Case Report

A 41-year-old nulliparous woman who underwent oocyte donation became pregnant with a dichorionic-diamniotic twin pregnancy. Her medical history was noteworthy for diagnostic hysteroscopy performed for primary infertility (10 years before). During hysteroscopy, a 5-mm uterine perforation occurred. No electrosurgical procedures were performed. At the age of 35 years, premature ovarian failure was diagnosed; no hormone replacement therapy was prescribed. She then decided to undergo in vitro fertilization-embryo transfer with oocyte donation at the age of 41 years. The pregnancy was uneventful, until the woman was admitted to the Obstetrics Department of the University of Insubria, Varese, Italy, because of diffuse itching at 35 weeks of gestation. Laboratory evaluation revealed normal findings. Clinical evaluation on admission showed an unfavorable cervix and a twin pregnancy with viable fetuses. Nine hours after admission the patient suddenly reported severe abdominal pain. Blood pressure decreased to 90/70 mm Hg with persistent maternal tachycardia. Ultrasound scan revealed bradycardia of the second twin. Her hemoglobin level decreased from 13.8-7.4 g/dL. The patient had general anesthesia and immediate laparotomy was performed through a Joel-Cohen incision, for fetal nonreassuring status before labor and suspected UR. At surgical exploration, massive hemoperitoneum was evident.

Two male infants were found extruded in the abdominal cavity and were extracted with no need for hysterotomic incision. The first fetus was delivered alive with Apgar scores of 2 and 7 at 1 and 5 minutes, respectively. The second fetus was already dead at the time of extraction. After evacuation of the hemoperitoneum a 10-cm fundal UR was observed. The uterine defect was repaired with a continuous double-layer closure with 1-0 synthetic, monofilament medium-term absorbable suture. Total estimated blood loss was 3500 mL; the patient was transfused with 5 U of red cell pack and 2 U of fresh frozen plasma.

The surviving infant was immediately intubated and received positive pressure ventilation for the first 24 hours. When he was extubated no oxygen support was needed. The woman and the infant were discharged on the fifth postoperative day in good condition.

Discussion

Traditionally, primigravidae and unscarred uteri are considered immune to rupture. Uterine perforation during operative hysteroscopy has been associated with the possibility of UR during subsequent pregnancies ; however, all the cases described in a review on this issue had hysteroscopic perforation due to excessive use of excisional electrosurgical procedures. The current case describes a prelabor UR 10 years after uterine perforation at diagnostic hysteroscopy with no electrosurgical procedures.

To provide more insight in the possible risk factors for prelabor UR in primigravid women, we performed a review of the literature. Twenty-four cases were identified ( Table ). In almost half of them, partial wall defect was the principal recognizable risk factor for UR before the onset of labor.

TABLE

Third-trimester spontaneous prelabor uterine rupture in primigravid women

Author	Year	Age, y	History of infertility	Gestational age, wk	Risk factor(s)	Hysterectomy
Pedowitz et al	1952	31 34	NA NA	33 Term	Myomectomy Myomectomy	No Yes
Felmus et al	1953	24	No	42	Adenomyosis	No
Taylor and Cumming	1979	28	Yes	35	Uterine damage due to trocar insertion, electrocautery	No
Olobo-Lalobo	1984	22	No	38	Uterine surgery	No
Martin et al	1990	33	No	32	Congenital abnormal uterus, abruptio placenta	No
Gonsoulin et al	1990	19	No	32	Placenta percreta, cocaine abuse	Yes
Harris	1992	24	Yes	34	Myomectomy, endometriosis	No
Dubuisson et al	1995	31	Yes	34	Myomectomy, uterine fistula	No
Gürgan et al	1996	27	Yes	36	Uterine perforation during hysteroscopic synechiae resection, electrocautery, genital tuberculosis	No
Abbi and Misra	1997	20	No	37	No risk factor	No
Pelosi and Pelosi	1997	39	No	33	Myomectomy	No
Welsh and Smith	1999	21	No	35	Uterine surgery	No
Dubuisson et al a	2000	32	Yes	34	Tubocornual anastomosis, myomectomy	NA
Kieser and Baskett	2002	NA	Yes	NA	No risk factor	NA
Kazandi	2003	29	No	39	Placenta percreta	Yes
Asakura et al b	2004	31	Yes	35	Myomectomy	No
Banas et al	2005	31	Yes	35	Myomectomy	No
Skrablin et al	2005	39	Yes	36	Myomectomy	No
Wada et al	2006	34	Yes	30	Adenomyomectomy	No
Walsh et al	2006	33	No	40	Ehlers-Danlos syndrome	No
Parker et al	2007	38	No	34	Myomectomy, electrosurgery	No
Matsubara et al c	2011	27	No	38	Thin uterine wall	No
Yazawa et al	2011	37	Yes	33	Adenomyomectomy	No
Current case	2011	41	Yes	35	Uterine perforation during diagnostic hysteroscopy, POF	No

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