidural anaesthesia, or attend antenatal classes, compared with other women in labour. Rapid labour was not influenced by the finding that the membranes were already ruptured before admission, the time spent at home with contractions, or social background. Women with rapid labour were more likely to arrive in hospital within 4 hours compared with other women in labour. Rapid labour depends on the efficiency of uterine action which is reflected by the dilatation of the cervix on admission.     

Where does the embryo implant after embryo transfer in humans?

OBJECTIVE: To investigate where human embryos implant after ET. DESIGN: Prospective analysis. SETTING: University hospital. PATIENT(S): Sixty infertile women without uterine fibroids, a major uterine anomaly, or a history of cesarean section. INTERVENTION(S): Transabdominal and transvaginal three-dimensional ultrasound examinations. MAIN OUTCOME MEASURE(S): The location of ET-associated air bubbles in the uterine cavity and the location of the resultant gestational sac. RESULT(S): Sixty ETs resulted in 22 pregnancies, and 32 gestational sacs were located. Twenty-six of the 32 embryos were within or between the area in which the catheter tip was situated and the area over which air bubbles had spread immediately after ET. CONCLUSION(S): In cases of pregnancy achieved through ET, approximately 80% of embryos implant in areas to which they initially are transferred and approximately 20% implant in other areas.     

Interstitial ectopic pregnancy: A more confident diagnosis with three-dimensional sonography

ObjectiveTo present a confident tool for the diagnosis of interstitial ectopic pregnancy. 3-Dimensional US helps to reach a more proper diagnosis and enables to arrange therapeutic and surgical strategies.Case reportA 36-year-old, gravida 4 para 2, woman was referred from the local medical department in the suspicion of ectopic pregnancy. Transabdominal ultrasound revealed an empty uterine cavity but an 8-week-old gestational sac located eccentrically on the right side of the uterine fundus. The Three-dimensional sonography (3D US) demonstrated a gestational sac (GS) over the right cornual region separated from the endometrial cavity. Interstitial pregnancy was impressed. Laparoscopic surgery was then arranged. After entering the pelvic cavity, a bulging mass was found over the utero-tubal junction, compatible with interstitial pregnancy. The wedge resection of interstitial ectopic pregnancy and right salpingectomy were undertaken. The patient was discharged within 2 days after the surgery.ConclusionThe conventional sonography still remained the primary tool to diagnose the ectopic pregnancy, but 3D US played an indispensable role in demonstrating the precise location of GS. Interstitial ectopic pregnancy was symptomatically late in gestation and rupture of an interstitial pregnancy causes catastrophic consequence due to massive bleeding, so prompt and accurate diagnosis was definitely life-saving. Appropriate therapy or surgical intervention could be arranged.     

Maternal plasma corticotrophin-releasing hormone--elevated in preterm labour but unaffected by indomethacin or nylidrin

The role of corticotrophin-releasing hormone (CRH) in preterm labour was studied in 23 women in preterm labour at between 26 and 33 weeks gestation who were randomly allocated to receive treatment with indomethacin (n = 11) or with nylidrin a beta-sympathomimetic agent (n = 12). Maternal plasma CRH in the preterm group (median 70, range 9-597 pmol/l) before therapy was higher (P less than 0.05) than that in 23 control pregnancies, without uterine contractions, matched for gestational age (median 51, range 4-127 pmol/l). CHR levels determined after 3 and 24 h of treatment showed a 10% decrease in the indomethacin group and 10-20% decrease in the nylidrin group, but these changes were not statistically significant. After cessation of uterine contractions during tocolysis, 12 women proceeded to give birth preterm (less than 37 weeks) and their pretreatment CRH levels (median 195, range 9-597 pmol/l) were higher (P less than 0.05) than those in women whose pregnancy proceeded to term (median 52, range 16-207 pmol/l). In another group of women, full-term labour was not accompanied by any changes in maternal CRH levels. Umbilical plasma CRH levels were 1.1-9.8% of the paired maternal levels and did not rise with advancing gestational age. Nor had the type of delivery (elective caesarean section before labour, or preterm or term vaginal delivery) any effect on fetal CRH levels.(ABSTRACT TRUNCATED AT 250 WORDS)     

Acceleration of fetal lung maturation following prolonged rupture of the membranes

Prolonged rupture of the membranes exerts an accelerating effect on fetal lung maturation independent of gestational age or birth weight and resulting in absence of the respiratory distress syndrome (RDS). Sixty-four true-premature infants born of mothers with no complications of pregnancy other than prolonged rupture of the membranes were evaluated for the presence of RDS. In 42 of these infants, membranes were ruptured 24 hours or less prior to delivery, and RDS occurred in 64 per cent. In 22 infants with membranes ruptured more than 24 hours prior to delivery, 31 per cent developed RDS. Lecithin/sphingomyelin ratios showed marked acceleration following membrane rupture, irrespective of gestational age.