{"paper_id":"259c9644-3a28-44f2-982c-c531afbb749c","body_text":"Datta and Basu  \nBulletin of the National Research Centre           (2023) 47:27  \nhttps://doi.org/10.1186/s42269-023-00998-y\nCASE REPORT\nSpontaneous antenatal uterine rupture \nin a primiparous patient with placenta \npraevia: Does previous laparoscopic treatment \nof endometriosis increase the risk?\nSujata Datta1 and Ritisha Basu2*   \nAbstract \nBackground Unprovoked spontaneous uterine rupture in a primigravid unscarred uterus is a rare but serious obstet-\nric complication. Our case highlights a prelabour uterine rupture in a primiparous patient with an anterior placenta \npraevia and transverse lie at 32 weeks.\nCase presentation The patient presented with severe continuous abdominal pain and an abnormal Cardiotoco-\ngraph antenatally. An emergency Caesarean section done with suspicion of concealed abruption revealed a cornual \nuterine rupture with 2 L of hemoperitoneum.\nConclusion The patient and her baby recovered well from surgery, thus, emphasizing the necessity of timely inter-\nvention. An association with previous laparoscopic treatment of severe endometriosis and adenomyosis is explored.\nKeywords Uterine rupture, Unscarred uterus, Endometriosis, Obstetric complication\n© The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which \npermits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the \noriginal author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or \nother third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line \nto the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory \nregulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this \nlicence, visit http://creativecommons.org/licenses/by/4.0/.\nBackground\nA ruptured uterus is a catastrophic complication that \ncan lead to severe maternal and fetal morbidity if not \ndiagnosed in time. Common causes of uterine rupture \ninclude prior caesarean (8.9 and 37.1 per 10,000 births) \n(Miller et  al. 1997), prior myomectomy, uterine malfor -\nmations, connective tissue disorders, and placental dis -\norders such as placenta percreta. Rupture of the uterus \nin the antenatal period prior to labour is a rare event, \nespecially in an unscarred uterus. Uterine rupture in an \nunscarred uterus is as rare as 0.6 per 10,000 deliveries \n(Spencer and Robarts 2008).\nOur case highlights an unprovoked uterine rupture in \na primigravida with an IVF (in vitro fertilization) preg -\nnancy at 32  weeks having a transverse lie and anterior \nplacenta praevia. She had adenomyosis and a past his -\ntory of laparoscopic treatment of severe endometriosis. \nSince this patient was not in labour and had an unscarred \nuterus, this was a rare complication encountered.\nCase presentation\nA primigravida with an IVF pregnancy following lapa -\nroscopic treatment of grade 4 endometriosis, presented \nat 32  weeks of gestation with an insidious onset of left \nupper quadrant abdominal pain for one and a half days. \nAn antenatal ultrasound showed an anterior placenta \npraevia covering the cervical os with the fetus in a trans -\nverse lie and normal fetal growth.\nOpen Access\nBulletin of the National\nResearch Centre\n*Correspondence:\nRitisha Basu\nbasu.ritisha312@gmail.com\n1 Obstetrics and Gynaecology, Fortis Hospital, Anandapur, Kolkata, West \nBengal 700107, India\n2 Obstetrics and Gynaecology, North Eastern Indira Gandhi Regional \nInstitute of Health and Medical Sciences, Shillong, Meghalaya 793018, \nIndia\n\nPage 2 of 3Datta and Basu  Bulletin of the National Research Centre           (2023) 47:27 \nOn admission, she complained of severe continuous \nabdominal pain with a single episode of minimal vaginal \nbleeding. On examination, she had stable vitals, and mild \npallor but generalized abdominal tenderness of rapidly \nincreasing severity. There were no uterine contractions \nand a speculum examination showed a closed cervical os \nwith no vaginal bleeding, which showed that the patient \nwas not in labour. A Cardiotocograph (CTG) was done \nconcomitantly, which showed fetal tachycardia, poor \nbeat-to-beat variability, and atypical variable decelera -\ntions, suggestive of non-reassuring fetal status.\nIn view of the abnormal CTG, an emergency Caesarean \nsection was done immediately on the suspicion of a con -\ncealed abruption. At caesarean, on entering the abdomi -\nnal cavity via a transverse incision, 2 L of blood was found \nin the peritoneal cavity. A transverse lower segment inci -\nsion was made on the uterus through the placenta to \ndeliver the baby in a transverse lie by the internal podalic \nversion. The uterus was delivered out of the abdomen to \nreveal a large rupture on the left side of the fundus, close \nto the cornu. The rupture was repaired in 3 layers with \ncontinuous sutures of Polyglactin 1.\nShe was transferred to ICU as she quickly became \nhemodynamically unstable during surgery, requiring 4 \nunits of packed red blood cells and fresh frozen plasma. \nThe baby was transferred in good condition to the neo -\nnatal care unit and in due course made an unevent -\nful recovery. Following stabilization, the patient had an \nuncomplicated postoperative period and was discharged \nin stable condition. She was advised against further preg -\nnancies (Figs. 1 and 2).\nDiscussions\nEarly detection of uterine rupture and prompt lapa -\nrotomy are essential in reducing maternal and peri -\nnatal morbidity. The classic clinical picture of acute \nabdomen, hypovolemia, vaginal bleeding, and foetal dis -\ntress may not always be accompanying symptom. There -\nfore, regardless of parity, it’s crucial to maintain a high \nindex of suspicion for uterine rupture in women pre -\nsenting with any of the above symptoms. Less common \nconditions that may present with a similar spectrum of \nsymptoms include subcapsular liver hematoma with or \nwithout rupture, rupture of the broad ligament, splenic \nrupture, uterine torsion, and uterine vein rupture. These \nconditions need prompt surgical exploration as they \ncause quick hemodynamic instability; therefore, a high \nFig. 1 Abnormal CTG with fetal tachycardia and unprovoked fetal decelerations\nFig. 2 Intraoperative image showing cornual rupture\n\nPage 3 of 3\nDatta and Basu  Bulletin of the National Research Centre           (2023) 47:27 \n \nlevel of clinical suspicion is always needed when above-\nmentioned symptoms occur in a non-laboring patient.\nOur patient, a primigravida at 32 weeks, presented with \ncontinuous abdominal pain and fetal distress—symptoms \nconsistent with concealed placental abruption. However, \non performing an emergency caesarean, a cornual rup -\nture in the uterus was identified, a rare event in a primi -\ngravid unscarred uterus. Early recourse to surgery, led \nto an optimal maternal and fetal outcome. It has been \nnoted that rupture of an unscarred uterus is a more cata -\nstrophic event than rupture through a previous scar, as \nthe area of rupture is more vascular (Miller et al. 1997).\nIt is important that we discuss that our patient had a \nhistory of primary subfertility with grade 4 endometriosis \nand adenomyosis. She underwent an uncomplicated lap -\naroscopic resection of an ovarian endometrioma and pel -\nvic adhesiolysis for grade 4 endometriosis, a year prior to \nher IVF. Literature suggests surgical treatment of severe \nendometriosis, such as deeply infiltrating endometriosis \n[DIE], has shown a causal relationship with uterine rup -\nture (Ziadeh 2020; Fettback et  al. 2015; Leone Roberti \nMaggiore et al. 2017; Vystavěl et al. 2018). This relation -\nship of DIE with uterine rupture may be explained by a \nlack of a consensus regarding the depth of excision of tis -\nsues and decreased vascularisation of the uterine tissue \nfollowing extensive bipolar coagulation required in these \nsurgeries.\nOur patient also had another risk factor of adenomyo -\nsis. There are case reports in the literature of spontane -\nous uterine rupture of an unscarred uterus caused by \nadenomyosis in the early third trimester (Vimercati et al. \n2022). Alteration in organization and resistance of uter -\nine fibers in adenomyosis may have a contributing role in \nthis pathology (Nikolaou et al. 2013).\nConclusion\nOur case demonstrates the potential of a primigravid \nunscarred uterus to rupture, even if not in labour. It is \nextremely important to keep this differential diagnosis in \nmind when a non-labouring primigravida presents with \npain abdomen and is diagnosed with abnormal CTG.\nAlso, we have reviewed the literature where a causal \nrelationship between laparoscopic treatment of severe \nendometriosis and adenomyosis with uterine rupture has \nbeen explored.\nAbbreviations\nIVF  In vitro fertilisation\nDIE  Deeply infiltrating endometriosis\nCTG   Cardiotocograph\nICU  Intensive care unit\nAcknowledgements\nNot Applicable.\nAuthor contributions\nBoth authors have contributed equally to the manuscript. Both authors have \nread and approved the manuscript.\nFunding\nNo funding was obtained for this study.\nAvailability of data and materials\nNot Applicable.\nDeclarations\nEthics approval and consent to participate\nNot Applicable.\nConsent for publication\nInformed consent taken from the patient.\nCompeting interests\nThe authors declare that they have no competing interests.\nReceived: 10 January 2023   Accepted: 13 February 2023\nReferences\nFettback PB, Pereira RM, Domingues TS, Zacharias KG, Chamié LP , Serafini PC \n(2015) Uterine rupture before the onset of labor following extensive \nresection of deeply infiltrating endometriosis with myometrial invasion. \nInt J Gynaecol Obstet 129(3):268–270. https:// doi. org/ 10. 1016/j. ijgo. 2015. \n01. 007\nLeone Roberti Maggiore U, Inversetti A, Schimberni M, Viganò P , Giorgione V, \nCandiani M (2017) Obstetrical complications of endometriosis, particu-\nlarly deep endometriosis. 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F S Rep 1(3):213–218. \nhttps:// doi. org/ 10. 1016/j. xfre. 2020. 09. 005\nPublisher’s Note\nSpringer Nature remains neutral with regard to jurisdictional claims in pub-\nlished maps and institutional affiliations.","source_license":"CC0","license_restricted":false}