Objective
This study aimed to present a case of first-trimester uterine rupture and perform a systematic review to identify common presentations, risk factors, and management strategies.
Data Sources
Searches were performed in PubMed, Ovid, and Scopus using a combination of key words related to “uterine rupture,” “first trimester,” and “early pregnancy” from database inception to September 30, 2020.
Study Eligibility Criteria
English language descriptions of uterine rupture at ≤14 weeks of gestation were included, and cases involving pregnancy termination and ectopic pregnancy were excluded.
Methods
Outcomes for the systematic review included maternal demographics, description of uterine rupture, and specifics of uterine rupture diagnosis and management. Data were extracted to custom-made reporting forms. Median values were calculated for continuous variables, and percentages were calculated for categorical variables. The risk of bias was assessed using the Joanna Briggs Institute critical appraisal checklist for case reports and case series.
Results
Overall, 61 cases of first-trimester uterine rupture were identified, including our novel case. First-trimester uterine ruptures occurred at a median gestation of 11 weeks. Most patients (59/61 [97%]) had abdominal pain as a presenting symptom, and previous uterine surgery was prevalent (44/61 [62%]), usually low transverse cesarean delivery (32/61 [52%]). The diagnosis of uterine rupture was generally made after surgical exploration (37/61 [61%]), with rupture noted in the fundus in 26 of 61 cases (43%) and in the lower segment in 27 of 61 cases (44%). Primary repair of the defect was possible in 40 of 61 cases (66%), whereas hysterectomy was performed in 18 of 61 cases (30%). Continuing pregnancy was possible in 4 of 61 cases (7%).
Conclusion
Uterine rupture is an uncommon occurrence but should be considered in patients with an acute abdomen in early pregnancy, especially in women with previous uterine surgery. Surgical exploration is typically needed to confirm the diagnosis and for management. Hysterectomy is not always necessary; primary uterine repair is sufficient in more than two-thirds of the cases to achieve hemostasis. Continuing pregnancy, although uncommon, is also possible.
Why was this study conducted?
This study aimed to identify the common clinical presentation, diagnostic tools, and management for first-trimester uterine rupture after an unstable patient presented to our hospital for management.
Key findings
Severe abdominal pain in early pregnancy can be caused by first-trimester uterine rupture. The patient should be evaluated promptly usually with ultrasound and surgery depending on hemodynamic status. Treatment is surgical, with repair of the uterine defect being the most common approach.
What does this add to what is known?
Previous uterine surgery is a risk of third-trimester uterine rupture, but it is also a risk factor for first-trimester uterine rupture.
Introduction
Spontaneous uterine rupture is a rare but often catastrophic obstetrical complication. A complete uterine rupture is defined by a defect through all layers of the uterine wall, including the serosa, with protrusion of the amniotic sac or fetal parts or placenta (in the event of ruptured membranes) into the peritoneal cavity. The overall incidence of spontaneous uterine rupture is approximately 1 of 1536 pregnancies, with uterine rupture being 5 times less common in resource-rich countries. Most cases of spontaneous uterine rupture occur in the third trimester of pregnancy. These cases in resource-poor countries are commonly due to rupture of the unscarred uterus secondary to prolonged obstructed labor, whereas cesarean scar or scarred uterus rupture is the most common cause of uterine rupture in resource-rich countries. However, reports of the presentation, predisposing risk factors, and management of uterine rupture in the first trimester of pregnancy are limited.
Objectives
This study aimed to present a new case of spontaneous uterine rupture in the first trimester of pregnancy and use a systematic review to identify possible risk factors for spontaneous first-trimester uterine rupture and describe characteristics of diagnosis, management, and outcomes.
Case Report
A gravida 10 para 3063 woman, in her mid-30s, at 13 3/7 weeks of gestation by last menstrual period (LMP), presented to an outside hospital with acute-onset severe abdominal pain, nausea, and vomiting. These symptoms started 1 hour before she arrived in the emergency department (ED). She was otherwise healthy with an obstetrical history notable for 2 full-term vaginal deliveries, 1 previous cesarean delivery for placental abruption at term, 2 first-trimester surgical abortions, 1 medically managed tubal ectopic pregnancy, and 3 medication abortions. Complete medical history was obtained from the patient, and no record was available for review of her medical history. She had no known complication in any procedures. Prenatal care was obtained at an outside institution, but she was scheduled for her ultrasound (US) on the day she presented to the ED. Only a bedside US was performed in the ED before her transfer, and therefore, a formal report was not available for review.
On initial evaluation in the outside hospital, she was tachycardic but otherwise stable. Within 30 minutes, she acutely decompensated, experiencing loss of consciousness. She was found to be in cardiopulmonary collapse and required intubation. Per report, a stat bedside US revealed a single live intrauterine pregnancy consistent with LMP and large hemoperitoneum. A norepinephrine drip was started, and she was transferred to our institution for surgical management as a surgical team was unavailable at the presenting institution. During transfer, she received 3 units of packed red blood cells.
She was received in the operating room at our institution where bedside US was repeated, revealing nonviable intrauterine pregnancy with large-volume hemoperitoneum. An exploratory laparotomy was performed using a midline vertical incision. On entering the abdomen, 2 L of hemoperitoneum were evacuated, and a 3-cm centrally located fundal defect was observed ( Figure 1 ). On manipulation of the uterus, the pregnancy contents extruded through the fundal defect. Brisk bleeding from this hysterotomy was observed, and the defect was closed with a single layer of 0 Vicryl in a running locked fashion. Additional figure-of-8 sutures were placed to achieve hemostasis. Because hemostasis was achieved quickly by primary repair of the defect, a hysterectomy, although considered, was not performed. A suction dilation and curettage (D&C) procedure was performed vaginally to ensure all products were evacuated from the uterus before the closure of the abdomen. The uterus was presumed to be empty of all pregnancy tissues as most tissues had extruded through the uterine defect before closure, but the inside of the uterus was not specifically wiped clean, and therefore, a suction curettage was performed once the patient was hemodynamically stable. Total blood loss during the procedure was 2700 mL. An additional 3 units of packed red blood cells and 1 unit of fresh frozen plasma were required. Postoperatively, the patient remained intubated and was transferred to the surgical intensive care unit (ICU) for further resuscitation and postoperative care. The patient was extubated on postoperative day 2 and discharged home on postoperative day 4 in good condition. The pathology report confirmed products of conception consistent with stated gestational age by LMP with a crown-rump length of 8.2 mm. The placenta was described as an immature placenta on pathology. As the patient did not desire future fertility, sterilization procedures and contraception were strongly encouraged, and she initiated depot medroxyprogesterone at her postoperative visit where she was doing well.
Interestingly, our patient had a fundal uterine rupture, although her previous cesarean delivery was presumed to be low transverse. The following possible etiologies were considered: previous surgical abortion complicated by uterine perforation unknown to the patient and or her providers, previous hysterotomy not low transverse, or undiagnosed connective tissue disorder. Our patient consented to the publication of her story with her medical history and photographs that were taken intraoperatively.
Methods
Information sources and search strategy
We reported a case of a first-trimester uterine rupture that occurred at our hospital. Following this case, a systematic review of the literature was performed using a protocol designed before study initiation. This systematic review was registered with the International Prospective Register of Systematic Reviews before data collection (registration number CRD42020209171). The following databases were searched from database inception to September 30, 2020: PubMed, Scopus, and Ovid MEDLINE. Search terms included “uterine rupture,” “pregnancy,” “first trimester,” “perforation,” “uterine,” and “early pregnancy.” In addition, reference lists were hand searched by the authors. This literature search was performed by 2 authors (L.F. and M.P.). Cases were restricted to those in English, but no restriction to geographic location was applied.
Eligibility criteria and study selection
Cases with English language descriptions of uterine rupture in the first trimester of pregnancy (≤14 weeks of gestation) were included. Cesarean scar pregnancies were considered intrauterine and included for analysis. Cases were excluded if they described medication or surgical pregnancy terminations during the affected pregnancy or if they described rupture in the setting of ectopic pregnancy (including cervical, cornual, and tubal ectopic pregnancies). Moreover, non-English language descriptions were excluded. Any disagreements on study inclusion were resolved by discussion with a third author (V.B.).
Data extraction
Data abstraction was completed by 2 independent investigators (M.P. and L.F.). Each investigator independently abstracted data from each study and analyzed data separately. The authors were contacted for missing data following data abstraction where necessary.
Assessment of risk of bias
The risk of bias was assessed using the Joanna Briggs Institute (JBI) critical appraisal checklist for case reports and case series.
Data synthesis
Outcomes for the systematic review included maternal demographics, description of uterine rupture, and specifics of uterine rupture diagnosis and management. Maternal demographics included gestational age, gravidity and parity, previous surgical history, and presence of uterine anomalies. Presenting symptoms were collected along with the location of the rupture in the uterus (lower segment, fundal, or other) and diagnosis of cesarean scar pregnancies and placenta accreta spectrum disorders (PASDs). Furthermore, diagnostic tools, including imaging and surgical modalities, surgical techniques, and blood transfusion, were recorded. Outcomes included blood transfusion, maternal mortality, and continuing pregnancy.
Data were extracted to custom-made reporting forms. Median values were calculated for continuous variables, and percentages were calculated for categorical variables.
Results
Study selection and characteristics
Systematic review resulted in 518 unique articles, which were evaluated for inclusion in this study. Overall, 476 articles were excluded as not relevant to the study question. Moreover, 59 unique publications of 60 cases of first-trimester (≤14 weeks of gestation) uterine rupture were included in this systematic review in addition to our novel case for a total of 61 cases ( Figure 2 ).
Patients in all cases of first-trimester uterine rupture were evaluated in the ED. There was a great deal of heterogeneity in obstetrical history among included cases Table 1 ). The median gestational age at which first-trimester uterine rupture occurred was 11 weeks ( Figure 3 ). Most patients (59/61 [97%]) complained of abdominal pain at the time of presentation. Only 14 of 61 patients (23%) complained of vaginal bleeding, whereas 10 of 61 patients (16%) experienced syncope.
| Demographics of first-trimester uterine rupture (n=61) | |
|---|---|
| Maternal age (y) | 29.5 (18–43) |
| Gravida | 3 (1–10) |
| Parity (number of deliveries) | 1 (0–7) |
| Gestational age at uterine rupture (wk) | 10.6 (5–14) |
| Presenting symptom | |
| Abdominal pain | 59 (97.0) |
| Vaginal bleeding | 14 (23.0) |
| Syncope | 10 (16.0) |
| Nausea and vomiting | 4 (7.0) |
Risk of bias of included studies
The risk of bias was assessed using the JBI critical appraisal tool for case series. Overall, the risk of bias was judged to be low for description of patient demographic characteristics, history, and treatment in all cases. The clinical condition, diagnostic tests, and takeaway lessons of the described patients were judged to be at low risk of bias in all but 1 study each. The postintervention clinical condition had the highest risk of bias and was not well described in 5 cases and was uncertain in 1 additional case. Adverse events were described in most cases but lacking in 2 cases and uncertain in 1 case ( Table 2 ).
| Study | Q1 | Q2 | Q3 | Q4 | Q5 | Q6 | Q7 | Q8 |
|---|---|---|---|---|---|---|---|---|
| Abbas et al (2017) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Abbas et al (2018) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Abbas et al (2018) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Abdulwahab et al (2014) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Akbaş et al (2015) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Ambrogi et al (2018) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Amro et al (2019) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Bandarian et al (2015) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Bolla et al (2016) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Bruand et al (2020) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Cecchini et al (2020) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Cheng et al (2003) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Cho et al (2017) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Dabulis et al (2007) | Yes | Yes | Yes | Yes | Yes | No | Yes | Yes |
| Dandawate et al (2009) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| deRoux et al (1999) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Dibbs et al (1995) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Esmans et al (2004) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Gupta et al (2012) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Hamsho et al (1999) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Hefny et al (2015) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Ijaz et al (2011) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Ishida et al (2018) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Ismail et al (2007) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Jain et al (2015) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Jang et al (2011) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Kabra et al (2016) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Lazarus et al (1978) | Yes | Yes | Yes | Yes | Yes | No | No | Yes |
| Lee et al (2019) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Liang et al (2003) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Liao et al (2009) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Lincenberg et al (2016) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Mahajan et al (2019) | Yes | Yes | No | No | Yes | No | Unc | Yes |
| Marcellus et al (1989) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Masia et al (2015) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Marcus et al (1999) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Matsuo et al (2004) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Miranda et al (2017) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Mosad et al (2017) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | No |
| Nassar et al (2009) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Visariya et al (2011) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Okada et al (2001) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Ozeren et al (1997) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Pandey et al (2015) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Park et al (2005) | Yes | Yes | Yes | Yes | Yes | No | Yes | Yes |
| Porcu et al (2003) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Pridjian et al (1990) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Saghafi et al (2019) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Shaikh et al (2012) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Sinha et al (2014) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Singh et al (2013) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Singh et al (2012) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Singh et al (2000) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Smith et al (1996) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Surve et al (2017) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Sujatha et al (2017) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Takashima et al (2018) | Yes | Yes | Yes | Yes | Yes | Unc | Yes | Yes |
| Tola (2014) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Vaezi (2017) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
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