Repair of an Extensive Tear of the Unscarred Uterus Resulting from Spontaneous Rupture

Abstract

Rupture of the uterus is the complete separation of the wall of the pregnant uterus with or without expulsion of the fetus. Spontaneous complete rupture of an unscarred uterus during labor is relatively rare with a reported incidence of 1 in 16 849 deliveries.1 Hysterectomy is frequently required, whereas suture of the wound with uterine preservation may be performed in selected cases. 2 Case ReportA 36-year-old woman, married for 12 years, was admitted to our hospital in active labor. She was 39-weeks pregnant and had not received any prenatal care. Her pain had started six hours previously and was regular. She gave no history of trauma and denied any previous history of uterine perforation, myomectomy or surgical pregnancy terminations. Her previous obstetric history revealed two pregnancies both of which ended with vaginal deliveries at home without any medical assistance at birth. At admission, her pulse rate was 80/min, respiratory rate 14/min, and blood pressure 120/80 mmHg. There was no uterine tenderness or irritability. Vaginal examination revealed a cervical dilatation of eight centimeters, 90% of the effacement, and -3 for the fetal head position. The initial fetal heart rate tracing was reassuring with a baseline rate of 140/min. Uterine hyperactivity was not present. Artificial rupture of the membranes revealed clear fluid. During hospitalization, neither oxytocin nor prostaglandin augmentation was administered.Fifty minutes after admission, she progressed to complete dilatation, and the fetus was at +1 station. After another 20 minutes, severe fetal heart rate decelerations (to 50-60 beats/ruin) developed which did not respond to changes of maternalposition and administration of oxygen. An abdomino-pelvic examination revealed loss of -3 station with cessation of contractions. The maternal pulse rate was 110/min, and blood pressure was measured as 90/60 mm Hg. An emergency cesarean delivery with the modifiedPfannenstiel incision was performed under general anesthesia. The time from onset of fetal bradycardia to delivery was 15 minutes.Operative findings included 1100 mL hemoperitoneum and the fetus bloating in the abdominal cavity. After urgent delivery of the fetus, the placenta was manually removed. Signs of placental abnormality or detachment were not present. A 15-cm vertical tear involving the visceral peritoneum, beginning at the fundus anteriorly with extension into the cervix and vagina, was observed. The bladder was intact. Repair of the laceration was attempted. Considerable hemostasis was achieved by three-layer closure with no. 1-0 Vicryl (Ethicon Inc, Edinburgh, United Kingdom). On seeing an enlarging hematoma on the left side of the uterine body, the broad ligament was entered, and the ascending uterine vein was clamped. Other bleeding vessels were visualized free of surrounding tissue and ligated. Total operating time was 80 minutes. Four units of cross-matched whole blood and prophylactic antibiotics were given perioperatively.The 3500 gram neonate, who had Apgar scores of two and fo...

Spontaneous Rupture of the Unscarred Uterus: A Review of the Literature

“…Whereas most of the women with ruptures had at least 1 risk factor, 25% of the women (21/84) did not have any 28,29,37–55 . A single risk factor was found in 47.6% (40/84) of the women 4,9,11,13,21,25,26,32,35,36,56–83 …”

“…Fourteen women (19%) were 35 years or older, 15,23,30,34,78–80,87,89,90,94–96 and 4 (4.8%) were grand multiparous, with 5 or more past deliveries 3,81,86,87 . Three women (3.6%) were pregnant with a macrocosmic baby (≥4000 g), 4,85,88 and 5 (6%) were pregnant with multiples: 1 with quadruplets 25 and 4 with twins 91,94–96 …”