Recurrent uterine rupture in third trimester of pregnancy

We report a case of recurrent upper segment uterine rupture in a 31-year-old woman at 32+5/40 weeks of gestation. She had fundal uterine rupture 3 years ago in her first pregnancy at 40 weeks of gestation. There was no history of uterine malformation or prior uterine surgery. However, we noted that she had had three laparoscopic procedures for endometriosis treatment. She was scheduled to have an elective repeat caesarean section at 34+6/40 weeks of gestation in the index pregnancy. Unfortunately, she presented at 32+5/40 weeks with features of acute abdomen and signs of fetal distress. She had a category 1 caesarean section and was found to have fundal uterine rupture at the same site. She had a smooth uneventful recovery following a timely intervention and discharged home on day 5 postoperatively in a good condition with her baby girl.

pregnancy, healthcare improvement and patient safety

Uterine rupture refers to a complete disruption of all uterine layers including the serosa. It is a grave complication with associated maternal and neonatal morbidity and mortality. While uterine dehiscence refers to an incomplete uterine scar separation with intact serosa, scar dehiscence is often clinically occult and incidentally noted at the time of caesarean delivery or found on ultrasound scan examination of the lower segment during the second or third trimester.1–3 Uterine rupture in an unscarred uterus of a primigravida is a very rare occurrence. The risk of uterine rupture in subsequent pregnancy is substantially increased in such cases. On literature review, there is no consensus and clarity on the optimum antenatal management in subsequent pregnancy due to paucity of guidelines. It is prudent to develop a robust evidence-based national guidance on how to best manage pregnancies following a prior uterine rupture. Case presentation A healthy 31-year-old woman was booked for antenatal care at a gestational age of 12+4 weeks in her second pregnancy. She had her first childbirth in October 2017 when she had an emergency (crash) lower segment caesarean section at 40 weeks under general anaesthesia on account of fetal distress and suspected placental abruption in the latent phase of labour. On presentation she described a constant excruciating upper abdominal pain and fetal bradycardia was noticed on the cardiotocography leading to need for a category 1 (crash) lower segment caesarean section. Intraoperatively, following the delivery of the baby by caesarean section, an unexplained spontaneous fundal uterine rupture was noted. The rupture was horizontal and measured about 10 cm in length; the repair was performed in two layers ensuring good haemostasis (see figure 1); estimated blood loss was 2000 mL. A live baby that required resuscitation was delivered and handed over to the paediatricians. The baby was managed in the special care baby unit (SCBU) and was discharged in good condition with the mother. The baby is currently well. In her surgical history, she had three laparoscopies for excision of pelvic endometriosis from the pouch of Douglas and ovarian fossa. She has no previous history of surgical termination of pregnancies or uterine surgery such as metroplasty or myomectomy. She is up to date with cervical smear screening and has normal cytology results. She is not allergic to any drug. She is a non-smoker and does not drink alcohol. In the index pregnancy, she booked for antenatal care at a gestational age of 12+4 weeks under consultant-led care. By dating scan, her expected date of confinement was 04 September 2020. On examination, her booking blood pressure was 110/74 mm Hg, body mass index was 23.1 kg/m2 and all her booking blood investigations were normal. She had the normal fetal anatomy scan at 20 weeks and three antenatal visits prior to the delivery. At 20 weeks gestation visit, she had thorough discussion with the consultant obstetrician, and it was agreed that she would be delivered at a gestational age of 34+6 weeks by elective lower segment caesarean section on account of the history of previous fundal uterine rupture. She presented to the labour ward at a 32+5/40 gestational age, with symptoms of severe lower abdominal pain and uterine contractions. The abdominal pain was unprovoked, sudden in onset, continuous in between contractions and associated with vomiting. She denied having any trauma and there were no associated symptoms or signs of infection. There was no associated vaginal bleeding or signs of spontaneous rupture of membrane. She was feeling good fetal movements prior to the onset of pain. On examination, she looked pale and clammy; vital signs were, however, stable: Pulse rate 70 beats per minute (bpm), blood pressure 125/60 mm Hg and temperature 37.3°C noted. Abdominal examination revealed soft abdomen and uterus with moderate tenderness. Uterine contractions were noted to be about two to three in 10 min. The fetus was in longitudinal lie with a cephalic presentation. Cardiotocograph tracing was commenced and showed fetal bradycardia (76–80 bpm). Bedside ultrasound scan was immediately carried out to differentiate fetal from maternal pulse which confirmed fetal bradycardia of about 80 bpm. Vaginal examination revealed no signs of labour (closed cervix) or bleeding. Differential diagnosis The differential diagnosis considered at presentation were uterine rupture and placenta abruption. However, the fact that she had a prior upper segment uterine rupture, which substantially increases the risk of recurrence made uterine rupture, the most likely diagnosis in this case. Treatment In view of the fetal distress, abdominal pain and uterine tenderness, an obstetrical crash call was activated for a category 1 caesarean section. Surgical procedure was commenced within 10 min of the decision for the category 1 caesarean section following general anaesthesia. Joel-Cohen incision was performed to expedite the delivery of the baby; about 200 mL of haemoperitoneum was noted on opening the abdominal cavity. A horizontal fundal uterine rupture measuring about 10 cm in length was identified along supposedly the line of the previous scar. Amniotomy was performed through the uterine rupture, a floppy female baby delivered and handed over to the paediatricians for resuscitation. The rest of the uterus including the lower segment caesarean scar was intact. Placenta and membranes delivered completely and about 150 mL of retroplacental clots were noted. The uterine rupture was repaired in two layers and haemostasis confirmed. A Robinson’s drain was left in the vesico-uterine pouch to ensure free drainage of any collection. Total blood loss of 650 mL was noted at the end of the procedure. All pelvic organs were inspected to look for any haematoma or involvement in the uterine rupture. Both ovaries, fallopian tubes, broad ligament and bladder were intact. Outcome and follow-up She had a baby girl, weighing 1.82 kg with Apgar score at birth of 3 in 1 min, 5 in 5 min and 6 in 10 min. Umbilical cord gas analysis revealed arterial cord pH 6.87, base excess −16.3 and venous cord pH 6.88, base excess −16.4. Baby was transferred to SCBU for monitoring in view of low cord pH and prematurity. In the immediate postoperative period, a further blood loss of 600 mL was noted in the drain. Tranexamic acid and uterotonics were administered and no further drainage was found after these medications. Her observations and modified early obstetrical warning scores were stable along with satisfactory urine output. Postoperative haemoglobin level was 90 g/L (preoperative haemoglobin level was 106 g/L). She received parenteral antibiotics for 24 hours followed by oral for 5 days. She had a smooth and uneventful recovery and was discharged on the fifth postoperative day with her baby in good condition. She was informed about the risk of uterine rupture in future pregnancies and counselled about the use of effective long-term contraception including the option of vasectomy with risks and benefits of each. She intended to have a long-term reversible contraception and needed time to discuss the option of vasectomy with her partner. She had a debrief meeting with her consultant obstetrician at 6 weeks postpartum when events at childbirth were discussed again. She recovered fully and was in good mental and physical health. The baby girl was doing well too. The need for long-term contraception was further reiterated. She mentioned her plan for permanent contraception and informed us that her partner had contemplated a vasectomy procedure.

Rupture of the gravid uterus is an unfortunate obstetrical complication and a serious threat to the reproductive health of affected women.4 It can complicate pregnancy and labour in scarred, congenitally malformed and very rarely unscarred (naive) uterus. The rate of uterine rupture in the unscarred uteri in developed countries is 1 per 8435 pregnancies (0.012%).5 In a meta-analysis of pooled data from 25 studies in a peer-reviewed publication (1976–2012), the incidence of uterine rupture was described as 1 in 146 making the rupture rate 0.7%.5 Overall incidence of uterine rupture in the UK is 2 in 10 000 maternities.6 The incidence in women undertaking vaginal birth after caesarean is quoted as 21 per 10 000 pregnancies.6 The general risk for the rupture of an upper segment scar and recurrent rate of uterine rupture is reported as between 4% and 19%,7 8 while that of the lower uterine scar is described as ranging between 0.2% and 1.5%.9 10 The common causes of uterine rupture include obstructed labour, hyperstimulation, previous scarred uterus, congenital malformation of the uterus with pregnancy especially in undeveloped uterine horn, intrauterine manipulation during labour and instrumental delivery such as forceps delivery which can result in tears extending from cervix to lateral uterine walls. Accidents and direct uterine trauma (motor vehicle accident, fall), violence (gunshot wound, blunt blow to the abdomen) and grand multiparity11 can also result in the catastrophic uterine rupture with serious maternal mortality and morbidity. Scarred uterus may result from previous caesarean delivery, myomectomy especially with breach of the endometrium, laparoscopy, hysteroscopy, surgical evacuation and uterine perforation. Placenta growth abnormalities such as placenta increta or percreta and trophoblastic diseases such as invasive mole or choriocarcinoma11 have also been noted to damage the uterine wall integrity at its implantation site. Our patient had recurrent same site uterine rupture following an upper segment spontaneous rupture. There was no identifiable risk factor in the primary uterine rupture when the uterus was unscarred other than that she had a history of three laparoscopic surgeries for the treatment of pelvic endometriosis. In some previous case reports uterine rupture has been tied to poor vascularisation and necrosis of the myometrium due to the extensive use of electrosurgery.12–14 Although it seems a theoretical postulation, it appears to be the most plausible explanation in our patient in the absence of other risk factors for primary rupture. With regard to the timing of rupture in relation to gestation and labour in our patient, the previous uterine rupture occurred in the early part of labour, whereas the recurrence happened antenatally at 32+5 weeks without any prior signs of labour. Literature review is consistent with our findings and has documented occurrence of upper segment/classical caesarean section scar rupture as being more likely in the antenatal period remote from labour in a ‘quiet uterus’, while the lower segment scars tend to give way during labour.7 8 10 15 The isthmic region of the pregnant uterus has been identified in various reports as the most common site of uterine rupture. Effacement of the cervix during labour practically involves the uptake of the cervix into the lower segment (isthmic region) of the labouring uterus. This part of the uterus has fewer contractile cells and thins out during labour when compared with the upper uterine segment.16–18 Also this is the site that harbours the most uterine scars following lower segment caesarean sections. These two factors generally make this area the weakest part of the uterus during labour and most vulnerable to rupture. Women with interdelivery interval of less than 18 months have been highlighted in various studies and case reports as having a higher risk of uterine rupture.15 18 This may be more applicable with lower segment uterine rupture than with ruptures associated with the upper uterine segment which is usually very unpredictable and antenatal. Our patient had an interdelivery interval of 36 months and still went ahead to experience an upper segment uterine rupture Abdominal pain is the most consistent clinical finding noted in uterine rupture in non-labouring women, whereas vaginal bleeding occurred more frequently with uterine rupture during labour.15 This was also the case with our patient. For the recurrent rupture, however, the factors that may affect wound healing like the method used for myometrial haemostasis and to close the myometrial defect, an actively contracting and retracting upper segment, the extent of local tissue destruction, the presence of infection or haematoma formation, individual healing characteristics; may all contribute to poor scar integrity in a previous uterine rupture scar.19 It is difficult to precisely identify factors responsible for the rupture in our case as any one or a combination of these factors may have contributed to the recurrence of the rupture. There have been debates on antenatal assessment of uterine wall integrity using ultrasonography to predict scar weakness for better timed intervention, to avoid associated catastrophic fetal and maternal outcomes. Fox et al1 in a case series reported the outcome of following up of 20 pregnancies with prior uterine rupture who were delivered at a gestational age of 36–37 weeks and none had a recurrent uterine rupture or any form of severe complication. The group advanced and adopted a standardised protocol for managing patients with prior uterine rupture or uterine dehiscence, which comprised four-weekly serial ultrasound scan for the assessment of the integrity of the lower uterine segment and fetal growth, as well as arranging for delivery via elective caesarean section or urgent caesarean section at the onset of any preterm labour. Delecour et al20 also applied a similar management protocol to 10 women with 11 pregnancies who had previous uterine rupture and recorded no recurrence of complete uterine rupture. All women had caesarean deliveries between gestational age of 32 and 37 weeks. They added hospitalisation, however, for all their patients during the third trimester for close clinical and ultrasound monitoring as practiced by Fox et al. The ultrasound monitoring involved four-weekly serial ultrasound scan. The lower uterine segment integrity was assessed in every one of the ultrasound scan sessions. This was the case in the protocol used by Fox et al. If a patient was found to have a sonographically apparent uterine window on ultrasound scan (ie, no identifiable myometrium in the lower uterine segment), the patient was followed up more closely and earlier delivery before 37 weeks was recommended.1 However an objective optimal cut-off value for assessing the integrity of the scar by measuring the scar thickness was suggested. It ranged between 2 mm and 3.5 mm uterine scar thickness for the lower segment in patients with a previous uterine scar and between 1.4 mm and 2 mm for the myometrial (upper segment) layer scars.21 Where uterine dehiscence in an earlier gestational period was incidentally noticed during serial ultrasound sessions, hospital admission and close observation was offered to the patient. However, it did not change the clinical decision-making in delivery time for those cases. Women were admitted for monitoring and delivered between 36 and 37 weeks of gestation or earlier if needed before the onset of labour.1 20 21 In another case presentation by Tiwari et al, ‘successful pregnancy after a previous uterine rupture’,21 ultrasound assessment was performed at 30 weeks of gestation and uterine thickness was found to be 2 mm, which helped in their decision to carry on the pregnancy and take a conservative approach. They admitted the patient at 34 weeks gestation for observation, corticosteroid administration and subsequent successful delivery at 37 weeks of gestation. Reflecting on the above models of management and their good outcomes, our patient could probably have benefitted from adopting one of those practices. Ultrasonic assessment and monitoring of the scar integrity at the beginning of the third trimester would have provided us with more precise information to guide the time of hospital admission, the administration of corticosteroid and delivery before the recurrent uterine rupture occurred. In terms of timing of delivery by elective repeat caesarean section, the site and nature of uterine rupture are the major determinant factors. For prior classical caesarean delivery or any uterine rupture, timing has been recommended for 36–37 weeks.12 13 Some other studies, however, are favouring earlier delivery between 34 and 35 weeks of gestation as the optimal timing for woman with a prior uterine rupture.22–24 In yet another recent study by Peker et al, 29 women out of 67 who had unscarred uterine rupture received primary repair of their rupture scar out of which 10 out of the 29 went ahead to conceive again. Among these 10 women that reconceived 8 of them who were noted to have had a history of isthmic rupture in their previous pregnancy had a successful delivery by elective caesarean section at 36–37 weeks of gestation, while the 2 women who had fundal rupture in the previous pregnancy experienced a recurrent rupture at 33 and 34 weeks of gestation, respectively, which was like the experience of our patient. The authors therefore opined that elective caesarean section between 36 and 37 weeks will best suit the optimum timing of delivery of patients with previous isthmic rupture, whereas patients with a history of previous fundal rupture should have an earlier caesarean section between 32 and 33 completed weeks of gestation after completion of fetal lung maturity with steroids. This will help prevent the characteristic early antenatal scar rupture associated with women with previous fundal rupture who go ahead to conceive again.15 We planned for elective caesarean section at 34+ weeks as per anecdotal reports, but unfortunately our patient could not make it to 34 weeks and presented early with recurrent uterine rupture. Patient’s perspective. After the uterine rupture in my first pregnancy, I did a lot of research into risks of having a second. I felt confident with the planned C-section at 34+5 weeks and just feel really unlucky that this happened again. I won’t be having any more children and am so grateful to the hospital for reacting as quickly as they did to save me and my baby. Learning points. The aetiology and pathogenesis of both primary rupture without underlying cause and recurrence are varied. Pelvic surgery involving extensive use of electrodiathermy has been postulated as possible risk factor for uterine rupture during pregnancy. More robust studies are needed to learn in depth the cellular level damage of myometrial integrity predisposing it to rupture or dehiscence in cases of exposure to electrodiathermy treatment. Advancement in the imaging modalities using Doppler, ultrasound scan and MRI may assist in monitoring uterine scar thickness more precisely during pregnancy and guide optimal time for delivery. With improved obstetrical practice many women with previous uterine rupture are able to carry subsequent pregnancy; the risk of recurrent uterine rupture in such cases still remains high. This calls for development of a standard protocol of antenatal management and timing of delivery. Footnotes Contributors: OU compiled and arranged the case report and also did the literature search and contributed to the discussion and the referencing. KM contributed to writing the case and in literature search. NK was the consultant that managed this patient antenatally and supervised and reviewed the case report. SS managed the patient intrapartum and supervised and reviewed the case report and discussions. Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. Competing interests: None declared. Provenance and peer review: Not commissioned; externally peer reviewed. Ethics statements Patient consent for publication Obtained.

- 1.Fox NS, Gerber RS, Mourad M, et al. Pregnancy outcomes in patients with prior uterine rupture or dehiscence. Obstet Gynecol 2014;123:785–9. 10.1097/AOG.0000000000000181 [DOI] [PubMed] [Google Scholar] - 2.Nasir A, Alnakhli Z, Iqbal A. Uterine rupture, case report and review of literature. Webmed central Obgyn 2015;6:WMC004909. [Google Scholar] - 3.Elliot ML. Uterine rupture vs Dehiscience letter to the editor. AJOG 2016;214:415. 10.1016/j.ajog.2015.11.025 [DOI] [PubMed] [Google Scholar] - 4.Odusoga OL, Afefuge PO, Oloyede OAO. Uterine rupture: a major contributor to obstetric morbidity in Sagamu. Trop J Obstet Gynaecol 2003;20:137–40. 10.4314/tjog.v20i2.14420 [DOI] [Google Scholar] - 5.Gerald GN. Uterine rupture in pregnancy. Medscape, 2012. [Google Scholar] - 6.Fitzpatrick KE, Kurinczuk JJ, Alfirevic Z, et al. Uterine rupture by intended mode of delivery in the UK: a national case-control study. PLoS Med 2012;9:e1001184. 10.1371/journal.pmed.1001184 [DOI] [PMC free article] [PubMed] [Google Scholar] - 7.Qureshi S, Gupta AS. Recurrent uterine rupture. J postgrad gynecol obs 2014;1. [Google Scholar] - 8.Ramphal SR, Moodley J. Antepartum uterine rupture in previous caesarean sections presenting as advanced extrauterine pregnancies: lessons learnt. Eur J Obstet Gynecol Reprod Biol 2009;143:3–8. 10.1016/j.ejogrb.2008.11.005 [DOI] [PubMed] [Google Scholar] - 9.Deka D, Bahadur A, Dadhwal V, et al. Successful outcome in pregnancy complicated by prior uterine rupture: a report of two cases. Arch Gynecol Obstet 2011;283:45–8. 10.1007/s00404-010-1798-1 [DOI] [PubMed] [Google Scholar] - 10.Cunningham FG, Leveno KJ, Bloom SL, et al. Chapter 26 Prior Cesarean Section. In: Williams obstetrics 23rd edition. McGraw Hill Companies inc, 2010. [Google Scholar] - 11.Danso KO. Ruptured uterus. In: Kwawukume EY, Emueyan EE, eds. Comprehensive obstetrics in the tropics. 1st edn. Dansoman Asante and Hittshcher Printing Press Limited, 2002: 86–92. [Google Scholar] - 12.Pelosi MA, Pelosi MA. Spontaneous uterine rupture at thirty-three weeks subsequent to previous superficial laparoscopic myomectomy. Am J Obstet Gynecol 1997;177:1547–9. 10.1016/S0002-9378(97)70110-8 [DOI] [PubMed] [Google Scholar] - 13.Propst AM, Liberman RF, Harlow BL, et al. Complications of hysteroscopic surgery: predicting patients at risk. Obstet Gynecol 2000;96:517–20. 10.1016/s0029-7844(00)00958-3 [DOI] [PubMed] [Google Scholar] - 14.Zhao B, Wang Y, Zhang Y. Uterine rupture in patients with a history of laparoscopy or hysteroscopy procedures: three case reports. Medicine 2019;98:e15491. 10.1097/MD.0000000000015491 [DOI] [PMC free article] [PubMed] [Google Scholar] - 15.Peker N, Aydın E, Evsen MS, et al. Unscarred uterine rupture and subsequent pregnancy outcome — a tertiary centre experience. Ginekol Pol 2020;91:95–90. 10.5603/GP.a2020.0012 [DOI] [PubMed] [Google Scholar] - 16.Konje JC, Odukoya OA, Ladipo OA. Ruptured uterus in Ibadan--a twelve year review. Int J Gynaecol Obstet 1990;32:207–13. 10.1016/0020-7292(90)90347-N [DOI] [PubMed] [Google Scholar] - 17.Turgut A, Ozler A, Evsen MS, et al. Uterine rupture revisited: predisposing factors, clinical features, management and outcomes from a tertiary care center in turkey. Pak J Med Sci 2013;29. 10.12669/pjms.293.3625 [DOI] [PMC free article] [PubMed] [Google Scholar] - 18.Bujold E, Gauthier RJ. Risk of uterine rupture associated with an interdelivery interval between 18 and 24 months. Obstet Gynecol 2010;115:1003–6. 10.1097/AOG.0b013e3181d992fb [DOI] [PubMed] [Google Scholar] - 19.Kim MS, Uhm YK, Kim JY, et al. Obstetric outcomes after uterine myomectomy: laparoscopic versus laparotomic approach. Obstet Gynecol Sci 2013;56:375–81. 10.5468/ogs.2013.56.6.375 [DOI] [PMC free article] [PubMed] [Google Scholar] - 20.Delecour L, Rudigoz R-C, Dubernard G, et al. Pregnancy and delivery after complete uterine rupture. J Gynecol Obstet Hum Reprod 2018;47:23–8. 10.1016/j.jogoh.2017.10.004 [DOI] [PubMed] [Google Scholar] - 21.Tiwari K, Karki A, Dangal G, et al. Successful pregnancy after previous uterine rupture. Europasian J Med Sci. 2020;2:99–102. 10.46405/ejms.v2i1.22 [DOI] [Google Scholar] - 22.Frank ZC, Lee VR, Hersh AR, et al. Timing of delivery in women with prior uterine rupture: a decision analysis. J Matern Fetal Neonatal Med 2021;34:238–44. 10.1080/14767058.2019.1602825 [DOI] [PubMed] [Google Scholar] - 23.Gyamfi –Bannerman C. Prior none lower segment uterine scar: when to plan cesarean delivery Society for maternal –fetal medicine. Contemporary Obgyn.net, 2013. [Google Scholar] - 24.Landon MB, Lynch CD. Optimal timing and mode of delivery after cesarean with previous classical incision or myomectomy: a review of the data. Semin Perinatol 2011;35:257–61. 10.1053/j.semperi.2011.05.008 [DOI] [PubMed] [Google Scholar]