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Case notes
A 22-year-old woman with dichorionic-diamniotic twins and a history of cesarean delivery for breech presentation presented for routine anatomy ultrasound. She was found to have a 2-cm defect in the lower uterine segment at the cervical junction, likely at the site of her previous hysterotomy ( Figure 1 ). On endovaginal scan, there was sludge within the defect that extended through the myometrium, covered only by serosa. A fetal foot intermittently kicked through the defect ( Video ). Magnetic resonance imaging confirmed the dehiscence at least 3 cm from the inferior margin of her anterior placenta adjacent to the normal-appearing bladder; there was no maternal free fluid ( Figure 2 ). She was asymptomatic, however she was admitted at 19 weeks and 4 days for observation given concern for catastrophic rupture as the pregnancy progressed. At 21 weeks and 2 days, she ruptured her membranes, began painfully contracting, and a fetal foot was protruding through the cervical os. The patient was hemodynamically stable, however, due to her tightly contracted cervix around the fetal foot, the decision was made to perform an emergent exploratory laparotomy. A classic hysterotomy was performed to deliver the twins, who were not resuscitated due to their early gestational age. This defect was repaired with a single layer of 0-Vicryl (Ethicon Inc., Blue Ash, OH) in a running locked fashion to reapproximate the myometrium.
