Expectant management of fetal arm extruding through a large uterine dehiscence following sonographic diagnosis at 27 weeks of gestation

Abstract

A 25-year-old woman, gravida 4 para 3, presented at our antenatal clinic complaining of abdominal pain at 27 weeks of gestation. The patient's obstetric history consisted of two normal term deliveries. In her third pregnancy holoprosencephaly was diagnosed and at 26 weeks of gestation feticide was performed followed by hysterotomy due to placenta previa. The uterine incision was low transverse.Ultrasound examination demonstrated a single fetus in breech presentation with an estimated weight of 1030 g and decreased amniotic fluid volume. The cervical length was 35 mm. Midway between the internal os and the uterine fundus, we observed dehiscence of the scar measuring 50 × 26 mm, with a large herniated amniotic sac extending into the maternal abdominal cavity ( Figure 1, Videoclip S1). The extrauterine amniotic sac measured 100 × 45 mm and contained most of the amniotic fluid as well as a fetal arm and shoulder. These findings were also demonstrated on three-dimensional (3D) ultrasound (Figure 2, Videoclip S2). Following broad perinatal consultation we presented to the patient the benefits and potential risks of immediate delivery compared with expectant management. As she was asymptomatic at this point, expectant management was chosen, with the understanding that any change for the worse would necessitate immediate intervention. She was assigned a dedicated midwife and was followed without intervention. Betamethasone for lung maturation and magnesium sulfate for tocolysis were administered and instructions were issued for complete bed rest. Tocolytic treatment was discontinued after 1 day and the following 2.5 weeks were uneventful. Serial ultrasound examinations demonstrated the fetal arm and a loop of cord moving repeatedly in and out of the uterine cavity and the herniated amniotic sac (Figure 3). Seventeen days later, on follow-up ultrasound examination, the herniated amniotic sac had disappeared and severe oligohydramnios was observed. The arm was located outside the uterine cavity. Premature rupture of the membranes was diagnosed and an

Prenatal Detection and Conservative Management of a Partial Fundal Uterine Dehiscence

“…The prenatal detection of corporeal uterine rupture without hemoperitoneum and maternal compromise is rare and limited to a few case reports [9,10] . Incomplete uterine rupture with preservation of the integrity of the amniotic sac, frequently denoted by the term uterine dehiscence, has also been reported prenatally, both in the lower uterine segment [1,11] and the uterine corpus [2,8,12] .…”

“…Uterine sacculation is a very rare condition occurring in pregnancy where part of the uterine wall balloons, usually due to a functional weakening of the myometrium secondary to retroversion and impaction [3] , creating a sac-like structure into which amnion, fluid and fetal parts can prolapse. There are only a few reported cases of either uterine fundal dehiscence or sacculation where the pregnancy continues into the third trimester [4][5][6][7][8][9][10] . The following case describes the prenatal imaging diagnosis and subsequent clinical management of a large fundal uterine defect in the third trimester of pregnancy.…”

Herniation of the amniotic sac through congenital uterine defect confirmed during operation: A case report

“…Obstetric ultrasound is a powerful and convenient tool to diagnose herniation of the amniotic sac by showing an anechoic herniation through a uterine defect. The content of herniation can include amniotic fluid, fetal parts and the umbilical cord . In some cases, ultrasound scan can find an empty uterus, fetus with no heart activity and placenta in the abdominal cavity .…”

Sonographic diagnosis of spontaneous uterine rupture at the site of cornual wedge resection scar – a case report

“…The risk of scar rupture during a subsequent pregnancy is strongly related to its location, with corporeal (upper uterine, cornu area) scars tending to rupture more easily and more often prior to the onset of labour than lower uterine segment scars 5 , 7 . It has been suggested that such ruptures may be due to attenuation of the cornual region musculature, connective tissue factors, a deficiency in the reconstruction of the uterine wall or tissue damage contributed by electrosurgery 4 , 6 , 8 – 10 …”