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.     

Spontaneous Uterine Rupture in the Second Trimester in a Patient With Previous Pelvic Radiotherapy in Childhood: A Case Report

BackgroundPelvic irradiation in childhood may result in abnormal uterine function. Poor obstetric outcomes have been reported in these patients.CaseA 30-year-old woman with a previous midtrimester miscarriage, G2, P0, presented at 23⁴ weeks gestation with acute abdominal pain and signs of hemodynamic instability. The patient was treated in childhood for Ewing sarcoma of the pelvis. Spontaneous uterine rupture was diagnosed. A supracervical hysterectomy with intrauterine fetus was performed.ConclusionA high index of suspicion is needed in primigravidas with risk factors for uterine rupture. Pelvic radiotherapy in childhood may be a risk factor.     

Spontaneous Rupture of the Liver during Pregnancy: A Case Report

Hepatic congestion resulting in hepatic rupture during pregnancy is a rare yet catastrophic event carrying a 60 to 70% maternal mortality rate. With preeclampsia and associated epigastric pain continuing to be a major problem confronting pregnant women, hepatic congestion may be more prevalent than believed. Current etiology, treatment, and characteristics of women who experience hepatic rupture are examined. A case report and nursing protocol are presented.     

Spontaneous Uterine Rupture in a Multigravid Pregnant Woman with Unscarred Uterus on Chronic Steroid Use: A Case Report

BackgroundUterine rupture in pregnancy is associated with severe maternal and fetal complications. Although it is a rare event, uterine rupture has been associated with certain risk factors. Glucocorticoids are known to weaken skeletal muscles; however, there have been no studies on the effects of chronic steroid use on the uterine myometrium.CaseWe present the case of a 40-year-old multigravid woman who experienced a posterior uterine wall rupture on an unscarred uterus. She was on chronic glucocorticoids for the treatment of psoriatic arthritis. We hypothesize that the catabolic effects of glucocorticoids on skeletal muscles also weakened the uterine myometrium, leading to a higher risk of uterine rupture.ConclusionUterine rupture may be associated with chronic use of corticosteroids. Identifying the different risk factors for uterine rupture can lead to more prompt diagnosis and management of uterine rupture, resulting in better maternal and fetal outcomes.     

Uterine Rupture Following One Successful Vaginal Birth After Caesarean Section: A Case Report

A 30-year-old, G3 P2 woman presented in spontaneous labour. Her first pregnancy had ended in a Caesarean section for failure to progress. Her second pregnancy had ended in a successful vaginal birth after Caesarean section (VBAC) after labour was augmented with oxytocin. During her third pregnancy, she presented in early labour and went on to a spontaneous complete rupture of her uterus which necessitated a Caesarean hysterectomy.     

Spontaneous Uterine Rupture in a Primigravida at 35 Weeks of Gestation. A Case Report and Review of the Literature

Spontaneous uterine rupture is a rare but life-threatening event. Usually, this complication is associated with such risk factors as previous injury of the uterine wall. We report a case of spontaneous rupture of an unscarred uterus in the absence of classical risk factors, and review the literature with respect to the possible aetiologies of this condition. We conclude that the differential diagnosis of atypical abdominal pain in pregnancy should include spontaneous uterine rupture, even in the absence of classical risk factors.     

Spontaneous Intestinal Perforation in Pregnancy from a Pre-Existing Postoperative Adhesion: A Case Report

BackgroundSpontaneous intestinal perforation is rare in pregnancy. Previously described cases have been associated with endometriosis, Crohn's disease, and intestinal tuberculosis.CaseWe describe a case of spontaneous intestinal perforation in pregnancy from a postoperative adhesion. The patient presented with multiple episodes of abdominal pain and vomiting starting at 25⁵ weeks. The diagnosis was made at 28 weeks when she presented with severe pain and abnormal fetal heart rate requiring emergency cesarean section with bowel resection.ConclusionThis case demonstrates that adhesions between the bowel and uterus from prior surgery may lead to spontaneous intestinal perforation as the uterus enlarges during pregnancy. As this diagnosis can be difficult because of imaging limitations and physiologic changes of pregnancy, it should be considered in cases of unremitting abdominal pain and vomiting.     

Uterine Arteriovenous Fistula Treated With Repetitive Transcatheter Embolization: Case Report

Uterine arteriovenous fistula (AVF) is a rare entity, but may lead to life-threatening hemorrhage. Although transcatheter embolization, surgical ligation, or hysterectomy would be considered for treatment of uterine AVF, there is poor knowledge as to how gynecologists can manage the uterine AVF with multiple large inflow arteries. Herein we report a uterine AVF successfully treated using multiple-step transcatheter embolization. The patient, a 58-year-old postmenopausal woman with a history of dilation and curettage, had intermittent massive uterine bleeding. Radiologic imaging revealed the presence of a large vasculature mass. The mass occupied the entire pelvis, and the source of hemorrhage was identified as an accompanying AVF. We thought that surgical intervention was contraindicated because of the potential risk of uncontrollable intraoperative bleeding. Multiple-step transcatheter embolization was performed, with complete resolution of the AVF. Thereafter, the patient had no further uterine bleeding. Multiple-step transcatheter embolization might be the most beneficial and efficient treatment option for a uterine AVF with multiple large inflow arteries.     

孕晚期子宫右前壁血管自发性破裂一例

孕晚期子宫血管自发性破裂是由于各种原因导致子宫动、静脉出现的自然破裂，由于孕晚期子宫血供极其丰富，一旦发生子宫血管破裂容易造成孕妇腹腔出血、休克、胎死宫内等不良事件。孕晚期子宫血管自发性破裂发病率低，但凶险性极高，诊断不及时或者漏诊将严重危害母儿安全。为提高对孕晚期子宫血管自发性破裂的认识，现回顾分析1例孕晚期子宫右前壁血管自发性破裂患者的临床资料，并复习相关文献，进一步分析其发病机制、辅助检查及临床表现，以加深临床医生对该病的认识，提高诊断和治疗水平。     

Uterine Vein Rupture at Delivery as a Delayed Consequence of Laparoscopic Surgery for Endometriosis: A Case Report

Laparoscopic resection of deep infiltrating endometriosis (DIE) has been reported to be an effective method for reduction of endometriosis-associated pain. As its complications, bowel perforation, urinary tract injury and neurogenic bladder are well known; however, uterine vein rupture during pregnancy has not been reported previously. We encountered a case of hemoperitoneum resulting from uterine vein rupture at a delivery as a delayed consequence of laparoscopic resection of DIE. A 31-year-old, para 2 woman underwent laparoscopic resection of lateral pelvic peritoneum, uterosacral ligaments, and bilateral endometriomas, exposing uterine vessels, which we covered with fibrin glue. Endometriosis-associated pain disappeared, and then the patient conceived 4 months later. The course of pregnancy and induction of labor with controlled oxytocin infusion was uneventful, and the patient delivered a female baby without asphyxia. Immediately after delivery, low abdominal pain with hypotension occurred despite absence of abnormal vaginal bleeding. Ultrasonography and the blood hemoglobin value suggested hemorrhagic shock owing to hemoperitoneum; therefore emergency exploratory laparotomy was performed. Active bleeding was found at the right uterine vein, which was then sutured for hemostasis. The patient received a blood transfusion and recovered without any problems. The bleeding lesion was located at the vein on which the peritoneum had been removed at the first laparoscopy, which suggested that the operation for DIE included a risk of uterine vessel rupture during pregnancy.     

Uterosacral Ligament Hysteropexy for Uterine Didelphys: A Case Report

Surgical approach to pelvic organ prolapse has traditionally included hysterectomy; however, in the past decade, uterine sparing prolapse surgery (hysteropexy) has become increasingly popular within female pelvic medicine and reconstructive surgery. The current literature demonstrates comparable outcomes for hysteropexy and traditional approach. As these procedures become more common, it is important to consider how to approach patients with unique anatomy such as uterine anomalies who desire uterine sparing surgery. In our case, we describe a woman aged 77 years with uterine didelphys who underwent a successful vaginal uterosacral ligament hysteropexy for stage 2 pelvic organ prolapse and was followed for 12 months postoperatively. Our case demonstrates that vaginal uterosacral ligament hysteropexy is feasible in a patient with uterine didelphys.     

Unscarred Uterine Rupture: A Retrospective Analysis

Introduction

Uterine rupture is a catastrophic obstetrical emergency associated with a significant feto-maternal morbidity and mortality. Many risk factors for uterine rupture, as well as a wide range of clinical presentations, have been identified.

Objectives

To analyze the frequency, predisposing factors, and maternal and fetal outcomes of uterine rupture.

Methods

A retrospective analysis of cases of unscarred uterine rupture was conducted at the Department of Obstetrics and Gynecology, RIMS, Imphal from June 1, 2010 to June 30, 2012.

Results

Our analysis comprised 13 cases. Of these, 30.8 % were booked cases. Most of the cases (46.2 %) were Para 2. Uterine rupture occurred at term in 10 cases. The rupture occurred due to mismanaged labor (30.8 %), the use of oxytocin (23 %), instrumental delivery (15.4 %), obstructed labor (15.4 %), induction by prostaglandin gel (7.7 %), and placenta percreta (7.7 %). Maternal deaths and perinatal deaths were 30.8 and 53.8 %, respectively. Sub-total hysterectomy was done in 8 cases and in 1 patient laparotomy with repair was performed.

Conclusion

Ruptured uterus causes a high risk in patients. An unscarred uterus can undergo rupture even without etiological or risk factors. The patients with mismanaged labor, grand multiparas, and obstructed prolonged labor must be managed by properly trained personnel at a tertiary care center in order to avoid the morbidity or mortality.

     

分娩期非瘢痕子宫自发性破裂一例

子宫破裂是指在分娩期或妊娠晚期子宫体部、底部或子宫下段发生裂开,直接威胁产妇及胎儿生命,是产科急危重症。最常见的原因是子宫操作史和梗阻性难产,其次还有子宫发育畸形、子宫肌层发育不良、剖宫产切口选择不当以及阴道助产损伤等。主要临床表现是胎心异常、腹痛和阴道出血。对于无子宫破裂高危因素且临床症状不典型的患者发生子宫破裂容易出现漏诊。讨论分析石家庄市第四医院收治的1例分娩期非瘢痕子宫自发性破裂病例,为该病的早期识别、早期诊断和及时处理提供帮助。     

Uterine Adenomyoma With Exophytic Subserosal Growth: Case Report of Rare Manifestation With Image Diagnosis and Laparoscopic-Assisted Excision

Uterine adenomyoma is a nodular aggregated form of adenomyosis composed of heterotopic endometrial or endometrium-like structures in the myometrium, with adjacent myometrial hyperplasia. Although adenomyoma is not extremely rare, reports of adenomyoma showing exophytic subserosal growth are limited. A 32-year-old nulligravida woman had sudden onset of lower abdominal pain. In addition to a left endometriotic cyst, a heterogeneous mass lesion showing mural and exophytic subserosal growth was noted in the posterior wall of the uterus. In a two-port laparoscopic-assisted procedure, the subserosal nodule was excised using ultrasonic coagulating shears, followed by excision of the mural lesion using a round loop electrode and a high-frequency electrosurgical unit. The histopathologic diagnosis was adenomyoma.     

Distal Vaginal Atresia with Spontaneous Perforation: A Case Report

BackgroundThe definitive treatment of distal vaginal atresia is surgery, but menstrual suppression is often helpful for initial management.CaseA 13-year-old presented with primary amenorrhea and progressive abdominal pain. She was diagnosed with distal vaginal atresia and started on hormonal suppression. She then re-presented with heavy vaginal bleeding, and follow-up imaging revealed that spontaneous perforation had occurred. There was now evidence of a tract leading from the obstructed vaginal bulge to the introitus. Vaginoplasty was complicated by the tortuosity of the tract. Under ultrasound guidance, a pull-through vaginoplasty was performed.Summary and ConclusionSpontaneous perforation of an atretic vagina is rare, but in such cases, urgent vaginoplasty is indicated to prevent infection. Despite the presence of a spontaneous tract leading to the obstruction, vaginoplasty can be complex, and intraoperative ultrasound could be beneficial.     

Spontaneous Rectus Sheath Hematoma in Pregnancy: A Case Report

BackgroundRectus sheath hematoma (RSH) is a rare yet important cause of abdominal pain in pregnancy.CaseA 32-year-old woman presented with right-sided abdominal pain at 31⁶ weeks gestation. Ultrasound revealed a heterogeneous structure consistent with an RSH. Conservative management was undertaken with analgesia and obstetrical and ultrasound follow-ups. Ultrasound revealed resolution of the RSH after 6 weeks. At 38 weeks, the patient was induced for pre-eclampsia and delivered a healthy baby girl.ConclusionOur case report presents a spontaneous RSH at 32 weeks gestation that was managed conservatively and resulted in a term delivery.