A rare case of prelabor uterine rupture in a primigravida was reported. A woman with a history of uterine perforation during hysteroscopy became pregnant after donor oocyte in vitro fertilization. To provide more insight into the possible risk factors for prelabor uterine rupture in primigravidae, a literature review was performed.
Spontaneous uterine rupture (UR) is a rare complication of pregnancy. Its occurrence may implicate a high morbidity and mortality rate in both the fetus and the mother. History of a uterine scar performed for cesarean section, myomectomy, or partial uterine resection is a well-known risk factor for UR during labor. UR is extremely uncommon before the onset of labor and in nulliparous women.
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.
| Author | Year | Age, y | History of infertility | Gestational age, wk | Risk factor(s) | Hysterectomy |
|---|---|---|---|---|---|---|
| Pedowitz et al | 1952 |
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| 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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