Fundal hiatus discovered in a presumably unscarred uterus at emergency cesarean: an old perforation or rupture?

Abstract

Rupture of the uterus is a disastrous event for both the mother and fetus, and can be classified into three groups according to its etiology: rupture of a previous cesarean section scar, iatrogenic or traumatic rupture of the intact uterus, and spontaneous rupture of the intact uterus. The last scenario can further be subdivided into (a) those associated with uterine anomaly, placenta percreta, pyometra, hydatidiform mole, grand multiparity or pathological growth and (b) that occurring in a primiparous patient with a sound, intact and normal uterus. The latter is a very rare entity.We present a case of an unexpected fundal hiatus discovered in a presumably unscarred uterus at emergency cesarean section in a twin pregnancy without labor. The appearance of the fibrotic edge of the defect strongly suggested a chronic event (rupture or previous perforation) with the expulsion of the second twin through the defect at a much later date. The two fetuses died in utero, but in retrospect one of the fetuses might have been salvaged or even both if a suspected uterine perforation at previous evacuation was dealt with adequately. Case reportA 32-year-old apparently healthy Saudi women, gravida 11, para 6, who had had four previous miscarriages presented to the emergency room (ER) at 31 weeks gestation with a 2-h history of mild lower abdominal pain and back ache. There was no associated vaginal bleeding nor were there urinary symptoms. She had been feeling fetal movements satisfactorily before admission. She had had uncomplicated full-term pregnancies, normal vaginal deliveries and four miscarriages. The birth weight ranged between 25000 and 3000 g, while the post partum periods were uneventful. She also had uneventful evacuation of the uterus following each miscarriage; the last miscarriage was a blighted ovum at 8 weeks followed by uncomplicated suction evacuation of the uterus. This event occurred approximately 6 months before the index pregnancy. There was no history of C Acta Obstet Gynecol Scand 81 (2002) twins in the family. No other relevant family history was obtained. Her periods were regular and this pregnancy was spontaneous.She booked for antenatal care at our hospital at 17 weeks gestation when the pregnancy was diagnosed as twins during routine ultrasound (dichorionic placenta), and other routine booking investigations were requested and were normal. She was admitted at 26 weeks because of painless vaginal bleeding and was diagnosed as having placenta praevia. She discharged herself against medical advice 4 days later only to attend the antenatal clinic at 29 weeks gestation. She was given the option of admission and refused, but returned to ER 2 weeks later with abdominal painsOn examination her general condition was satisfactory with a pulse rate of 96 beats/min and a blood pressure of 110/70 mmHg. She was mildly pale but not jaundiced.Chest and cardiovascular systems were unremarkable. Abdominal examination revealed a 34-week sized uterus, which was neither tense nor tender. The pregnancy was twin with c...

Successful Pregnancy Outcome After Conservative Management of Second‐Trimester Cornual Uterine Rupture

“…Pregnancy after documented cornual uterine rupture secondary to perforation after D&C or hysteroscopy has rarely been described, [3][4][5] since approximately 86% of uterine perforations after a first-trimester D&C remain undiagnosed and do not have long-term sequelae. 6 We suspect that the uterine rupture in this case occurred because of perforation during the prior D&C.…”