Silent Danger: Risk Factors and Outcomes of Fortuitously Discovered Uterine Rupture – A 41-Case Cohort Study

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While typically detected during labor, some cases are clinically silent, discovered incidentally during imaging/surgery, highlighting a knowledge gap in risk assessment. In Tunisia, 1.5% of pregnancies involve UR, mostly scar-related. The study aim was to identify factors associated with the development of complete UR in cases that were incidentally found during pregnancy or delivery. Methods This was retrospective, longitudinal cohort study conducted over an eleven-year period, from January 2014 to December 2024, at the Gynaecology and Obstetrics department B, Charles Nicolle Hospital, Tunis, Tunisia. Asymptomatic UR cases (complete/incomplete) were analysed to compare clinical profiles, identify risk factors, and assess maternal and neonatal outcomes. Results A total of 41 cases of asymptomatic UR were included, which accounted for an average of 50% of the UR cases. In a cohort comparing complete UR cases (N=27) and incomplete UR cases (N=14), significant differences in duration of pregnancy and labor were found. The mean gestational age was longer in the incomplete UR group (p=0.03), and the duration of labor was also significantly longer (p=0.006). No significant differences were observed in sociodemographic characteristics, quality of prenatal care, or complications such as gestational diabetes or preeclampsia. Nonsignificant factors included pregnancy interval, scars number and labor stagnation. The analysis showed two significant predictors of complete UR outcomes. Prolonged labor (>220 minutes) was strongly associated with increased odds of complete UR (OR=45.231, 95% CI=2.591-789.486, p=0.009) and lower maternal weight (<68 kg) correlated with reduced odds of incomplete UR (OR=0.033, 95% CI=0.001–0.837, p=0.039), suggesting a protective effect per kilogram decrease. Conclusion Findings redefine UR as part of a broader clinical spectrum, not just an acute complication, enabling tailored surveillance and improved prevention in high-risk pregnancies. " } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://f1000research.com/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://f1000research.com/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://f1000research.com/articles/14-585/v1", "name": "Silent Danger: Risk Factors and Outcomes of Fortuitously Discovered..." } } ] } Home Browse Silent Danger: Risk Factors and Outcomes of Fortuitously Discovered... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article karmous N, Ghrab S, Masmoudi A et al. Silent Danger: Risk Factors and Outcomes of Fortuitously Discovered Uterine Rupture – A 41-Case Cohort Study [version 1; peer review: 2 approved with reservations] . F1000Research 2025, 14 :585 ( https://doi.org/10.12688/f1000research.164778.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Research Article Silent Danger: Risk Factors and Outcomes of Fortuitously Discovered Uterine Rupture – A 41-Case Cohort Study [version 1; peer review: 2 approved with reservations] Narjes karmous https://orcid.org/0009-0001-9101-7849 1,2 , Siwar Ghrab 2 , Abdelwahab Masmoudi 2 , [...] Badreddine Bouguerra 1,2 , Aymen Mabrouk 3 , Anis ben Dhaou 3 , Abdennour Karmous 4 Narjes karmous https://orcid.org/0009-0001-9101-7849 1,2 , Siwar Ghrab 2 , [...] Abdelwahab Masmoudi 2 , Badreddine Bouguerra 1,2 , Aymen Mabrouk 3 , Anis ben Dhaou 3 , Abdennour Karmous 4 PUBLISHED 13 Jun 2025 Author details Author details 1 University of Tunis El Manar Faculty of Medicine of Tunis, Tunis, Tunisia 2 Department B of Obstetrics and Gynecology, Charles Nicolle Hospital, Tinis, Tunisia 3 General surgery department B, Charles Nicolle Hospital, Tunis, Tunisia 4 Psychiatry Department, Razi Hospital, Manouba, Tunisia Narjes karmous Roles: Conceptualization, Methodology, Writing – Original Draft Preparation Siwar Ghrab Roles: Data Curation, Visualization Abdelwahab Masmoudi Roles: Writing – Review & Editing Badreddine Bouguerra Roles: Supervision, Validation Aymen Mabrouk Roles: Writing – Review & Editing Anis ben Dhaou Roles: Writing – Review & Editing Abdennour Karmous Roles: Formal Analysis, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS Abstract Background Uterine rupture (UR) remains a major cause of maternal morbidity, especially in low-resource settings. While typically detected during labor, some cases are clinically silent, discovered incidentally during imaging/surgery, highlighting a knowledge gap in risk assessment. In Tunisia, 1.5% of pregnancies involve UR, mostly scar-related. The study aim was to identify factors associated with the development of complete UR in cases that were incidentally found during pregnancy or delivery. Methods This was retrospective, longitudinal cohort study conducted over an eleven-year period, from January 2014 to December 2024, at the Gynaecology and Obstetrics department B, Charles Nicolle Hospital, Tunis, Tunisia. Asymptomatic UR cases (complete/incomplete) were analysed to compare clinical profiles, identify risk factors, and assess maternal and neonatal outcomes. Results A total of 41 cases of asymptomatic UR were included, which accounted for an average of 50% of the UR cases. In a cohort comparing complete UR cases (N=27) and incomplete UR cases (N=14), significant differences in duration of pregnancy and labor were found. The mean gestational age was longer in the incomplete UR group (p=0.03), and the duration of labor was also significantly longer (p=0.006). No significant differences were observed in sociodemographic characteristics, quality of prenatal care, or complications such as gestational diabetes or preeclampsia. Nonsignificant factors included pregnancy interval, scars number and labor stagnation. The analysis showed two significant predictors of complete UR outcomes. Prolonged labor (>220 minutes) was strongly associated with increased odds of complete UR (OR=45.231, 95% CI=2.591-789.486, p=0.009) and lower maternal weight (<68 kg) correlated with reduced odds of incomplete UR (OR=0.033, 95% CI=0.001–0.837, p=0.039), suggesting a protective effect per kilogram decrease. Conclusion Findings redefine UR as part of a broader clinical spectrum, not just an acute complication, enabling tailored surveillance and improved prevention in high-risk pregnancies. READ ALL READ LESS Keywords "Uterine rupture", "Silent uterine rupture", "Incidental diagnosis", "Scarred uterus", "Post-cesarean delivery complications", "Third-trimester obstetric emergencies". Corresponding Author(s) Narjes karmous ( [email protected] ) Close Corresponding author: Narjes karmous Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2025 karmous N et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: karmous N, Ghrab S, Masmoudi A et al. Silent Danger: Risk Factors and Outcomes of Fortuitously Discovered Uterine Rupture – A 41-Case Cohort Study [version 1; peer review: 2 approved with reservations] . F1000Research 2025, 14 :585 ( https://doi.org/10.12688/f1000research.164778.1 ) First published: 13 Jun 2025, 14 :585 ( https://doi.org/10.12688/f1000research.164778.1 ) Latest published: 28 Aug 2025, 14 :585 ( https://doi.org/10.12688/f1000research.164778.3 )  There is a newer version of this article available. Suppress this message for one day. Introduction Uterine rupture (UR) is still a significant cause of injury in the obstetrician’s field, it is particularly prevalent in low-income settings and contributes to the majority of maternal morbidity. 1 While typically detected during labor via classic symptoms, emerging evidence suggests that a subset of UR cases are likely to remain clinically silent. 2 These asymptomatic discoveries, which were made during imaging or surgery, represent a significant knowledge deficiency in the assessment of obstetric risks. 3 – 5 In Tunisia, 1.5% of pregnancies have UR, the majority of which are caused by scarred uteri. Today, the diagnostic paradigm is primarily concerned with incidental presentations, which may or may not include silent cases that predispose to future obstetric issues. 2 Notably, the clinical importance of having complete or incomplete rupture in women that are symptomatic remains poorly understood, despite the potential difference in management and outcome. This study analyzed a cohort of asymptomatic UR which includes both complete and incomplete UR, to address critical knowledge gaps regarding asymptomatic rupture. The analysis compared clinical and demographic characteristics of different UR types and identified specific risk factors for asymptomatic events. Particular attention was paid to the impact of evaluating the completeness of the UR on subsequent reproductive outcomes and to provide important data for parturient counseling and treatment. Hence, the study aim was to identify factors associated with the development of complete UR in cases that were incidentally found during pregnancy or delivery. Methods Study design and setting Retrospective, longitudinal and descriptive cohort study was conducted over an eleven-year period, from January 1, 2014, to December 31, 2024, at Gynaecology and Obstetrics department B, Charles Nicolle Hospital, Tunis, Tunisia. Study population This retrospective case series analyzed asymptomatic parturients with incidentally discovered and intraoperatively confirmed complete UR. The cohort was defined according to the following criteria: ▪ At least one previous uterine surgery (e.g., cesarean section, myomectomy); ▪ Incidental diagnosis of UR in a non-urgent clinical setting (e.g., routine antenatal imaging, elective cesarean section for other reasons, or non-urgent surgery); ▪ And complete clinical records, including surgical records, were available. Symptomatic cases or UR discovered during labor or in an emergency setting were excluded to isolate the unique clinical features of asymptomatic, incidentally discovered ruptures. Variables Data were retrospectively extracted from electronic medical records and focused on four domains: ▪ Maternal characteristics: Age, sociodemographic status, medical and surgical history, obstetric history … ▪ Characteristics of the pregnancy in question: Prenatal follow-up, delivery history … ▪ UR characteristics: Gestational age at diagnosis, clinical settings, anatomical type, surgical treatment … ▪ Maternal and neonatal outcomes: Maternal blood transfusion, intensive care unit (ICU) admission, neonatal status (Apgar score, birth weight, neonatal ICU admission …) … Statistical analysis Data were entered and analysed with SPSS software (version 26.0, IBM Corp). Microsoft Office Excel was used to create the tables and graphs ( https://www.office.com/?omkt=fr-FR ). For the primary analysis, we focused on the asymptomatic (randomized) group and compared cases of complete and incomplete UR. Bivariate comparisons were performed using the chi-square test or Fisher’s exact test for categorical variables and Student’s t test or Mann-Whitney U test for continuous variables. Multivariate logistic regression models were then constructed to identify independent predictors of complete UR in incidentally diagnosed cases. Variables with a p value ≤ 0.20 in the univariate analysis were included in the model. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were reported. A p value ≤ 0.05 was considered statistically significant. 6 , 7 Ethical considerations The study protocol was approved on 13 February 2025 by the institutional ethics committee of Charles Nicolle Hospital, Tunis, Tunisia before conducting the study with approval number FWA 00032748- IORG0011243. As this was a retrospective study using anonymized data, informed consent was waived. Results During the study period, a total of 41 cases of asymptomatic UR were included. From 2014 to 2024 ( Table 1 and Figure 1 ), the maternity unit experienced a significant decrease in annual births, falling from 3939 to just 1964. UR cases peaked at 16 in 2017 but decreased afterward, with only one case reported in 2024. Cesarean deliveries reached their highest point in 2018 at 2033 but declined steadily to 1166 by 2024. In contrast, the number of vaginal deliveries remained relatively stable from 2019 onward, varying between 798 and 1043 each year. Asymptomatic UR accounted for an average of 50% of the UR cases over the eleven-year study period. It exhibited a fluctuating pattern, with the highest occurrence in 2017 (14 cases (88%). Table 1. Annual distribution of asymptomatic uterine ruptures (UR), total of UR, and total births (2014–2024). Year Asymptomatic UR (N = 41) Total UR (N = 69) Cesarean deliveries (N = 15266) Vaginal deliveries (N = 14600) Total births (N = 29866) Prevalence of Asymptomatic UR Incidence of UR Incidence of asymptomatic UR 2014 8 15 1547 2392 3939 53% 0,38% 0,20% 2015 8 13 1628 2582 4210 62% 0,31% 0,19% 2016 4 7 1289 2003 3292 57% 0,21% 0,12% 2017 14 16 1158 1390 2548 88% 0,63% 0,55% 2018 1 2 2033 654 2687 50% 0,07% 0,04% 2019 1 3 1340 892 2232 33% 0,13% 0,04% 2020 1 2 1215 870 2085 50% 0,10% 0,05% 2021 3 6 1223 1006 2229 50% 0,27% 0,13% 2022 0 3 1411 1043 2454 0% 0,12% 0% 2023 0 0 1256 970 2226 0% 0% 0% 2024 1 2 1166 798 1964 50% 0,10% 0,05% Figure 1. Trends in asymptomatic Uterine Rupture (UR) prevalence (2014-2024): proportion of asymptomatic cases among total UR at Charles Nicolle Hospital. The average age was 33.29 ± 4.9 years (24-44 years). Among the 41 parturients, 51% were classified as having an average socioeconomic status, followed by 32% with a high status, and 17% with a low status. In terms of educational attainment, 49% had completed secondary education, 32% held a university-level degree, and 19% had attained only primary education. Table 2 presents descriptive statistics for various variables related to the study population including weight, height, gravidity, parity, term, interpregnancy interval, and duration of labor. Table 2. Descriptive statistics of parturients demographics and labor parameters. Variable Median Minimum 25 th percentile (Q1) 75 th percentile (Q3) Maximum Weight (kg) 72 61 69 75 80 Height (m) 1.61 1.53 1.57 1.66 1.73 Gravidity 3 1 2 4 5 Parity 3 2 2 3.5 6 Term (weeks) 39 22 37 39 41 Interpregnancy Interval (months) 24 6 12 48 72 Duration of Labor (min) 170 60 63.75 300 600 Thirty-six (88%) of the parturients arrived in active labor. Clinically, seven parturients (17%) developed hypertension during pregnancy, and four parturients (10%) were diagnosed with gestational diabetes Labor stagnation occurred in 7 individuals (17%). Regarding the time of UR diagnosis, 40 parturients (98%) were diagnosed after delivery, whilst 1 parturient (2%) was diagnosed during labor. Table 3 presents UR type (complete or incomplete), maternal and neonatal outcomes. Table 3. Uterine Rupture (UR) type, maternal and neonatal outcomes. Variable Statistics Complete UR N (%) 27 (66%) Incomplete UR N (%) 14 (34%) Transfusion N (%) 7 (17%) Urological Injury N (%) 1 (2%) Duration of Hospitalization (days) median [IQR] 3 [2-7] APGAR Score at 5 Minutes median [IQR] 10 [6-10] Birth Weight (PFN) median [IQR] 3460 [1150-4050] Neonatal Hospitalization N (%) 1 (2%) Neonatal Death N (%) 0 In a cohort comparing complete UR cases (N = 27) and incomplete UR cases (N = 14) ( Table 4 ), significant differences in duration of pregnancy and labor were found. The mean gestational age was longer in the incomplete UR group (38.86 weeks vs. 36.85 weeks, p = 0.03), and the duration of labor was also significantly longer (305.45 minutes vs. 142.94 minutes, p = 0.006). Trends showed that the parity and the proportion of parturients with multiple scars was higher in the complete UR group (3.22 vs. 2.50, p = 0.071 and 82% vs. 18%, p = 0.092 respectively). No significant differences were observed in demographic characteristics (age, weight, BMI), socioeconomic status or education level, quality of prenatal care, or complications such as gestational diabetes or preeclampsia. Preeclampsia occurred only in the incomplete UR group (14% vs. 0%, p = 0.111). Nonsignificant factors included pregnancy interval, number of scars and labor stagnation. Table 4. Univariate analysis comparing complete Uterine Ruptures (UR) cases and incomplete UR cases. Characteristics Complete UR (N = 27) Incomplete UR (N = 14) P Age (Mean ± SD) 33 ± 5 34 ± 6 0,634 Weight (kg) 72 ± 3 70 ± 5 0,115 Height (m) 1.62 ± 0.06 1.60 ± 0.04 0,246 Body mass index 27.51 ± 1.59 27.17 ± 1.20 0,422 Gravidity 3.30 ± 1.17 3.07 ± 1.21 0,523 Parity 3.22 ± 1.37 2.50 ± 0.94 0,071 Gestational age (weeks) 36.85 ± 3.98 38.86 ± 1.70 0,03 Scar number 1.52 ± 0.75 1.36 ± 0.74 0,333 One scar 13 (54%) 11 (46%) 0,092 More than one scar 14 (82%) 3 (18%) Socioeconomic status 0,922 - Poor 4 (15%) 3 (21%) - Average 14 (52%) 7 (50%) - Good 9 (33%) 4 (29%) Education Level 0,744 - Primary 5 (19%) 3 (21%) - Secondary 13 (48%) 7 (50%) - University 9 (33%) 4 (29%) Prenatal Follow-up 0,901 - Poor 2 (7%) 1 (7%) - Average 11 (41%) 6 (43%) - Good 14 (52%) 7 (50%) Gestational Diabetes 2 (50%) 2 (50%) 1 Pre-eclampsia 0 (0%) 2 (14%) 0,111 Stagnation of Dilation 5 (19%) 2 (14%) 0,385 Moment of Discovery 1 - During Labor 1 (4%) 0 (0%) - After Delivery 26 (96%) 14 (100%) Interval (months) 30.92 ± 17.26 28.71 ± 20.87 0,592 Duration of Labor (min) 142.94 ± 111.78 305.45 ± 150.76 0,006 The analysis identified two significant predictors of complete UR outcomes ( Table 5 ): Prolonged labor (>220 minutes) was strongly associated with increased odds of complete UR (OR = 45.231, 95% CI = 2.591-789.486, p = 0.009), indicating a 45-fold higher risk compared to shorter labor durations and lower maternal weight (<68 kg) correlated with reduced odds of incomplete UR (OR = 0.033, 95% CI = 0.001–0.837, p = 0.039), suggesting a protective effect per kilogram decrease. Table 5. Multivariate analysis for identification of predictors of complete Uterine Rupture (UR) outcomes. p OR Confidence interval Low High Parity 0,132 0,318 0,072 1,413 Number of scar 0,113 10,343 0,574 186,467 Prolonged labor (>220 minutes) 0,009 45,231 2,591 789,486 Weight <68 kg 0,039 0,033 0,001 0,837 Discussion Between 2014 and 2024, the number of deliveries per year at the institution decreased by 53% (from 3939 to 1964), and the number of cesarean sections decreased by 43% (from a peak of 2033 in 2018 to 1166 in 2024). These trends likely reflect changes in medical practices and demographic factors over the decade. The high proportion of asymptomatic UR (median 50% of cases) highlights the limitations of symptom-based diagnosis, especially in years with increasing prevalence (up to 88%). At the same time, the number of UR cases decreased from 16 in 2017 to 1 in 2024. This is consistent with the literature linking prior cesarean sections to the risk of UR. 8 , 9 This suggests that the decline in surgical births and improvements in surgical techniques may have led to the reduction in UR. Of note, there was also a decrease in asymptomatic cases of UR after 2018 (from 14 in 2017 to 1-3 per year), which may be due to advances in prenatal imaging, as described by Giampaolino et al. 10 However, 98% of UR cases in this cohort were diagnosed after delivery, which contradicts studies advocating prenatal MRI/ultrasound for early detection, indicating a major gap in prenatal surveillance. 11 , 12 This cohort showed no demographic (age, body mass index, socioeconomic status) or obstetric (quality of antenatal care, gestational diabetes) associations with UR outcomes. However, two new predictors emerged: Prolonged labor: Labor longer than 220 minutes increased the odds of complete UR by 45 times (OR=45.231, p=0.009), which is consistent with Savukyne et al., 9 who identified prolonged labor as a major risk factor. Lower maternal weight: Weight less than 68 kg decreased the odds of incomplete UR (OR=0.033/kg, p=0.039), a finding that contradicts the literature that frequently links obesity to obstetric risk. This warrants further investigation of biomechanical or metabolic protective mechanisms. Gestational age (38.86 weeks vs. 36.85 weeks, p=0.03) and delivery time (306 minutes vs. 143 minutes, p=0.006) were also longer in incomplete UR cases, suggesting that sustained uterine pressure may have led to partial UR. Despite advances in imaging technology, 98% of UR cases were diagnosed after birth. This highlights the underutilization of prenatal MRI and ultrasound, an important tool for detecting scar dehiscence or placenta accreta. 13 , 14 Although the treatment of UR has not been described in detail, the dramatic decline in cases may be due to improved surgical interventions 14 or conservative strategies for asymptomatic cases. 10 Study strengths and limitations This study’s analysis of UR trends over a decade (2014–2024) offers significant contributions to the literature, particularly through its identification of novel risk factors- prolonged labor (>220 minutes) and lower maternal weight- and its demonstration of a 94% decline in UR cases coinciding with reduced cesarean delivery rates, reflecting broader improvements in obstetric practices. The cohort of 41 UR cases, larger than most prior studies, 8 enabled robust comparisons between complete and incomplete UR types, revealing key differences in gestational age and labor duration. However, the retrospective, single-center design introduces limitations, including potential selection bias and underpowered subgroup analyses (e.g., preeclampsia rates), while the near-exclusive reliance on post-delivery diagnosis (98% of cases) contrasts sharply with literature advocating prenatal MRI/ultrasound for early detection of scar dehiscence or placental anomalies. 11 , 12 Recommendations The findings advance UR risk stratification by expanding beyond traditional predictors (prior uterine surgery) and highlight the need for prospective, multicenter studies to validate novel associations while integrating advanced imaging and standardized management protocols to bridge diagnostic and care disparities observed across institutions. Conclusions Our findings redefine UR as part of the clinical picture rather than simply an acute complication of obstetrics. This paradigm shift enables customized surveillance of the scarred uterus and improves detection and prevention capabilities in high-risk obstetrics. Ethical considerations We confirm that we have read the Journal’s position on issues involved in ethical publication and affirm that this report is consistent with those guidelines. The study protocol was approved on 13 February 2025 by the institutional ethics committee of Charles Nicolle Hospital, Tunis, Tunisia before conducting the study (approval number: FWA 00032748- IORG0011243). Consent to participate As this was a retrospective study using anonymized data, informed consent was waived. Data availability statement All data sets can be assessed and all study findings reported in the article are shared via Harvard Dataverse: “Silent Danger: Risk Factors and Outcomes of Fortuitously Discovered Uterine Rupture – A 41-Case Cohort Study”, https://doi.org/10.7910/DVN/D9OO16 . 15 This project contains the following: • Dataset silent UR- English • Study findings silent UR Extended data Harvard Dataverse: “Silent Danger: Risk Factors and Outcomes of Fortuitously Discovered Uterine Rupture – A 41-Case Cohort Study”, https://doi.org/10.7910/DVN/D9OO16 . 15 This project contains the following: Questionnaire (in English) Reporting guidelines This work has been reported in line with the STROBE guidelines. 16 Harvard Dataverse: “Silent Danger: Risk Factors and Outcomes of Fortuitously Discovered Uterine Rupture – A 41-Case Cohort Study”, https://doi.org/10.7910/DVN/D9OO16 . 15 This project contains the following: STROBE Checklist Data are available under the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication). References 1. Ahmed DM, Mengistu TS, Endalamaw AG: Incidence and factors associated with outcomes of uterine rupture among women delivered at Felegehiwot referral hospital, Bahir Dar, Ethiopia: cross sectional study. BMC Pregnancy Childbirth. 2018 Nov 16; 18 : 447. PubMed Abstract | Publisher Full Text | Free Full Text 2. Zine S, Abed A, Sfar E, et al. : Uterine rupture during labor. Report of 106 cases at the Maternity Center of Tunis (Tunisia). Rev. Fr. Gynecol. Obstet. 1995 Mar; 90 (3): 166, 169–173. PubMed Abstract 3. Yang H, Zhao Y, Tu J, et al. : Clinical analysis of incomplete rupture of the uterus secondary to previous cesarean section. Open Med (Wars). 2024 Apr 1; 19 (1): 20240927. PubMed Abstract | Publisher Full Text | Free Full Text 4. Guiliano M, Closset E, Therby D, et al. : Signs, symptoms and complications of complete and partial uterine ruptures during pregnancy and delivery. Eur. J. Obstet. Gynecol. Reprod. Biol. 2014 Aug; 179 : 130–134. PubMed Abstract | Publisher Full Text 5. Ahmadi F, Siahbazi S, Akhbari F: Incomplete Cesarean Scar Rupture. J. Reprod. Infertil. 2013; 14 (1): 43–45. PubMed Abstract 6. Rybak A, Levy C, Ouldali N, et al. : Dynamics of Antibiotic Resistance of Streptococcus pneumoniae in France: A Pediatric Prospective Nasopharyngeal Carriage Study from 2001 to 2022. Antibiotics. 2023 Jun; 12 (6): 1020. PubMed Abstract | Publisher Full Text | Free Full Text 7. Hasan MM, Kamruzzaman M, Anik KS, et al. : Dengue Encephalopathy, its Presentations and Outcome, A Study on 200 Dengue Encephalopathy Patients in Tertiary Level Hospitals in Bangladesh. Sch. J. App. Med. Sci. 2024 Nov 11; 12 (11): 1550–1557. Publisher Full Text 8. Xiao J, Zhang C, Zhang Y, et al. : Ultrasonic manifestations and clinical analysis of 25 uterine rupture cases. J. Obstet. Gynaecol. Res. 2021 Apr; 47 (4): 1397–1408. PubMed Abstract | Publisher Full Text 9. Savukyne E, Bykovaite-Stankeviciene R, Machtejeviene E, et al. : Symptomatic Uterine Rupture: A Fifteen Year Review. Medicina (Kaunas). 2020 Oct 29; 56 (11): 574. PubMed Abstract | Publisher Full Text | Free Full Text 10. Giampaolino P, De Rosa N, Morra I, et al. : Management of Cesarean Scar Pregnancy: A Single-Institution Retrospective Review. Biomed. Res. Int. 2018; 2018 (1): 6486407. 11. Zermano S, Seminara G, Parisi N, et al. : Prenatal Detection and Conservative Management of Uterine Scar Dehiscence in Patient with Previous Uterine Rupture and Multiple Surgeries-A Case Report. Healthcare (Basel). 2024 May 10; 12 (10): 988. PubMed Abstract | Publisher Full Text | Free Full Text 12. Hoffman MK, Grant GH: Induction of labor in women with a prior cesarean delivery. Semin. Perinatol. 2015 Oct 1; 39 (6): 471–474. Publisher Full Text 13. Li XF, Wu J, Zhou Y, et al. : Clinical analysis of 12 cases of spontaneous uterine rupture caused by placenta percreta. Zhonghua Fu Chan Ke Za Zhi. 2020 Oct 25; 55 (10): 691–696. PubMed Abstract | Publisher Full Text 14. Setubal A, Alves J, Osório F, et al. : Treatment for Uterine Isthmocele, A Pouchlike Defect at the Site of a Cesarean Section Scar. J. Minim. Invasive Gynecol. 2018 Jan; 25 (1): 38–46. PubMed Abstract | Publisher Full Text 15. Karmous N, Ghrab S, Masmoudi A, et al. : Silent danger: risk factors and outcomes of fortuitously discovered uterine rupture – a 41-case cohort study. [Dataset]. Harvard Dataverse. 2025. 16. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J. Clin. Epidemiol. 2008 Apr; 61 (4): 344–349. Publisher Full Text Comments on this article Comments (0) Version 3 VERSION 3 PUBLISHED 13 Jun 2025 ADD YOUR COMMENT Comment Author details Author details 1 University of Tunis El Manar Faculty of Medicine of Tunis, Tunis, Tunisia 2 Department B of Obstetrics and Gynecology, Charles Nicolle Hospital, Tinis, Tunisia 3 General surgery department B, Charles Nicolle Hospital, Tunis, Tunisia 4 Psychiatry Department, Razi Hospital, Manouba, Tunisia Narjes karmous Roles: Conceptualization, Methodology, Writing – Original Draft Preparation Siwar Ghrab Roles: Data Curation, Visualization Abdelwahab Masmoudi Roles: Writing – Review & Editing Badreddine Bouguerra Roles: Supervision, Validation Aymen Mabrouk Roles: Writing – Review & Editing Anis ben Dhaou Roles: Writing – Review & Editing Abdennour Karmous Roles: Formal Analysis, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (3) version 3 Revised Published: 28 Aug 2025, 14:585 https://doi.org/10.12688/f1000research.164778.3 version 2 Revised Published: 08 Aug 2025, 14:585 https://doi.org/10.12688/f1000research.164778.2 version 1 Published: 13 Jun 2025, 14:585 https://doi.org/10.12688/f1000research.164778.1 Copyright © 2025 karmous N et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article karmous N, Ghrab S, Masmoudi A et al. Silent Danger: Risk Factors and Outcomes of Fortuitously Discovered Uterine Rupture – A 41-Case Cohort Study [version 1; peer review: 2 approved with reservations] . F1000Research 2025, 14 :585 ( https://doi.org/10.12688/f1000research.164778.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 13 Jun 2025 Views 0 Cite How to cite this report: Adebisi MO. Reviewer Report For: Silent Danger: Risk Factors and Outcomes of Fortuitously Discovered Uterine Rupture – A 41-Case Cohort Study [version 1; peer review: 2 approved with reservations] . F1000Research 2025, 14 :585 ( https://doi.org/10.5256/f1000research.181350.r392395 ) The direct URL for this report is: https://f1000research.com/articles/14-585/v1#referee-response-392395 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 30 Jun 2025 Mathew Olumide Adebisi , Afe Babalola University, Ado-Ekiti, Ekiti, Nigeria; Obstetrics and Gynaecology, Federal Teaching Hospital Ido-Ekiti (Ringgold ID: 605037), Ido Ekiti, Ekiti, Nigeria Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.181350.r392395 GENERAL COMMENTS The manuscript delved into an important obstetric mishap that is a major contributor to maternal morbidity and mortality especially in developing nations. However, manuscript needs major revisions especially in the areas of literature review on the ... Continue reading READ ALL GENERAL COMMENTS The manuscript delved into an important obstetric mishap that is a major contributor to maternal morbidity and mortality especially in developing nations. However, manuscript needs major revisions especially in the areas of literature review on the existing knowledge and knowledge gap, methodology, result presentation, discussion and conclusion. SPECIFIC COMMENTS ON SECTIONS Title: Nothing remarkable and it is well written. Abstract: “The aim is to identify factors associated with complete uterine rupture (UR)”. In your methodology, asymptomatic UR cases (complete/incomplete) were analyzed. This should be harmonized to make the methodology reproducible and thoroughly understood by the readers. Result (in the abstract section): ……. protective effect per kilogram decrease? This statement should be clearly mentioned. For example, …. protective effect per kilogram maternal body weight. Main text: Introduction: This is grossly inadequate. Are there no studies on the topic of silent uterine rupture either scarred or unscarred from developing countries? Are there no studies on how asymptomatic UR cases are being recognized either by imaging or at surgery? Suggested citations: Ebeigbe PN et.al. (2005) - Ref. 1 Kadowa I. (2010) - Ref. 2 Fofie C and Baffoe P (2011) - Ref. 3 There are still many more that can be cited to add to the literature review. Methodology: Is this study only on complete uterine rupture? Your stated in the methodology that “asymptomatic uterine rupture cases (complete/incomplete) were analyzed to compare clinical profiles, identify risk factors and assess maternal and neonatal outcomes. Also, result section revealed comparison of complete UR versus incomplete UR. You also stated that symptomatic cases and those in labour or other emergency settings were excluded from the study. However, some of the tables (2 and 4) in the result section show duration of labour as variable. I suggest that the different sections of the manuscript should be harmonized. Statistical analysis: Is this study a randomized study? Results: Parturient refers to a woman in labour and those in labour were said to be excluded. Other terms or phrases could be used to describe the 41 cases. For example; Among the 41 women with asymptomatic uterine rupture….. Tables 2 and 4- Harmonized the Methodology and the variables. Discussion: Quoting your statement from this section- “This cohort showed no demographic (Age, body mass index, socioeconomic status) or obstetric (quality of antenatal care, gestational diabetes) association with uterine rupture outcomes. However, it was reported that two “new predictors” emerged; namely (1) prolonged labour, leading to uterine rupture is a reflection of the type of obstetric care received (2) lower maternal weight. “Gestational age and delivery time were also noted to be longer in the incomplete uterine rupture cases”. These are also obstetric /labour factors. I therefore suggest that the exclusion criteria (and by extension, the methodology) and result presentation should be revised. Conclusion: The study reported that two new predictors emerged which is a strong point in this study. However, authors concluded on factor which the study did not reveal. The conclusion should be revised. References: some references have been suggested. If the literature review (introduction section) is revised as recommended, definitely 2 or more citations will be added to the reference. Is the work clearly and accurately presented and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? No If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? Partly Are the conclusions drawn adequately supported by the results? No References 1. Ebeigbe P, Enabudoso E, Ande A: Ruptured uterus in a Nigerian community: a study of sociodemographic and obstetric risk factors. Acta Obstetricia et Gynecologica Scandinavica . 2005; 84 (12): 1172-1174 Publisher Full Text 2. I, Kadowa: Ruptured uterus in rural Uganda: prevalence, predisposing factors and outcomes dust. https://pubmed.ncbi.nlm.nih.gov/20200773/ . 2010. 3. Fofie C, Baffoe P: A two-year review of uterine rupture in a regional hospital. Ghana Medical Journal . 2011; 44 (3). Publisher Full Text 4. Karmous, Narjes: Silent Danger: Risk Factors and Outcomes of Fortuitously Discovered Uterine Rupture - ; A 41-Case Cohort Study. https://dataverse.harvard.edu/dataset.xhtml?persistentId . 2025. Publisher Full Text Competing Interests: No competing interests were disclosed. Reviewer Expertise: Obstetrics and Gynaecology I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Adebisi MO. Reviewer Report For: Silent Danger: Risk Factors and Outcomes of Fortuitously Discovered Uterine Rupture – A 41-Case Cohort Study [version 1; peer review: 2 approved with reservations] . F1000Research 2025, 14 :585 ( https://doi.org/10.5256/f1000research.181350.r392395 ) The direct URL for this report is: https://f1000research.com/articles/14-585/v1#referee-response-392395 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 23 Aug 2025 Narjes karmous , Department B of Obstetrics and Gynecology, Charles Nicolle Hospital, Tinis, Tunisia 23 Aug 2025 Author Response Dear Mathew Olumide Adebisi, We sincerely appreciate your constructive feedback. Your insightful comments have helped us refine and enhance the quality of our manuscript. Reviewer comment: Abstract: Harmonize the ... Continue reading Dear Mathew Olumide Adebisi, We sincerely appreciate your constructive feedback. Your insightful comments have helped us refine and enhance the quality of our manuscript. Reviewer comment: Abstract: Harmonize the aim and methodology regarding complete/incomplete UR. Author response: The Abstract has been revised to clearly state that both complete and incomplete forms of asymptomatic uterine rupture were included and analyzed in the study, ensuring coherence with the Methods and Results sections. Reviewer comment: Result (Abstract): Clarify “protective effect per kilogram decrease”. Author response: We revised the phrasing in the Abstract to “a protective effect per kilogram of maternal body weight” for clarity and statistical accuracy. Reviewer comment: Introduction is grossly inadequate. Literature on silent uterine rupture in developing countries should be reviewed. Suggested citations: Ref. 1–3. Author response: The Introduction has been substantially expanded and now includes data from studies conducted in Nigeria, Uganda, and Ghana, as suggested (references [7]–[9]). These studies help contextualize our findings within a broader regional framework of silent uterine rupture and its risk factors. Reviewer comment: Methodology unclear: Complete vs incomplete UR? Harmonize with Results. Author response: This issue has been addressed. We now explicitly state in the Methods that both complete and incomplete asymptomatic uterine ruptures were included in the study and compared across multiple variables. Terminology and consistency have been corrected throughout. Reviewer comment: Tables 2 and 4 mention labor variables, yet laboring women were excluded. Author response: We clarified that “asymptomatic” in our study refers to the absence of clinical signs of rupture (pain, bleeding, fetal distress), but not necessarily the absence of labor. Some patients had labor activity before cesarean delivery, which justifies the inclusion of labor variables. This is now clearly stated in the 'Study Population' and 'Discussion' sections. Reviewer comment: Is this a randomized study? Author response: No. We confirm this is a retrospective observational cohort study. This has been clearly stated in the revised Methodology section. Reviewer comment: Replace “parturient” with more appropriate term for asymptomatic cases. Author response: We have replaced the term “parturient” with “women with asymptomatic uterine rupture” or more specific language throughout the manuscript for precision and accuracy. Reviewer comment: Discussion contradicts exclusion criteria: Prolonged labor and gestational age as predictors? Author response: This has been clarified. Although these women had no rupture symptoms, many experienced labor prior to cesarean. This distinction has been made clear in the revised Discussion and Methods sections. Reviewer comment: Conclusion not supported by results. Revise accordingly. Author response: We have revised the Conclusion to focus strictly on statistically supported findings: prolonged labor and maternal weight <68 kg as independent predictors of complete rupture. Speculative elements were removed. Reviewer comment: References: more literature needed if Introduction is revised. Author response: We have included all the suggested references and added several recent publications to strengthen the Introduction and Discussion. Reviewer comment: Are sufficient details of methods and analysis provided to allow replication by others? → No Author response: The Methods section has been substantially revised to improve clarity and reproducibility. It now includes more precise definitions of study population, variables, criteria, and analysis thresholds. Reviewer comment: Are the conclusions drawn adequately supported by the results? → No Author response: The conclusions have been adjusted to align fully with the results. We now only report findings that were statistically demonstrated and explicitly acknowledge study limitations. Sincerely, Narjes Karmous Dear Mathew Olumide Adebisi, We sincerely appreciate your constructive feedback. Your insightful comments have helped us refine and enhance the quality of our manuscript. Reviewer comment: Abstract: Harmonize the aim and methodology regarding complete/incomplete UR. Author response: The Abstract has been revised to clearly state that both complete and incomplete forms of asymptomatic uterine rupture were included and analyzed in the study, ensuring coherence with the Methods and Results sections. Reviewer comment: Result (Abstract): Clarify “protective effect per kilogram decrease”. Author response: We revised the phrasing in the Abstract to “a protective effect per kilogram of maternal body weight” for clarity and statistical accuracy. Reviewer comment: Introduction is grossly inadequate. Literature on silent uterine rupture in developing countries should be reviewed. Suggested citations: Ref. 1–3. Author response: The Introduction has been substantially expanded and now includes data from studies conducted in Nigeria, Uganda, and Ghana, as suggested (references [7]–[9]). These studies help contextualize our findings within a broader regional framework of silent uterine rupture and its risk factors. Reviewer comment: Methodology unclear: Complete vs incomplete UR? Harmonize with Results. Author response: This issue has been addressed. We now explicitly state in the Methods that both complete and incomplete asymptomatic uterine ruptures were included in the study and compared across multiple variables. Terminology and consistency have been corrected throughout. Reviewer comment: Tables 2 and 4 mention labor variables, yet laboring women were excluded. Author response: We clarified that “asymptomatic” in our study refers to the absence of clinical signs of rupture (pain, bleeding, fetal distress), but not necessarily the absence of labor. Some patients had labor activity before cesarean delivery, which justifies the inclusion of labor variables. This is now clearly stated in the 'Study Population' and 'Discussion' sections. Reviewer comment: Is this a randomized study? Author response: No. We confirm this is a retrospective observational cohort study. This has been clearly stated in the revised Methodology section. Reviewer comment: Replace “parturient” with more appropriate term for asymptomatic cases. Author response: We have replaced the term “parturient” with “women with asymptomatic uterine rupture” or more specific language throughout the manuscript for precision and accuracy. Reviewer comment: Discussion contradicts exclusion criteria: Prolonged labor and gestational age as predictors? Author response: This has been clarified. Although these women had no rupture symptoms, many experienced labor prior to cesarean. This distinction has been made clear in the revised Discussion and Methods sections. Reviewer comment: Conclusion not supported by results. Revise accordingly. Author response: We have revised the Conclusion to focus strictly on statistically supported findings: prolonged labor and maternal weight <68 kg as independent predictors of complete rupture. Speculative elements were removed. Reviewer comment: References: more literature needed if Introduction is revised. Author response: We have included all the suggested references and added several recent publications to strengthen the Introduction and Discussion. Reviewer comment: Are sufficient details of methods and analysis provided to allow replication by others? → No Author response: The Methods section has been substantially revised to improve clarity and reproducibility. It now includes more precise definitions of study population, variables, criteria, and analysis thresholds. Reviewer comment: Are the conclusions drawn adequately supported by the results? → No Author response: The conclusions have been adjusted to align fully with the results. We now only report findings that were statistically demonstrated and explicitly acknowledge study limitations. Sincerely, Narjes Karmous Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 23 Aug 2025 Narjes karmous , Department B of Obstetrics and Gynecology, Charles Nicolle Hospital, Tinis, Tunisia 23 Aug 2025 Author Response Dear Mathew Olumide Adebisi, We sincerely appreciate your constructive feedback. Your insightful comments have helped us refine and enhance the quality of our manuscript. Reviewer comment: Abstract: Harmonize the ... Continue reading Dear Mathew Olumide Adebisi, We sincerely appreciate your constructive feedback. Your insightful comments have helped us refine and enhance the quality of our manuscript. Reviewer comment: Abstract: Harmonize the aim and methodology regarding complete/incomplete UR. Author response: The Abstract has been revised to clearly state that both complete and incomplete forms of asymptomatic uterine rupture were included and analyzed in the study, ensuring coherence with the Methods and Results sections. Reviewer comment: Result (Abstract): Clarify “protective effect per kilogram decrease”. Author response: We revised the phrasing in the Abstract to “a protective effect per kilogram of maternal body weight” for clarity and statistical accuracy. Reviewer comment: Introduction is grossly inadequate. Literature on silent uterine rupture in developing countries should be reviewed. Suggested citations: Ref. 1–3. Author response: The Introduction has been substantially expanded and now includes data from studies conducted in Nigeria, Uganda, and Ghana, as suggested (references [7]–[9]). These studies help contextualize our findings within a broader regional framework of silent uterine rupture and its risk factors. Reviewer comment: Methodology unclear: Complete vs incomplete UR? Harmonize with Results. Author response: This issue has been addressed. We now explicitly state in the Methods that both complete and incomplete asymptomatic uterine ruptures were included in the study and compared across multiple variables. Terminology and consistency have been corrected throughout. Reviewer comment: Tables 2 and 4 mention labor variables, yet laboring women were excluded. Author response: We clarified that “asymptomatic” in our study refers to the absence of clinical signs of rupture (pain, bleeding, fetal distress), but not necessarily the absence of labor. Some patients had labor activity before cesarean delivery, which justifies the inclusion of labor variables. This is now clearly stated in the 'Study Population' and 'Discussion' sections. Reviewer comment: Is this a randomized study? Author response: No. We confirm this is a retrospective observational cohort study. This has been clearly stated in the revised Methodology section. Reviewer comment: Replace “parturient” with more appropriate term for asymptomatic cases. Author response: We have replaced the term “parturient” with “women with asymptomatic uterine rupture” or more specific language throughout the manuscript for precision and accuracy. Reviewer comment: Discussion contradicts exclusion criteria: Prolonged labor and gestational age as predictors? Author response: This has been clarified. Although these women had no rupture symptoms, many experienced labor prior to cesarean. This distinction has been made clear in the revised Discussion and Methods sections. Reviewer comment: Conclusion not supported by results. Revise accordingly. Author response: We have revised the Conclusion to focus strictly on statistically supported findings: prolonged labor and maternal weight <68 kg as independent predictors of complete rupture. Speculative elements were removed. Reviewer comment: References: more literature needed if Introduction is revised. Author response: We have included all the suggested references and added several recent publications to strengthen the Introduction and Discussion. Reviewer comment: Are sufficient details of methods and analysis provided to allow replication by others? → No Author response: The Methods section has been substantially revised to improve clarity and reproducibility. It now includes more precise definitions of study population, variables, criteria, and analysis thresholds. Reviewer comment: Are the conclusions drawn adequately supported by the results? → No Author response: The conclusions have been adjusted to align fully with the results. We now only report findings that were statistically demonstrated and explicitly acknowledge study limitations. Sincerely, Narjes Karmous Dear Mathew Olumide Adebisi, We sincerely appreciate your constructive feedback. Your insightful comments have helped us refine and enhance the quality of our manuscript. Reviewer comment: Abstract: Harmonize the aim and methodology regarding complete/incomplete UR. Author response: The Abstract has been revised to clearly state that both complete and incomplete forms of asymptomatic uterine rupture were included and analyzed in the study, ensuring coherence with the Methods and Results sections. Reviewer comment: Result (Abstract): Clarify “protective effect per kilogram decrease”. Author response: We revised the phrasing in the Abstract to “a protective effect per kilogram of maternal body weight” for clarity and statistical accuracy. Reviewer comment: Introduction is grossly inadequate. Literature on silent uterine rupture in developing countries should be reviewed. Suggested citations: Ref. 1–3. Author response: The Introduction has been substantially expanded and now includes data from studies conducted in Nigeria, Uganda, and Ghana, as suggested (references [7]–[9]). These studies help contextualize our findings within a broader regional framework of silent uterine rupture and its risk factors. Reviewer comment: Methodology unclear: Complete vs incomplete UR? Harmonize with Results. Author response: This issue has been addressed. We now explicitly state in the Methods that both complete and incomplete asymptomatic uterine ruptures were included in the study and compared across multiple variables. Terminology and consistency have been corrected throughout. Reviewer comment: Tables 2 and 4 mention labor variables, yet laboring women were excluded. Author response: We clarified that “asymptomatic” in our study refers to the absence of clinical signs of rupture (pain, bleeding, fetal distress), but not necessarily the absence of labor. Some patients had labor activity before cesarean delivery, which justifies the inclusion of labor variables. This is now clearly stated in the 'Study Population' and 'Discussion' sections. Reviewer comment: Is this a randomized study? Author response: No. We confirm this is a retrospective observational cohort study. This has been clearly stated in the revised Methodology section. Reviewer comment: Replace “parturient” with more appropriate term for asymptomatic cases. Author response: We have replaced the term “parturient” with “women with asymptomatic uterine rupture” or more specific language throughout the manuscript for precision and accuracy. Reviewer comment: Discussion contradicts exclusion criteria: Prolonged labor and gestational age as predictors? Author response: This has been clarified. Although these women had no rupture symptoms, many experienced labor prior to cesarean. This distinction has been made clear in the revised Discussion and Methods sections. Reviewer comment: Conclusion not supported by results. Revise accordingly. Author response: We have revised the Conclusion to focus strictly on statistically supported findings: prolonged labor and maternal weight <68 kg as independent predictors of complete rupture. Speculative elements were removed. Reviewer comment: References: more literature needed if Introduction is revised. Author response: We have included all the suggested references and added several recent publications to strengthen the Introduction and Discussion. Reviewer comment: Are sufficient details of methods and analysis provided to allow replication by others? → No Author response: The Methods section has been substantially revised to improve clarity and reproducibility. It now includes more precise definitions of study population, variables, criteria, and analysis thresholds. Reviewer comment: Are the conclusions drawn adequately supported by the results? → No Author response: The conclusions have been adjusted to align fully with the results. We now only report findings that were statistically demonstrated and explicitly acknowledge study limitations. Sincerely, Narjes Karmous Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Nguyen PN. Reviewer Report For: Silent Danger: Risk Factors and Outcomes of Fortuitously Discovered Uterine Rupture – A 41-Case Cohort Study [version 1; peer review: 2 approved with reservations] . F1000Research 2025, 14 :585 ( https://doi.org/10.5256/f1000research.181350.r392398 ) The direct URL for this report is: https://f1000research.com/articles/14-585/v1#referee-response-392398 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 25 Jun 2025 Phuc Nhon Nguyen , Tu Du Hospital, Ho Chi Minh City, Vietnam Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.181350.r392398 Thank you for paper. I have some comments: In introduction, the study should mention some etiologies of uterine rupture, even in rare cases of placenta accreta spectrum on unscarred uterus. PMCID: PMC9568723 The inclusion criteria: “At least one ... Continue reading READ ALL Thank you for paper. I have some comments: In introduction, the study should mention some etiologies of uterine rupture, even in rare cases of placenta accreta spectrum on unscarred uterus. PMCID: PMC9568723 The inclusion criteria: “At least one previous uterine surgery” is necessary? A study flowchart with inclusion/exclusion cases should be added. Maternal weight < 68kg is a protective factor? Could the authors please explain the relationship between maternal weight and uterine rupture? The neonatal weight may be more significant? Blood loss and blood transfusion should be presented additionally as median [IQR]. Definition of important variable should be added. For example: complete/incomplete UR. BMI should be represented instead of separate weight and height. The small sample size made the CI of multivariate logistic regression too large. This is confused. Please discuss why the period 2014-2017 related to increasing number of UR cases? In discussion, some other etiologies of intraabdominal hemorrhage in pregnancy should be also noted as well as role of imaging modalities such as ultrasound. doi: 10.1186/s12245-023-00498-w. Pulmonary embolism complication should be prevented in cesarean with severe blood loss.refer to 1 Please discuss the role of cardiotocography in monitoring labor and detecting UR. r efer to 2 Change of fetal head's position during labor should be exanimated. Practical points should be summarized. Is the work clearly and accurately presented and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? I cannot comment. A qualified statistician is required. Are all the source data underlying the results available to ensure full reproducibility? Partly Are the conclusions drawn adequately supported by the results? Partly References 1. Vuong A, Pham T, Bui V, Nguyen X, et al.: Successfully conservative management of the uterus in acute pulmonary embolism during cesarean section for placenta previa: a case report from Tu Du Hospital, Vietnam and literature review. International Journal of Emergency Medicine . 2024; 17 (1). Publisher Full Text 2. Overtoom E, Huynh T, Rosman A, Zwart J, et al.: Predicting the risks and recognizing the signs: a two-year prospective population-based study on pregnant women with uterine rupture in The Netherlands. The Journal of Maternal-Fetal & Neonatal Medicine . 2024; 37 (1). Publisher Full Text Competing Interests: No competing interests were disclosed. Reviewer Expertise: Pregnancy pathology I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Nguyen PN. Reviewer Report For: Silent Danger: Risk Factors and Outcomes of Fortuitously Discovered Uterine Rupture – A 41-Case Cohort Study [version 1; peer review: 2 approved with reservations] . F1000Research 2025, 14 :585 ( https://doi.org/10.5256/f1000research.181350.r392398 ) The direct URL for this report is: https://f1000research.com/articles/14-585/v1#referee-response-392398 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 23 Aug 2025 Narjes karmous , Department B of Obstetrics and Gynecology, Charles Nicolle Hospital, Tinis, Tunisia 23 Aug 2025 Author Response Dear Phuc Nhon Nguyen, We sincerely appreciate your constructive feedback. Your insightful comments have helped us refine and enhance the quality of our manuscript. Reviewer comment: In introduction, the ... Continue reading Dear Phuc Nhon Nguyen, We sincerely appreciate your constructive feedback. Your insightful comments have helped us refine and enhance the quality of our manuscript. Reviewer comment: In introduction, the study should mention some etiologies of uterine rupture, even in rare cases of placenta accreta spectrum on unscarred uterus. PMCID: PMC9568723 Author response: We appreciate this suggestion. A sentence addressing rare etiologies of uterine rupture, including placenta accreta spectrum in unscarred uteri, has been added to the Introduction, with citation [6]. Reviewer comment: The inclusion criteria: “At least one previous uterine surgery” is necessary? Author response: Thank you for your insightful comment. We acknowledge that our earlier wording may have created some confusion. To clarify: a history of uterine surgery was not required for inclusion in this study. Our aim was to analyze all cases of fortuitously discovered uterine rupture, regardless of uterine surgical history. As such, the presence or absence of a uterine scar was not used as an inclusion criterion. What defined eligibility was the asymptomatic nature of the rupture and its intraoperative or immediate postpartum discovery, combined with complete medical documentation. Both scarred and unscarred uteri were represented in our cohort. We have updated the Materials and Methods section accordingly to ensure clarity and consistency with this inclusion approach. Reviewer comment: A study flowchart with inclusion/exclusion cases should be added. Author response: A flowchart has been included as Figure 1 to illustrate the inclusion and exclusion process clearly. Reviewer comment : Maternal weight < 68kg is a protective factor? Could the authors please explain the relationship between maternal weight and uterine rupture? The neonatal weight may be more significant? Author response : This point has been expanded in the Discussion, with added references [21–26] explaining the physiopathological links between obesity, uterine healing, and rupture. The role of neonatal weight is also discussed. Reviewer comment : Blood loss and blood transfusion should be presented additionally as median [IQR]. Author response: We have revised Table 3 to present blood loss and transfusion data as median [IQR], in line with reviewer recommendations. Reviewer comment: Definition of important variable should be added. For example: complete/incomplete UR. Author response: Definitions of 'complete' and 'incomplete' uterine rupture have been added to the Methods section under the 'Definitions' subsection. Reviewer comment: BMI should be represented instead of separate weight and height. Author response: We replaced separate weight and height with BMI throughout the manuscript and added BMI statistics in Table 2. Reviewer comment: The small sample size made the CI of multivariate logistic regression too large. This is confused. Author response: We agree. This limitation is acknowledged explicitly in the Methods and Discussion sections. Reviewer comment: Please discuss why the period 2014–2017 related to increasing number of UR cases? Author response: We provided an explanation in the Discussion, linking the peak in 2017 to institutional practices and changes in intraoperative exploration and documentation. Reviewer comment: In discussion, some other etiologies of intraabdominal hemorrhage in pregnancy should be also noted as well as role of imaging modalities such as ultrasound. Author response: These aspects have been discussed in the revised Discussion, with references [17,18,19]. Reviewer comment: Pulmonary embolism complication should be prevented in cesarean with severe blood loss. Author response: We agree. The importance of thromboprophylaxis has been added to the Discussion, citing reference [29]. Reviewer comment: Please discuss the role of cardiotocography in monitoring labor and detecting UR. Author response: The role of CTG as an early indicator of uterine rupture has been included in the Discussion with appropriate reference [27]. Reviewer comment: Change of fetal head's position during labor should be examined. Author response: This was mentioned in the Discussion as a potential indirect sign of uterine dehiscence, citing reference [28]. Reviewer comment: Practical points should be summarized. Author response: We added a bullet-style summary of clinical implications and recommendations at the end of the Discussion section. Sincerely, Narjes Karmous Dear Phuc Nhon Nguyen, We sincerely appreciate your constructive feedback. Your insightful comments have helped us refine and enhance the quality of our manuscript. Reviewer comment: In introduction, the study should mention some etiologies of uterine rupture, even in rare cases of placenta accreta spectrum on unscarred uterus. PMCID: PMC9568723 Author response: We appreciate this suggestion. A sentence addressing rare etiologies of uterine rupture, including placenta accreta spectrum in unscarred uteri, has been added to the Introduction, with citation [6]. Reviewer comment: The inclusion criteria: “At least one previous uterine surgery” is necessary? Author response: Thank you for your insightful comment. We acknowledge that our earlier wording may have created some confusion. To clarify: a history of uterine surgery was not required for inclusion in this study. Our aim was to analyze all cases of fortuitously discovered uterine rupture, regardless of uterine surgical history. As such, the presence or absence of a uterine scar was not used as an inclusion criterion. What defined eligibility was the asymptomatic nature of the rupture and its intraoperative or immediate postpartum discovery, combined with complete medical documentation. Both scarred and unscarred uteri were represented in our cohort. We have updated the Materials and Methods section accordingly to ensure clarity and consistency with this inclusion approach. Reviewer comment: A study flowchart with inclusion/exclusion cases should be added. Author response: A flowchart has been included as Figure 1 to illustrate the inclusion and exclusion process clearly. Reviewer comment : Maternal weight < 68kg is a protective factor? Could the authors please explain the relationship between maternal weight and uterine rupture? The neonatal weight may be more significant? Author response : This point has been expanded in the Discussion, with added references [21–26] explaining the physiopathological links between obesity, uterine healing, and rupture. The role of neonatal weight is also discussed. Reviewer comment : Blood loss and blood transfusion should be presented additionally as median [IQR]. Author response: We have revised Table 3 to present blood loss and transfusion data as median [IQR], in line with reviewer recommendations. Reviewer comment: Definition of important variable should be added. For example: complete/incomplete UR. Author response: Definitions of 'complete' and 'incomplete' uterine rupture have been added to the Methods section under the 'Definitions' subsection. Reviewer comment: BMI should be represented instead of separate weight and height. Author response: We replaced separate weight and height with BMI throughout the manuscript and added BMI statistics in Table 2. Reviewer comment: The small sample size made the CI of multivariate logistic regression too large. This is confused. Author response: We agree. This limitation is acknowledged explicitly in the Methods and Discussion sections. Reviewer comment: Please discuss why the period 2014–2017 related to increasing number of UR cases? Author response: We provided an explanation in the Discussion, linking the peak in 2017 to institutional practices and changes in intraoperative exploration and documentation. Reviewer comment: In discussion, some other etiologies of intraabdominal hemorrhage in pregnancy should be also noted as well as role of imaging modalities such as ultrasound. Author response: These aspects have been discussed in the revised Discussion, with references [17,18,19]. Reviewer comment: Pulmonary embolism complication should be prevented in cesarean with severe blood loss. Author response: We agree. The importance of thromboprophylaxis has been added to the Discussion, citing reference [29]. Reviewer comment: Please discuss the role of cardiotocography in monitoring labor and detecting UR. Author response: The role of CTG as an early indicator of uterine rupture has been included in the Discussion with appropriate reference [27]. Reviewer comment: Change of fetal head's position during labor should be examined. Author response: This was mentioned in the Discussion as a potential indirect sign of uterine dehiscence, citing reference [28]. Reviewer comment: Practical points should be summarized. Author response: We added a bullet-style summary of clinical implications and recommendations at the end of the Discussion section. Sincerely, Narjes Karmous Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 23 Aug 2025 Narjes karmous , Department B of Obstetrics and Gynecology, Charles Nicolle Hospital, Tinis, Tunisia 23 Aug 2025 Author Response Dear Phuc Nhon Nguyen, We sincerely appreciate your constructive feedback. Your insightful comments have helped us refine and enhance the quality of our manuscript. Reviewer comment: In introduction, the ... Continue reading Dear Phuc Nhon Nguyen, We sincerely appreciate your constructive feedback. Your insightful comments have helped us refine and enhance the quality of our manuscript. Reviewer comment: In introduction, the study should mention some etiologies of uterine rupture, even in rare cases of placenta accreta spectrum on unscarred uterus. PMCID: PMC9568723 Author response: We appreciate this suggestion. A sentence addressing rare etiologies of uterine rupture, including placenta accreta spectrum in unscarred uteri, has been added to the Introduction, with citation [6]. Reviewer comment: The inclusion criteria: “At least one previous uterine surgery” is necessary? Author response: Thank you for your insightful comment. We acknowledge that our earlier wording may have created some confusion. To clarify: a history of uterine surgery was not required for inclusion in this study. Our aim was to analyze all cases of fortuitously discovered uterine rupture, regardless of uterine surgical history. As such, the presence or absence of a uterine scar was not used as an inclusion criterion. What defined eligibility was the asymptomatic nature of the rupture and its intraoperative or immediate postpartum discovery, combined with complete medical documentation. Both scarred and unscarred uteri were represented in our cohort. We have updated the Materials and Methods section accordingly to ensure clarity and consistency with this inclusion approach. Reviewer comment: A study flowchart with inclusion/exclusion cases should be added. Author response: A flowchart has been included as Figure 1 to illustrate the inclusion and exclusion process clearly. Reviewer comment : Maternal weight < 68kg is a protective factor? Could the authors please explain the relationship between maternal weight and uterine rupture? The neonatal weight may be more significant? Author response : This point has been expanded in the Discussion, with added references [21–26] explaining the physiopathological links between obesity, uterine healing, and rupture. The role of neonatal weight is also discussed. Reviewer comment : Blood loss and blood transfusion should be presented additionally as median [IQR]. Author response: We have revised Table 3 to present blood loss and transfusion data as median [IQR], in line with reviewer recommendations. Reviewer comment: Definition of important variable should be added. For example: complete/incomplete UR. Author response: Definitions of 'complete' and 'incomplete' uterine rupture have been added to the Methods section under the 'Definitions' subsection. Reviewer comment: BMI should be represented instead of separate weight and height. Author response: We replaced separate weight and height with BMI throughout the manuscript and added BMI statistics in Table 2. Reviewer comment: The small sample size made the CI of multivariate logistic regression too large. This is confused. Author response: We agree. This limitation is acknowledged explicitly in the Methods and Discussion sections. Reviewer comment: Please discuss why the period 2014–2017 related to increasing number of UR cases? Author response: We provided an explanation in the Discussion, linking the peak in 2017 to institutional practices and changes in intraoperative exploration and documentation. Reviewer comment: In discussion, some other etiologies of intraabdominal hemorrhage in pregnancy should be also noted as well as role of imaging modalities such as ultrasound. Author response: These aspects have been discussed in the revised Discussion, with references [17,18,19]. Reviewer comment: Pulmonary embolism complication should be prevented in cesarean with severe blood loss. Author response: We agree. The importance of thromboprophylaxis has been added to the Discussion, citing reference [29]. Reviewer comment: Please discuss the role of cardiotocography in monitoring labor and detecting UR. Author response: The role of CTG as an early indicator of uterine rupture has been included in the Discussion with appropriate reference [27]. Reviewer comment: Change of fetal head's position during labor should be examined. Author response: This was mentioned in the Discussion as a potential indirect sign of uterine dehiscence, citing reference [28]. Reviewer comment: Practical points should be summarized. Author response: We added a bullet-style summary of clinical implications and recommendations at the end of the Discussion section. Sincerely, Narjes Karmous Dear Phuc Nhon Nguyen, We sincerely appreciate your constructive feedback. Your insightful comments have helped us refine and enhance the quality of our manuscript. Reviewer comment: In introduction, the study should mention some etiologies of uterine rupture, even in rare cases of placenta accreta spectrum on unscarred uterus. PMCID: PMC9568723 Author response: We appreciate this suggestion. A sentence addressing rare etiologies of uterine rupture, including placenta accreta spectrum in unscarred uteri, has been added to the Introduction, with citation [6]. Reviewer comment: The inclusion criteria: “At least one previous uterine surgery” is necessary? Author response: Thank you for your insightful comment. We acknowledge that our earlier wording may have created some confusion. To clarify: a history of uterine surgery was not required for inclusion in this study. Our aim was to analyze all cases of fortuitously discovered uterine rupture, regardless of uterine surgical history. As such, the presence or absence of a uterine scar was not used as an inclusion criterion. What defined eligibility was the asymptomatic nature of the rupture and its intraoperative or immediate postpartum discovery, combined with complete medical documentation. Both scarred and unscarred uteri were represented in our cohort. We have updated the Materials and Methods section accordingly to ensure clarity and consistency with this inclusion approach. Reviewer comment: A study flowchart with inclusion/exclusion cases should be added. Author response: A flowchart has been included as Figure 1 to illustrate the inclusion and exclusion process clearly. Reviewer comment : Maternal weight < 68kg is a protective factor? Could the authors please explain the relationship between maternal weight and uterine rupture? The neonatal weight may be more significant? Author response : This point has been expanded in the Discussion, with added references [21–26] explaining the physiopathological links between obesity, uterine healing, and rupture. The role of neonatal weight is also discussed. Reviewer comment : Blood loss and blood transfusion should be presented additionally as median [IQR]. Author response: We have revised Table 3 to present blood loss and transfusion data as median [IQR], in line with reviewer recommendations. Reviewer comment: Definition of important variable should be added. For example: complete/incomplete UR. Author response: Definitions of 'complete' and 'incomplete' uterine rupture have been added to the Methods section under the 'Definitions' subsection. Reviewer comment: BMI should be represented instead of separate weight and height. Author response: We replaced separate weight and height with BMI throughout the manuscript and added BMI statistics in Table 2. Reviewer comment: The small sample size made the CI of multivariate logistic regression too large. This is confused. Author response: We agree. This limitation is acknowledged explicitly in the Methods and Discussion sections. Reviewer comment: Please discuss why the period 2014–2017 related to increasing number of UR cases? Author response: We provided an explanation in the Discussion, linking the peak in 2017 to institutional practices and changes in intraoperative exploration and documentation. Reviewer comment: In discussion, some other etiologies of intraabdominal hemorrhage in pregnancy should be also noted as well as role of imaging modalities such as ultrasound. Author response: These aspects have been discussed in the revised Discussion, with references [17,18,19]. Reviewer comment: Pulmonary embolism complication should be prevented in cesarean with severe blood loss. Author response: We agree. The importance of thromboprophylaxis has been added to the Discussion, citing reference [29]. Reviewer comment: Please discuss the role of cardiotocography in monitoring labor and detecting UR. Author response: The role of CTG as an early indicator of uterine rupture has been included in the Discussion with appropriate reference [27]. Reviewer comment: Change of fetal head's position during labor should be examined. Author response: This was mentioned in the Discussion as a potential indirect sign of uterine dehiscence, citing reference [28]. Reviewer comment: Practical points should be summarized. Author response: We added a bullet-style summary of clinical implications and recommendations at the end of the Discussion section. Sincerely, Narjes Karmous Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Comments on this article Comments (0) Version 3 VERSION 3 PUBLISHED 13 Jun 2025 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 Version 3 (revision) 28 Aug 25 Version 2 (revision) 08 Aug 25 read read Version 1 13 Jun 25 read read Phuc Nhon Nguyen , Tu Du Hospital, Ho Chi Minh City, Vietnam Mathew Olumide Adebisi , Afe Babalola University, Ado-Ekiti, Nigeria; Federal Teaching Hospital Ido-Ekiti (Ringgold ID: 605037), Ido Ekiti, Nigeria Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Nguyen P. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 28 Aug 2025 | for Version 2 Phuc Nhon Nguyen , Tu Du Hospital, Ho Chi Minh City, Vietnam 0 Views copyright © 2025 Nguyen P. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Thank you for your revision. The paper is more improved in scientific points. Competing Interests No competing interests were disclosed. Reviewer Expertise Pregnancy pathology I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Nguyen PN. Peer Review Report For: Silent Danger: Risk Factors and Outcomes of Fortuitously Discovered Uterine Rupture – A 41-Case Cohort Study [version 1; peer review: 2 approved with reservations] . F1000Research 2025, 14 :585 ( https://doi.org/10.5256/f1000research.186053.r403829) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-585/v2#referee-response-403829 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Adebisi M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 28 Aug 2025 | for Version 2 Mathew Olumide Adebisi , Afe Babalola University, Ado-Ekiti, Ekiti, Nigeria; Obstetrics and Gynaecology, Federal Teaching Hospital Ido-Ekiti (Ringgold ID: 605037), Ido Ekiti, Ekiti, Nigeria 0 Views copyright © 2025 Adebisi M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions No further comments to make. Competing Interests No competing interests were disclosed. Reviewer Expertise Obstetrics and Gynaecology I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Adebisi MO. Peer Review Report For: Silent Danger: Risk Factors and Outcomes of Fortuitously Discovered Uterine Rupture – A 41-Case Cohort Study [version 1; peer review: 2 approved with reservations] . F1000Research 2025, 14 :585 ( https://doi.org/10.5256/f1000research.186053.r403828) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-585/v2#referee-response-403828 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Adebisi M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 30 Jun 2025 | for Version 1 Mathew Olumide Adebisi , Afe Babalola University, Ado-Ekiti, Ekiti, Nigeria; Obstetrics and Gynaecology, Federal Teaching Hospital Ido-Ekiti (Ringgold ID: 605037), Ido Ekiti, Ekiti, Nigeria 0 Views copyright © 2025 Adebisi M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions GENERAL COMMENTS The manuscript delved into an important obstetric mishap that is a major contributor to maternal morbidity and mortality especially in developing nations. However, manuscript needs major revisions especially in the areas of literature review on the existing knowledge and knowledge gap, methodology, result presentation, discussion and conclusion. SPECIFIC COMMENTS ON SECTIONS Title: Nothing remarkable and it is well written. Abstract: “The aim is to identify factors associated with complete uterine rupture (UR)”. In your methodology, asymptomatic UR cases (complete/incomplete) were analyzed. This should be harmonized to make the methodology reproducible and thoroughly understood by the readers. Result (in the abstract section): ……. protective effect per kilogram decrease? This statement should be clearly mentioned. For example, …. protective effect per kilogram maternal body weight. Main text: Introduction: This is grossly inadequate. Are there no studies on the topic of silent uterine rupture either scarred or unscarred from developing countries? Are there no studies on how asymptomatic UR cases are being recognized either by imaging or at surgery? Suggested citations: Ebeigbe PN et.al. (2005) - Ref. 1 Kadowa I. (2010) - Ref. 2 Fofie C and Baffoe P (2011) - Ref. 3 There are still many more that can be cited to add to the literature review. Methodology: Is this study only on complete uterine rupture? Your stated in the methodology that “asymptomatic uterine rupture cases (complete/incomplete) were analyzed to compare clinical profiles, identify risk factors and assess maternal and neonatal outcomes. Also, result section revealed comparison of complete UR versus incomplete UR. You also stated that symptomatic cases and those in labour or other emergency settings were excluded from the study. However, some of the tables (2 and 4) in the result section show duration of labour as variable. I suggest that the different sections of the manuscript should be harmonized. Statistical analysis: Is this study a randomized study? Results: Parturient refers to a woman in labour and those in labour were said to be excluded. Other terms or phrases could be used to describe the 41 cases. For example; Among the 41 women with asymptomatic uterine rupture….. Tables 2 and 4- Harmonized the Methodology and the variables. Discussion: Quoting your statement from this section- “This cohort showed no demographic (Age, body mass index, socioeconomic status) or obstetric (quality of antenatal care, gestational diabetes) association with uterine rupture outcomes. However, it was reported that two “new predictors” emerged; namely (1) prolonged labour, leading to uterine rupture is a reflection of the type of obstetric care received (2) lower maternal weight. “Gestational age and delivery time were also noted to be longer in the incomplete uterine rupture cases”. These are also obstetric /labour factors. I therefore suggest that the exclusion criteria (and by extension, the methodology) and result presentation should be revised. Conclusion: The study reported that two new predictors emerged which is a strong point in this study. However, authors concluded on factor which the study did not reveal. The conclusion should be revised. References: some references have been suggested. If the literature review (introduction section) is revised as recommended, definitely 2 or more citations will be added to the reference. Is the work clearly and accurately presented and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? No If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? Partly Are the conclusions drawn adequately supported by the results? No References 1. Ebeigbe P, Enabudoso E, Ande A: Ruptured uterus in a Nigerian community: a study of sociodemographic and obstetric risk factors. Acta Obstetricia et Gynecologica Scandinavica . 2005; 84 (12): 1172-1174 Publisher Full Text 2. I, Kadowa: Ruptured uterus in rural Uganda: prevalence, predisposing factors and outcomes dust. https://pubmed.ncbi.nlm.nih.gov/20200773/ . 2010. 3. Fofie C, Baffoe P: A two-year review of uterine rupture in a regional hospital. Ghana Medical Journal . 2011; 44 (3). Publisher Full Text 4. Karmous, Narjes: Silent Danger: Risk Factors and Outcomes of Fortuitously Discovered Uterine Rupture - ; A 41-Case Cohort Study. https://dataverse.harvard.edu/dataset.xhtml?persistentId . 2025. Publisher Full Text Competing Interests No competing interests were disclosed. Reviewer Expertise Obstetrics and Gynaecology I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 23 Aug 2025 Narjes karmous, Department B of Obstetrics and Gynecology, Charles Nicolle Hospital, Tinis, Tunisia Dear Mathew Olumide Adebisi, We sincerely appreciate your constructive feedback. Your insightful comments have helped us refine and enhance the quality of our manuscript. Reviewer comment: Abstract: Harmonize the aim and methodology regarding complete/incomplete UR. Author response: The Abstract has been revised to clearly state that both complete and incomplete forms of asymptomatic uterine rupture were included and analyzed in the study, ensuring coherence with the Methods and Results sections. Reviewer comment: Result (Abstract): Clarify “protective effect per kilogram decrease”. Author response: We revised the phrasing in the Abstract to “a protective effect per kilogram of maternal body weight” for clarity and statistical accuracy. Reviewer comment: Introduction is grossly inadequate. Literature on silent uterine rupture in developing countries should be reviewed. Suggested citations: Ref. 1–3. Author response: The Introduction has been substantially expanded and now includes data from studies conducted in Nigeria, Uganda, and Ghana, as suggested (references [7]–[9]). These studies help contextualize our findings within a broader regional framework of silent uterine rupture and its risk factors. Reviewer comment: Methodology unclear: Complete vs incomplete UR? Harmonize with Results. Author response: This issue has been addressed. We now explicitly state in the Methods that both complete and incomplete asymptomatic uterine ruptures were included in the study and compared across multiple variables. Terminology and consistency have been corrected throughout. Reviewer comment: Tables 2 and 4 mention labor variables, yet laboring women were excluded. Author response: We clarified that “asymptomatic” in our study refers to the absence of clinical signs of rupture (pain, bleeding, fetal distress), but not necessarily the absence of labor. Some patients had labor activity before cesarean delivery, which justifies the inclusion of labor variables. This is now clearly stated in the 'Study Population' and 'Discussion' sections. Reviewer comment: Is this a randomized study? Author response: No. We confirm this is a retrospective observational cohort study. This has been clearly stated in the revised Methodology section. Reviewer comment: Replace “parturient” with more appropriate term for asymptomatic cases. Author response: We have replaced the term “parturient” with “women with asymptomatic uterine rupture” or more specific language throughout the manuscript for precision and accuracy. Reviewer comment: Discussion contradicts exclusion criteria: Prolonged labor and gestational age as predictors? Author response: This has been clarified. Although these women had no rupture symptoms, many experienced labor prior to cesarean. This distinction has been made clear in the revised Discussion and Methods sections. Reviewer comment: Conclusion not supported by results. Revise accordingly. Author response: We have revised the Conclusion to focus strictly on statistically supported findings: prolonged labor and maternal weight <68 kg as independent predictors of complete rupture. Speculative elements were removed. Reviewer comment: References: more literature needed if Introduction is revised. Author response: We have included all the suggested references and added several recent publications to strengthen the Introduction and Discussion. Reviewer comment: Are sufficient details of methods and analysis provided to allow replication by others? → No Author response: The Methods section has been substantially revised to improve clarity and reproducibility. It now includes more precise definitions of study population, variables, criteria, and analysis thresholds. Reviewer comment: Are the conclusions drawn adequately supported by the results? → No Author response: The conclusions have been adjusted to align fully with the results. We now only report findings that were statistically demonstrated and explicitly acknowledge study limitations. Sincerely, Narjes Karmous View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Adebisi MO. Peer Review Report For: Silent Danger: Risk Factors and Outcomes of Fortuitously Discovered Uterine Rupture – A 41-Case Cohort Study [version 1; peer review: 2 approved with reservations] . F1000Research 2025, 14 :585 ( https://doi.org/10.5256/f1000research.181350.r392395) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-585/v1#referee-response-392395 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Nguyen P. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 25 Jun 2025 | for Version 1 Phuc Nhon Nguyen , Tu Du Hospital, Ho Chi Minh City, Vietnam 0 Views copyright © 2025 Nguyen P. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Thank you for paper. I have some comments: In introduction, the study should mention some etiologies of uterine rupture, even in rare cases of placenta accreta spectrum on unscarred uterus. PMCID: PMC9568723 The inclusion criteria: “At least one previous uterine surgery” is necessary? A study flowchart with inclusion/exclusion cases should be added. Maternal weight < 68kg is a protective factor? Could the authors please explain the relationship between maternal weight and uterine rupture? The neonatal weight may be more significant? Blood loss and blood transfusion should be presented additionally as median [IQR]. Definition of important variable should be added. For example: complete/incomplete UR. BMI should be represented instead of separate weight and height. The small sample size made the CI of multivariate logistic regression too large. This is confused. Please discuss why the period 2014-2017 related to increasing number of UR cases? In discussion, some other etiologies of intraabdominal hemorrhage in pregnancy should be also noted as well as role of imaging modalities such as ultrasound. doi: 10.1186/s12245-023-00498-w. Pulmonary embolism complication should be prevented in cesarean with severe blood loss.refer to 1 Please discuss the role of cardiotocography in monitoring labor and detecting UR. r efer to 2 Change of fetal head's position during labor should be exanimated. Practical points should be summarized. Is the work clearly and accurately presented and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? I cannot comment. A qualified statistician is required. Are all the source data underlying the results available to ensure full reproducibility? Partly Are the conclusions drawn adequately supported by the results? Partly References 1. Vuong A, Pham T, Bui V, Nguyen X, et al.: Successfully conservative management of the uterus in acute pulmonary embolism during cesarean section for placenta previa: a case report from Tu Du Hospital, Vietnam and literature review. International Journal of Emergency Medicine . 2024; 17 (1). Publisher Full Text 2. Overtoom E, Huynh T, Rosman A, Zwart J, et al.: Predicting the risks and recognizing the signs: a two-year prospective population-based study on pregnant women with uterine rupture in The Netherlands. The Journal of Maternal-Fetal & Neonatal Medicine . 2024; 37 (1). Publisher Full Text Competing Interests No competing interests were disclosed. Reviewer Expertise Pregnancy pathology I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 23 Aug 2025 Narjes karmous, Department B of Obstetrics and Gynecology, Charles Nicolle Hospital, Tinis, Tunisia Dear Phuc Nhon Nguyen, We sincerely appreciate your constructive feedback. Your insightful comments have helped us refine and enhance the quality of our manuscript. Reviewer comment: In introduction, the study should mention some etiologies of uterine rupture, even in rare cases of placenta accreta spectrum on unscarred uterus. PMCID: PMC9568723 Author response: We appreciate this suggestion. A sentence addressing rare etiologies of uterine rupture, including placenta accreta spectrum in unscarred uteri, has been added to the Introduction, with citation [6]. Reviewer comment: The inclusion criteria: “At least one previous uterine surgery” is necessary? Author response: Thank you for your insightful comment. We acknowledge that our earlier wording may have created some confusion. To clarify: a history of uterine surgery was not required for inclusion in this study. Our aim was to analyze all cases of fortuitously discovered uterine rupture, regardless of uterine surgical history. As such, the presence or absence of a uterine scar was not used as an inclusion criterion. What defined eligibility was the asymptomatic nature of the rupture and its intraoperative or immediate postpartum discovery, combined with complete medical documentation. Both scarred and unscarred uteri were represented in our cohort. We have updated the Materials and Methods section accordingly to ensure clarity and consistency with this inclusion approach. Reviewer comment: A study flowchart with inclusion/exclusion cases should be added. Author response: A flowchart has been included as Figure 1 to illustrate the inclusion and exclusion process clearly. Reviewer comment : Maternal weight < 68kg is a protective factor? Could the authors please explain the relationship between maternal weight and uterine rupture? The neonatal weight may be more significant? Author response : This point has been expanded in the Discussion, with added references [21–26] explaining the physiopathological links between obesity, uterine healing, and rupture. The role of neonatal weight is also discussed. Reviewer comment : Blood loss and blood transfusion should be presented additionally as median [IQR]. Author response: We have revised Table 3 to present blood loss and transfusion data as median [IQR], in line with reviewer recommendations. Reviewer comment: Definition of important variable should be added. For example: complete/incomplete UR. Author response: Definitions of 'complete' and 'incomplete' uterine rupture have been added to the Methods section under the 'Definitions' subsection. Reviewer comment: BMI should be represented instead of separate weight and height. Author response: We replaced separate weight and height with BMI throughout the manuscript and added BMI statistics in Table 2. Reviewer comment: The small sample size made the CI of multivariate logistic regression too large. This is confused. Author response: We agree. This limitation is acknowledged explicitly in the Methods and Discussion sections. Reviewer comment: Please discuss why the period 2014–2017 related to increasing number of UR cases? Author response: We provided an explanation in the Discussion, linking the peak in 2017 to institutional practices and changes in intraoperative exploration and documentation. Reviewer comment: In discussion, some other etiologies of intraabdominal hemorrhage in pregnancy should be also noted as well as role of imaging modalities such as ultrasound. Author response: These aspects have been discussed in the revised Discussion, with references [17,18,19]. Reviewer comment: Pulmonary embolism complication should be prevented in cesarean with severe blood loss. Author response: We agree. The importance of thromboprophylaxis has been added to the Discussion, citing reference [29]. Reviewer comment: Please discuss the role of cardiotocography in monitoring labor and detecting UR. Author response: The role of CTG as an early indicator of uterine rupture has been included in the Discussion with appropriate reference [27]. Reviewer comment: Change of fetal head's position during labor should be examined. Author response: This was mentioned in the Discussion as a potential indirect sign of uterine dehiscence, citing reference [28]. Reviewer comment: Practical points should be summarized. Author response: We added a bullet-style summary of clinical implications and recommendations at the end of the Discussion section. Sincerely, Narjes Karmous View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Nguyen PN. Peer Review Report For: Silent Danger: Risk Factors and Outcomes of Fortuitously Discovered Uterine Rupture – A 41-Case Cohort Study [version 1; peer review: 2 approved with reservations] . F1000Research 2025, 14 :585 ( https://doi.org/10.5256/f1000research.181350.r392398) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. 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