Is gestational age an independent variable affecting uterine scar rupture rates?

OBJECTIVE: To evaluate the influence of gestational age on uterine scar rupture. METHODS: This was a population-based study of data from Cardiff Births Survey over a 10-year (1990-1999) period. Women with only one previous lower segment caesarean section with singleton uncomplicated pregnancy of 37 or more week's gestation, undergoing trial of vaginal delivery were included. SPSS version 10 was used for statistical analysis. Mann-Whitney, Fisher's exact test and Chi-square tests were used wherever appropriate. Odds ratio (OR) with confidence intervals (CI) was used to quantify the risk. Potential confounding by other factors was controlled using logistic regression and corrected odds ratios with 95% confidence intervals were calculated. The data was analysed separately for induced and spontaneous labours. Primary outcome measure assessed was uterine scar rupture rate. Secondary outcome measures were repeat caesarean section rates, maternal and perinatal mortality and morbidity. RESULTS: Total sample number was 1620. Eighty percent (n = 1301) of the population went into spontaneous labour and 20% (n = 319) were induced. Successful trial of vaginal birth was accomplished in 60% and trial of scar after estimated date of delivery did not alter this outcome significantly (39.1% versus 43.6%, p > 0.05). We noted an overall scar rupture rate of 0.9% (n = 14) and caesarean section rate of 40.4% (n = 654). Scar rupture rates significantly increased in women who underwent trial of labour after estimated date of delivery (p < 0.001, OR 6.3, CI 1.9-20.2) without a corresponding increase in caesarean section, maternal and perinatal morbidity figures. The influence of gestational age on scar rupture persisted even after controlling for other confounding factors such as birth weight, induction of labour and BMI (corrected OR 1.9, CI 1.1-3.5). CONCLUSIONS: The overall incidence of scar rupture and success of trial of scar after previous caesarean section in our population was similar to that quoted in the literature. Previous evidence has suggested that it is safe for these women to exceed 40 weeks gestation but our data do not support this.     

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.     

Evaluation of endocervical, first-void urine and self-administered vulval swabs for the detection of Chlamydia trachomatis in a miscarriage population

BACKGROUND: The issues related to safety of induction of labour in women with previous caesarean section remain controversial. The main adverse outcome fuelling this debate is a "small" risk of uterine rupture that is potentially devastating for both the mother and the fetus. OBJECTIVE: To estimate the risk of uterine rupture or dehiscence in women who require induction of labour with previous caesarean sections. DESIGN: Five year retrospective review of computerised hospital records and case note review of index cases. SETTING: Large inner city teaching hospital. POPULATION: Two hundred and five women who had their labour induced with history of one lower segment caesarean section. METHODS: This study was conducted at Liverpool Women's Hospital, a tertiary referral centre, with approximately 6000 births per annum. We searched the hospital's computerised records of deliveries from June 1997 to June 2002 and reviewed all indications and outcomes of induction of labour in women with one previous caesarean section. Women with singleton pregnancy and cephalic presentation were then divided into three groups: those with one previous caesarean section and no previous vaginal deliveries, those whose last delivery was a caesarean section but had delivered vaginally before and those whose last delivery was by vaginal route, but had had one caesarean section in the past. MAIN OUTCOME MEASURES: Uterine rupture or dehiscence, adverse neonatal outcome. RESULTS: Two hundred and five women were included. There were four cases of uterine rupture and one dehiscence (2.4%, 95% CI 0.8-5.6%). Two babies were profoundly acidotic at birth, but all five neonates were healthy when discharged from hospital with no long term morbidity. All five cases occurred in the group of women with no previous vaginal deliveries. The intrauterine pressure catheter recordings had contributed to the diagnosis of uterine rupture/dehiscence in three out of five cases. CONCLUSION: In women with previous caesarean section and no vaginal deliveries, induction of labour carries a relatively high risk of uterine rupture/dehiscence despite all precautions, including intrauterine pressure monitoring.     

Risks of induction of labour in women with a uterine scar from previous low transverse caesarean section

OBJECTIVE: Recent studies have shown that among women with uterine scars from previous caesarean section of any type, induction of labour is associated with increased risk of uterine rupture compared with spontaneous labour. We have assessed the risk of uterine rupture in a cohort of women with a previous low transverse caesarean section in whom induction and management of labour were performed according to a strict protocol. DESIGN: Cohort study. SETTING: University Hospital. POPULATION: All women with a singleton pregnancy and a previous low transverse caesarean section requiring induction of labour from 1/1/1992 to 12/30/2001 (n = 310) were compared with a control cohort during the same study period constituted of women with a previous low transverse caesarean section in spontaneous labour (n = 1011). METHODS: Clinical characteristics and rate of uterine rupture of women with previous caesarean section undergoing induction of labour were compared with those of women with previous caesarean section in spontaneous labour. MAIN OUTCOME MEASURE: Incidence of uterine rupture. RESULTS: Uterine rupture occurred in 0.3% in the previous caesarean section--induction group versus 0.3% in the previous caesarean section--spontaneous labour group (P = 0.9). Logistic regression analysis showed no significant difference in the rate of uterine rupture between the induction and spontaneous labour group (P = 0.67) after controlling for maternal age, parity, duration of labour, gestational age at delivery and birthweight. CONCLUSION: Among women with a previous low transverse caesarean section, induction of labour is not associated with significantly higher rates of uterine rupture compared with spontaneous labour, provided a consistent protocol with strict criteria for intervention is adopted.     

Uterine Rupture After Induction of Labour for Intrauterine Death Using the Prostaglandin E2 Analogue Sulprostone

A 30-year old pregnant woman who had had an earlier stillbirth and 2 children, the oldest of whom was delivered by Cesarean section, presented at the National University Hospital in Singapore at 32 weeks because she had not felt fetal movements for 3 days. Doptone did not detect a fetal heart beat and ultrasound confirmed intrauterine death. She did not have any soreness at the previous lower segment Cesarean scar. After she opted to have labor induced, health workers injected 0.5 mg of the prostaglandin E2 analogue, sulprostone, into a muscle every 6 hours. Painful uterine contractions did not start until after the 2nd injection of sulprostone. 20 hours after the 1st injection, her pulse increased to 100/minute, blood pressure fell from 120/70 to 80/50, and she began to perspire. She noted tenderness at the lower segment scar. Abdominal examination did not reveal any free fluid. There was no blood in the urine. 20 minutes after her blood pressure increased to 100/70, the woman had steady abdominal pain and vaginal bleeding. Her abdomen swelled and rebound tenderness occurred. Physicians diagnosed uterine rupture and performed a laparotomy promptly. They found 800 ml of free blood in the peritoneal cavity and a complete rupture all along the Cesarean scar. The removed the dead fetus and repaired the scar. They also applied Filshie clips on her Fallopian tubes since she wanted to be sterilized. She was discharged 7 days after laparotomy and recovered uneventfully. This case report confirms that vaginal delivery at term after lower segment Cesarean section is no guarantee against scar rupture in subsequent pregnancies, particularly when health workers use prostaglandins. Nevertheless, prostaglandins are still a reasonably safe and predictable method of terminating pregnancy even in cases of previous Cesarean section. It is important that health workers supervise closely women who have had a Cesarean section and are being administered a prostaglandin to terminate a pregnancy because of the possibility of uterine rupture.     

Uterine Rupture During Labour in a Primigravida

EDITORIAL COMMENT: We accepted this case for publication because it will interest readers. Certainly the woman had a haemoperitoneum and signs indistinguishable from a case of rupture of the uterus although technically this is not a rupture because the tear did not extend through the uterine wall to the endometrial cavity. The editor saw a patient some 38 years ago who had a haemoperitoneum and who came to laparotomy on 2 occasions where it appeared that the bleeding had come from a tear in the peritoneum between the uterosacral ligaments. This patient died during her third laparotomy. There is also literature describing tears in the peritoneum over the uterosacral ligaments as a cause of chronic pelvic pain. The editorial committee find it feasible that a patient in labour can develop a tear in the peritoneum and superficial myometrium in her posterior uterine wall which if it involved vessels could cause a life-threatening haemoperitoneum. Of course similar tears occur due to trauma such as a motor-car accident when the woman is wearing a seat belt which can localize trauma to the uterus.
Summary: Uterine rupture ie extremely rare in the absence of any of the commonly recognized risk factors. We describe here a case of incomplete uterine rupture in a woman in her first pregnancy who had no previous instrumentation to the genital tract. Her only significant history was that of 2 episodes of minor antepartum haemorrhage occurring prior to induction of labour with artificial rupture of membranes and intravenous oxytocin. The rupture was manifested by 450 mL blood in the peritoneal cavity when an emergency Caesarean section was performed for persistent fetal bradycardia.     

Rupture of the uterine scar during term labour: contractility or biochemistry?

OBJECTIVE: Vaginal birth after a prior low transverse caesarean section (VBAC) is advocated as a safe and effective method to reduce the total caesarean section rate. However, the risk of uterine rupture has dampened the enthusiasm of practising clinicians for VBAC. Uterine rupture occurs more frequently in women receiving prostaglandins in preparation for the induction of labour. We hypothesised that similar to the cervix, prostaglandins induces biochemical changes in the uterine scar favouring dissolution, predisposing the uterus to rupture at the scar of the lower segment as opposed to elsewhere. DESIGN: We tested aspects of this hypothesis by investigating the location of uterine rupture associated with prostaglandins and compared it with the sites of rupture in the absence of prostaglandins. SETTINGS: Two North American University Hospitals. POPULATION: Twenty-six women with a prior caesarean section, experiencing uterine rupture in active labour. METHODS: Retrospective review of all pregnancies complicated by uterine rupture at two North American teaching hospitals from 1991 to 2000. MAIN OUTCOME MEASURE: Site of the uterine rupture. RESULTS: Thirty-four women experienced rupture after a previous caesarean section with low transverse uterine incision. Ten of the women who ruptured (29%) received prostaglandins for cervical ripening (dinoprostone: n= 8 or misoprostol: n= 2) followed by either spontaneous contractions (n= 3) or oxytocin augmentation during labour (n= 7). In 16 women (47%), oxytocin alone was sufficient for the induction/augmentation of labour. Eight (23%) women ruptured at term before reaching the active phase of labour in the absence of pro-contractile agents or attempted VBAC. There were no differences among the groups in terms of age, body mass index, parity, gestational age, fetal weight or umbilical cord pH measurements. Women treated with prostaglandins experienced rupture at the site of their old scar more frequently than women in the oxytocin-alone group whose rupture tended to occur remote from their old scar (prostaglandins 90%vs oxytocin 44%; OR: 11.6, 95% CI: 1.2-114.3). CONCLUSION: Women in active labour treated with prostaglandins for cervical ripening appear more likely to rupture at the site of their old scar than women augmented without prostaglandins. We propose that prostaglandins induce local, biochemical modifications that weaken the scar, predisposing it to rupture.     

Uterine scar rupture - Prediction,prevention, diagnosis,and management

The increasing rate of elective and indicated caesarean sections worldwide has led to new pathologies and management challenges. The number of patients undergoing trial of labor after caesarean section (TOLAC) is also increasing. Three professional societies provide detailed guidelines based on scientific evidence for the management of patients attempting vaginal birth after caesarean section (VBAC). However, they do not provide any recommendations for the actual surgical steps to be followed to minimize the risks of uterine rupture (UR) during TOLAC. Uterine scar condition, intrapartum management and maternal health status correlate to uterine scar rupture risk and provide guidance for parturient TOLAC eligibility. TOLAC and vaginal delivery success rate as reported by the largest studies is between 60% and 77%. Uterine rupture is more prevalent in VBAC-2 patients (1.59%) in contrast to VBAC-1 (0.72%). Additionally, VBAC-2 patients have higher incidence of caesarean hysterectomy 0.56% vs. 0.19% for VBAC-1. The chances of successful VBAC increase when the interpregnancy/interdelivery interval is less than 6.3 years and less than 24 months, respectively. No difference was detected between the techniques of uterine incision closure of the previous CS and TOLAC results, although closure of the CS uterine incision in 2 layers seems to be practiced more widely. Niche or isthmocele presents another complication of CS. Secondary infertility due to niche, will eventually direct to hysteroscopic or laparoscopic repair, depending on the residual myometrial thickness (RMT) as measured by US scan. When RMT is below 3 mm or 2.5 mm surgery can be performed, to prevent any spontaneous UR in case of pregnancy. Monitoring by US scanning of hysterotomy scar after myomectomy can detect hematoma. In patients with severe postoperative pain but hemodynamically stable follow up by US scan examination can direct the management decision. In those patients with active bleeding and deterioration of hysterotomy scar edema will be an indication to surgery. There is no firm evidence regarding which type of thread, knotting or sequence of suturing is more favorable to reduce the risk of UR after VBAC or hysterotomy after myomectomy.     

Uterine rupture and labour after a previous low transverse caesarean section

This study reviewed all cases of complete uterine rupture (UR) in pregnancy during the decade 1993-2002. In 69,412 deliveries, 5,320 women had a single prior caesarean section. Of these, 4,021 had a trial of labour and 3,129 (77.8%) delivered vaginally. In nine (0.22%) cases, the previous transverse scar ruptured during labour. None of these nine ruptures resulted in maternal or fetal death, peripartum hysterectomy or fetal morbidity. In our practice, a trial of labour in women with a previous low transverse caesarean is associated with a high rate of vaginal delivery and a low rate of UR.     

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.     

Risk factors for uterine rupture and neonatal consequences of uterine rupture: a population-based study of successive pregnancies in Sweden

Objective  Uterine rupture is a rare but a catastrophic event. The aim of the present study was to explore the risk factors for uterine rupture and associated neonatal morbidity and mortality among a cohort of Swedish women attempting vaginal birth in their second delivery.
Design  Population-based cohort study.
Setting  Sweden.
Population  A total of 300 200 Swedish women delivering two single consecutive births between 1983 and 2001.
Methods  Swedish population-based registers were used to obtain information concerning demographics, pregnancy and birth characteristics, and neonatal outcomes. Logistic regression was used to analyse potential risk factors for uterine rupture and risk of neonatal mortality associated with uterine rupture. Odds ratios were used to estimate relative risks using 95% CI.
Main outcome measure  Uterine rupture and neonatal mortality in the second pregnancy.
Results  Compared with women who delivered vaginally in their first birth, women who underwent a caesarean delivery were, during their second delivery, at increased risk of uterine rupture (adjusted OR 41.79; 95% CI 29.73–57.00). Induction of labour, high (≥4000 g) birthweight, postterm (≥42 weeks) births, high (≥35 years) maternal age, and short (≤164 cm) maternal stature were also associated with increased risk of uterine rupture. Uterine rupture was associated with a substantially increased risk in neonatal mortality (adjusted OR 65.62; 95% CI 32.60–132.08).
Conclusion  The risk of uterine rupture in subsequent deliveries is not only markedly increased among women with a previous caesarean delivery but also influenced by induction of labour, birthweight, gestational age, and maternal characteristics.     

Rupture of the Pregnant Uterus: The Evidence from this Decade on Risk Factors,Predictability and Prognosis

Objectives: to identify the incidence of risk factors for and the tools to predict and diagnose uterine wall disruptions. To elaborate on the perinatal and maternal prognosis and on the future reproductive potential of patients who suffered uterine wall disruptions.Method: this is a comprehensive review of the evidence published over the past decade in the English language. Publications were retrieved through Medline search, categorized as to topic and evaluated as to quality of evidence.Results: in contrast to the incidence of uterine rupture in the developing world, the incidence in the developed world is low (0.04%). Grand multiparity, dysfunctional labour and fetal malpresentations remain the major risk factors for uterine wall disruption in the unscarred uterus. Undertaking a trial of labour in the previously scarred uterus is identified as the major risk factor for uterine rupture. Evidence supports the recommendation of a cautionary and highly selective approach to the use of oxytocin to correct dysfunctional labour at any phase, and in the use of prostaglandin for ripening the cervix and induction of labour. Use of epidural anaesthesia, fetal macrosomia, type of lower uterine segment scar (vertical or horizontal) and previous Caesarean section for cephalopelvic disproportion do not seem to be important risk factors. Evidence is lacking as to the safety of trials of labour in multifetal pregnancies. Past history of a previous vaginal birth after Caesarean section (VBAC) seems to be reassuring. Sonography emerges as having a role in evaluating the potential for uterine rupture in labour. Use of partographs in labour could help to reduce the risk of uterine rupture. The most consistent sign of uterine wall disruption in labour is a non-reassuring fetal heart pattern, the severity of which seems to correlate well with the degree of disruption and fetal expulsion. Expediting delivery within 18 minutes of a non-reassuring fetal heart rate pattern carries a good neonatal prognosis, but maternal reproductive potential, while possible, will become guarded.Conclusion: while rare, uterine wall disruption may carry high rates of perinatal morbidity and mortality and maternal morbidity. In the past decade, risk factors have been better defined, with trials of labour after a previous Caesarean section being the most prominent of the risk factors. Overzealous advocacy of such trials cannot be supported. Trials of labour after previous Caesarean section need to be undertaken on a selective basis. Evidence is needed about the safety of trials of labour when certain conditions prevail, including those pertaining to the use of oxytocin, prostaglandin, trials involving patients with more than one previous Caesarean section, and the multifetal pregnancy. Sonography and partographs seem to have potential roles as tools that might help in the selection of candidates for a safe trial of scar and identify women at increased risk for uterine wall disruption.     

Successful outcome in pregnancy complicated by prior uterine rupture: a report of two cases

Background

Rupture of the uterus, especially in a scarred uterus, intrapartum is well known. The risk of uterine rupture in women with a previous lower segment caesarean section is 0.2–1.5%, whereas in an unscarred uterus it is extremely rare.

Case

Case 1 A 26-year-old woman in her third pregnancy was referred at 16 weeks from a community hospital. She had a history of uterine perforation at the fundus in her first pregnancy during a dilatation and curettage requiring laparotomy and repair. In her second pregnancy, fetal death had occurred in the second trimester. She conceived subsequently and in her third pregnancy, the risk of silent rupture of uterus was explained, but the couple opted for continuation of this pregnancy.Case 2 A 25-year-old woman in her third pregnancy was referred. In her first pregnancy, she had a septic abortion during the fifth month of pregnancy. Two years later, she presented at 16 weeks gestation with a severe abdominal pain. An ultrasound/MRI revealed a uterine wall defect with an empty uterus, fetus lying outside the uterine cavity with moderate free fluid. In her third pregnancy, 18 months later, at 10 weeks gestation an ultrasound revealed a single live intrauterine pregnancy with an indistinct thinning and sacculation of the fundo-posterior uterine wall.

Conclusion

With increasing caesarean rates, every obstetrician is bound to face the challenge of this life-threatening obstetric hazard and must be prepared to handle this emergency with an expeditious recourse to laparotomy.

     

妊娠期子宫破裂8例报告及文献复习

目的:探讨妊娠期子宫破裂的可能原因、临床表现及预防措施。方法:回顾2013—2016年首都医科大学附属北京安贞医院妇产科收治的8例子宫破裂患者的临床特点、治疗情况及预后,并结合相关文献进行分析。结果:8例妊娠期子宫破裂患者中有7例是瘢痕子宫破裂,1例是非瘢痕子宫破裂,临床表现多样。妊娠期瘢痕子宫发生破裂的概率较非瘢痕子宫高,而剖宫产术是造成瘢痕子宫及再次妊娠子宫破裂的高危因素。结论:剖宫产术后再次妊娠的时机及分娩方式的选择对预防妊娠期子宫破裂的发生至关重要。     

Obstetric management and outcome of pregnancy in women with a history of caesarean section in the Netherlands

OBJECTIVE: To determine mode of delivery and occurrence of uterine rupture in women with a previous caesarean section (CS) in the Netherlands. MATERIALS AND METHODS: During a 1-year period 38 hospitals in the Netherlands registered prospectively mode of delivery, use of prostaglandins or oxytocin and occurrence of uterine rupture in all women with a previous CS. RESULTS: There were 4569 women with a previous CS. Trial of labour (TOL) was attempted in 71.7%, of whom 76.0% delivered vaginally. The vaginal birth after caesarean (VBAC)-rate was 54.4%. Forty-nine uterine ruptures occurred (1.1%), of which 48 occurred during a TOL (1.5%). There were four perinatal deaths (1.2/1000 TOL) and 3 hysterectomies (0.9/1000 TOL) related to the rupture. Use of prostaglandin E2 alone or combined with oxytocin was significantly associated with an increased risk of uterine rupture (OR 6.8, 95% CI 3.2-14.3, OR 4.8, 95% CI 1.6-14.6, respectively). The same held for augmentation with oxytocin (OR 2.2, 95% CI 1.04-5.0). CONCLUSION: The success rate of TOL was 76%, resulting in a VBAC rate of 54%. Uterine rupture occurred in 1.5% during a TOL, with a risk of perinatal death of 1.2 per 1000. The risk of uterine rupture increased significantly when labour was induced with prostaglandins alone or combined with oxytocin or when labour was augmented with oxytocin.     

子宫下段妊娠人工流产术中大出血临床分析--附四例报告

目的 探讨早期子宫下段妊娠人工流产术中大出血的病例特点和保守治疗的方法。方法 回顾性分析1994年5月至2002年7月我们收治的4例子宫下段妊娠行人工流产术中大出血的病例资料。结果 4例患者均有剖宫产史;其中3例停经后有阴道不规则出血;子宫动脉造影显示子宫下段供血区出血;4例均于人工流产术中发生大出血,采用子宫动脉栓塞治疗,止血效果好。无一例因子宫动脉栓塞而行全子宫切除者。结论 有剖宫产史的患者再受孕时,有发生子宫下段妊娠的危险,行人工流产术中易发生难以控制的大出血;子宫动脉栓塞是行之有效的治疗方法。严格剖宫产指征和重视产后避孕,是主要的预防办法。     

Recurrent uterine rupture after abdominal pregnancy.

Uterine rupture can occur at any time throughout gestation. We present a woman with a previous Cesarean section followed by an abdominal pregnancy. In her next pregnancy, complete uterine rupture resulted in an emergency laparotomy. This case is unique in that it gives insight into the variable presentations of uterine rupture and the risks associated with prior Cesarean sections.     

Post-caesarean Niche (Isthmocele) in Uterine Scar: An Update

Uterine niche is one of the emerging complications of caesarean section. With rising caesarean rates, the caesarean-related iatrogenic complications are also on the rise. These include placenta accreta, scar ectopic pregnancy and uterine niche which is a newer entity being described in the recent literature. Uterine niche, also described as uterine isthmocele, caesarean scar defect and diverticulum, is an iatrogenic defect in the myometrium at the site of previous caesarean scar due to defective tissue healing. Patients may have varied symptoms including abnormal uterine bleeding, post-menstrual spotting and infertility, though many women may be asymptomatic and diagnosed incidentally. Diagnosis is made radiologically by transvaginal sonography, saline instillation sonohysterography or magnetic resonance imaging. Occurrence of niche may be prevented by using correct surgical technique during caesarean. Patients may be managed medically; however, subfertility and persistent symptoms may require surgical correction either by hysteroscopic resection or transabdominal or transvaginal repair. This mini-review comprehensively covers the potential risk factors, clinical presentation, diagnosis and management of this increasingly encountered condition due to rising caesarean rates.     

Caesarean scar pregnancy

Caesarean scar pregnancy is one of the rarest forms of ectopic pregnancy. Little is known about its incidence and natural history. With increasing incidence of caesarean section worldwide, more and more cases are diagnosed and reported. Transvaginal ultrasound and colour flow Doppler provides a high diagnostic accuracy with very few false positives. A delay in diagnosis and/or treatment can lead to uterine rupture, major haemorrhage, hysterectomy and serious maternal morbidity. Early diagnosis can offer treatment options of avoiding uterine rupture and haemorrhage, thus preserving the uterus and future fertility. Management plan should be individually tailored. Available data suggest that termination of pregnancy is the treatment of choice in the first trimester soon after the diagnosis. Expectant treatment has a poor prognosis because of risk of rupture. There are no reliable scientific data on the risk of recurrence of the condition in future pregnancy, role of the interval between the previous caesarean delivery and occurrence of caesarean scar pregnancy, and effect of caesarean wound closure technique on caesarean scar pregnancy. In this article, we aim to find the demography, pathophysiology, clinical presentation, most appropriate methods of diagnosis and management, with their implications in clinical practice for this condition.     

Placenta percreta with subsequent uterine rupture at 15 weeks of gestation after two previous cesarean sections

A 25-year-old gravida 3 para 2 woman was referred to our hospital at 15 weeks' gestation with an acute abdomen and free fluid in the peritoneal cavity. On admission she was somnolent. She had a history of two cesarean sections. Fetal cardiac activity was detectable by ultrasound preoperatively. Intraoperatively, a lower uterine-segment rupture was identified in the area of the presumed prior uterine incision. The great blood loss with consecutive coagulopathy required an emergency hysterectomy and multiple blood transfusions. The placenta was located on the lower anterior uterine wall. Intervening decidual cells between placenta and maternal scar tissue were absent in the area of the prior uterine incision. Placental villous tissue deeply invaded and perforated the scar tissue. Histological examination revealed a placenta percreta. Placenta percreta with subsequent uterine rupture is a rare but dramatic complication after previous cesarean section. This should be kept in mind as the rate of elective cesarean sections is rising continuously. Our patient recovered completely.