Ruptura uterina asociada con útero didelfo y placenta acreta. Reporte de caso / Uterine rupture associated with uterus didelphus and placenta accreta. A case report

Resumen ANTECEDENTES: Las malformaciones müllerianas son consecuencia de una alteración en la formación de los conductos de Müller durante el desarrollo del feto. El momento en que sucede la alteración determina el tipo de malformación. La clasificación actual es la de la American Society for Reproductive Medicine ASMR que se asocia con múltiples complicaciones obstétricas, entre las más graves está la ruptura uterina. CASO CLÍNICO: Paciente primigesta de 23 años, con 39.1 semanas de embarazo, sin antecedentes personales patológicos para el padecimiento actual, sin control prenatal, con dolor abdominal intenso generalizado y disminución de los movimientos fetales desde 12 horas previas a su valoración. Al ingreso de la paciente al hospital su feto se encontró muerto; hemoglobina de 7.9 g/dL, tensión arterial de 96-53 mmHg, taquicárdica, con datos clínicos de irritación peritoneal. En la laparotomía exploradora el feto se encontró muerto, en la cavidad abdominal. Hemoperitoneo de 1300 mL, útero didelfo, con ruptura uterina hacia el fondo. Datos de acretismo placentario. Por lo anterior, se procedió a la histerectomía obstétrica, con sangrado de 2000 cc. Fue necesaria la reanimación y la permanencia de 24 horas en la unidad de cuidados intensivos. La TAC abdomino-pélvica se reportó sin alteraciones renales, con una tumoración adherida cerca del peritoneo parietal sugerente de riñón ectópico. El puerperio trascurrió sin contratiempos por lo que fue dada de alta del hospital. CONCLUSIÓN: En el embarazo, las malformaciones müllerianas son causa de complicaciones obstétricas graves, entre ellas la ruptura uterina. El diagnóstico oportuno es decisivo para la prevención de complicaciones y el control prenatal.

Abstract BACKGROUND: Müllerian malformations are the consequence of an alteration in the formation of the Müllerian ducts during fetal development. The time at which the alteration occurs determines the type of malformation. The current classification is that of the American Society for Reproductive Medicine ASMR, which is associated with multiple obstetric complications, among the most serious of which is uterine rupture. CLINICAL CASE: A 23-year-old primigravid patient, 39.1 weeks pregnant, with no personal pathological history for the current condition, without prenatal control, with severe generalized abdominal pain and decreased fetal movements for 12 hours prior to her evaluation. On the patient admission to the hospital her fetus was found dead; hemoglobin 7.9 g/dL, blood pressure 96-53 mmHg, tachycardic, with clinical data of peritoneal irritation. At exploratory laparotomy the fetus was found dead, in abdominal cavity. Hemoperitoneum of 1300 mL, didelphic uterus, with uterine rupture towards the fundus. Data of placental accretism. Therefore, obstetric hysterectomy was performed, with bleeding of 2000 cc. Resuscitation and a 24-hour stay in the intensive care unit was necessary. The abdomino-pelvic CT scan showed no renal alterations, with an adherent tumor near the parietal peritoneum suggestive of ectopic kidney. The puerperium was uneventful, and she was discharged from the hospital. CONCLUSION: In pregnancy, Müllerian malformations are a cause of serious obstetric complications, including uterine rupture. Timely diagnosis is decisive for the prevention of complications and prenatal management.

Uterine rupture; An obstetric tragedy still with us. A six year review of cases in a specialist hospital, NorthWest Nigeria

Uterine rupture is a major cause of perinatal and maternal morbidity and mortality, it usually has a devastating outcome if not promptly attended to. The study determined the trends, risk factors, feto-maternal outcomes following uterine rupture as seen at ASYBSH. Method: The study was a retrospective review of cases of uterine rupture managed at the ASYBSH between March 2015 and February 2021. Records of the theatre and labour wards were searched and the folders of patients with uterine rupture were retrieved. Relevant information such as socio-demographic variables, booking status, clinical presentations were retrieved and entered into a structured profoma. Results: Deliveries in the hospital during the period were eleven thousand four hundred and twenty (11,420), out of which one hundred and fifty-six (156) were complicated by uterine rupture giving an overall incidence of 1.36 percent or one in every seventy-four (74) deliveries. Uterine rupture occurred mainly among women of low socio-economic status and high parity. The major predisposing factors were injudicious use of oxytocin (62.8%) prolonged obstructed labour (19.8%), previous caesarean section scar (8.5%), use of misoprostol (5.3%), fundal pressure (2.4%) and unexplained factors (1.2%) Conclusion: Uterine rupture remains a devastating obstetric calamity with a high incidence. Injudicious use of oxytocin, prolonged obstructed labour and previous caesarean section scar were the three leading predisposing factors identified in this study

Parto vaginal exitoso y resultados maternos y perinatales en pacientes con antecedente de cesárea y prueba de trabajo de parto: estudio de corte transversal / Successful vaginal delivery and maternal and perinatal outcomes in patients with a history of cesarean section and labor trial: cross-sectional study

Objetivos: determinar la proporción de parto vaginal exitoso en mujeres con cesárea previa, describir las complicaciones maternas y perinatales, y realizar una aproximación a los factores asociados al parto vaginal. Materiales y métodos: estudio de corte transversal descriptivo. Se incluyeron mujeres con antecedente de un parto por cesárea, con edad gestacional mayor a 24 semanas y fetos únicos vivos que tuvieron prueba de parto vaginal, atendidas en una institución pública de alta complejidad en 2019. Se excluyeron aquellas pacientes con antecedente de más de una cesárea o miomectomía. Muestreo consecutivo. Se midieron variables sociodemográficas, obstétricas, vía del parto y complicaciones maternas y perinatales. Se hace análisis descriptivo y un análisis exploratorio multivariado de los factores asociados al parto vaginal exitoso. Resultados: de 286 gestantes incluidas, el porcentaje de éxito de parto vaginal fue del 74,5 %. Se identificaron complicaciones maternas en el 3,2 % de los partos vaginales y en el 6,8 % de las cesáreas. El 1,3 % de los recién nacidos tuvo alguna complicación. Hubo 2 muertes perinatales. Se encontró asociación entre parto vaginal exitoso y tener antecedente de parto vaginal (OR: 2,7; IC 95 %: 1,15-6,29); puntaje de Bishop mayor de 6 (OR: 2,2; IC 95 %: 1,03-4,56); inicio de trabajo de parto espontáneo (OR: 4,5; IC 95 %: 2,07-9,6); y edad materna menor de 30 años (OR: 2,28; IC 95 %: 1,2-4,2). Conclusiones: el parto vaginal es una opción segura para considerar en pacientes con cesárea anterior, especialmente si inician trabajo de parto espontáneo o han tenido un parto vaginal previamente. Se requieren cohortes prospectivas para confirmar estos hallazgos.

Objectives: To determine the proportion of successful vaginal deliveries in women with prior cesarean section; to describe maternal and perinatal complications; and to examine the factors associated with vaginal delivery. Materials and methods: Descriptive cross-sectional study of women with a history of cesarean delivery, gestational age of more than 24 weeks, singleton live fetuses, with prior vaginal delivery who received care in a high complexity public institution in 2019. Patients with a history of more than one cesarean section or myomectomy were excluded. Consecutive sampling was used. Sociodemographic and obstetric variables, delivery route and maternal and perinatal complications were measured. A descriptive analysis as well as a multivariate exploratory analysis of the factors associated with successful vaginal delivery were carried out. Results: Among 286 pregnant women included, the percentage of successful vaginal deliveries was 74.5 %. Maternal complications were identified in 3.2 % of vaginal delivery cases and in 6.8 % of cesarean births. Complications occurred in 1.3 % of all live neonates; there were 2 perinatal deaths. An association was found between successful vaginal delivery and a history of prior vaginal delivery (OR: 2.7; 95 % CI: 1.15-6.29); a Bishop score greater than 6 (OR: 2.2; 95 % CI: 1.03-4.56); spontaneous labor initiation (OR: 4.5; IC 95 % CI: 2.07-9.6); and maternal age under 30 years (OR:2.28; 95 % CI: 1.2-4.2). Conclusions: Vaginal delivery is a safe option to consider in patients with prior cesarean section, in particular in cases of spontaneous labor initiation or prior vaginal delivery. Prospective cohorts are needed in order to confirm these findings.

Embarazo cornual de 31 semanas con ruptura uterina. Reporte de caso / 31-week cornual pregnancy with uterine rupture. A case report

Resumen ANTECEDENTES: El embarazo cornual es un reto diagnóstico debido a que la capacidad de estiramiento del miometrio hace que la manifestación sea tardía y con alta mortalidad debido al riesgo de choque hemorrágico que llega a suceder, incluso, hasta en un tercio de las pacientes. OBJETIVO: Hacer hincapié en la importancia del adecuado control prenatal para el diagnóstico oportuno de embarazo ectópico y la consecuente disminución de complicaciones asociadas. CASO CLÍNICO: Paciente primigesta, de 20 años de edad, originaria y residente de Guadalupe, Nuevo León. Sin antecedentes heredofamiliares o personales médicos o quirúrgicos relevantes. Ingresó a la sala de urgencias de Obstetricia con un cuadro de choque hipovolémico y 31 semanas de embarazo. En la revisión la cavidad abdominal se encontró con un embarazo cornual izquierdo, con ruptura uterina y acretismo placentario. Por lo anterior, se procedió a la histerectomía obstétrica, salpingectomía bilateral y ooforectomía izquierda, con reporte de 1000 mL de hemoperitoneo. La evolución posquirúrgica fue satisfactoria. CONCLUSIONES: El embarazo cornual debe sospecharse en toda mujer con amenorrea, dolor abdominal y sangrado transvaginal, con búsqueda intencionada de los hallazgos ultrasonográficos de cavidad uterina vacía, saco coriónico separado por lo menos 1 cm desde el borde lateral de la cavidad uterina, capa del miometrio delgada (menos de 5 mm) que rodea el saco gestacional y signo de la línea intersticial (visualización de una línea ecogénica que se extiende desde la cavidad endometrial hasta la región cornual, contigua al saco gestacional). El diagnóstico temprano de estos embarazos evita complicaciones y afectaciones al futuro obstétrico.

Abstract BACKGROUND: Cornual pregnancy is a diagnostic challenge because the stretching capacity of the myometrium makes the manifestation late and with high mortality due to the risk of hemorrhagic shock that occurs in up to one third of patients. OBJECTIVE: To emphasize the importance of adequate prenatal care for the timely diagnosis of ectopic pregnancy and the consequent reduction of associated complications. CLINICAL CASE: Primigestation patient, 20 years old, native, and resident of Guadalupe, Nuevo Leon. No relevant heredofamilial or personal medical or surgical history. She was admitted to the obstetrics emergency room with hypovolemic shock and 31 weeks of pregnancy. On examination the abdominal cavity was found to have a left cornual pregnancy, with uterine rupture and placental accretism. Therefore, obstetric hysterectomy, bilateral salpingectomy and left oophorectomy were performed, with a report of 1000 mL of hemoperitoneum. The postoperative evolution was satisfactory. CONCLUSIONS: Cornual pregnancy should be suspected in any woman with amenorrhea, abdominal pain and transvaginal bleeding, with purposeful search for ultrasonographic findings of empty uterine cavity, chorionic sac separated at least 1 cm from the lateral border of the uterine cavity, thin myometrial layer (less than 5 mm) surrounding the gestational sac, and interstitial line sign (the visualization of an echogenic line extending from the endometrial cavity to the cornual region, contiguous with the gestational sac). The early diagnosis of these pregnancies avoids complications and affects the future obstetrician.

Associação entre a técnica de fechamento uterino na cesárea e a istmocele: uma visão global / Association between uterine closure technique after cesarean and isthmocele: an overview

A istmocele (ou "defeito cicatricial de cesariana") é uma alteração anatômica na parede uterina responsável por formar um "nicho", que é visualizado como uma área hipoecoica por histerografia ou por outros métodos de imagem, devido a uma cicatrização inapropriada de uma cesárea anterior. Essa modificação leva a complicações ginecológicas e obstétricas. Este estudo pretendeu analisar, entre os fatores de risco, a relação da istmocele com a técnica de fechamento uterino, comparando a sutura em camada simples com a dupla. Foi realizada uma revisão de literatura por meio de pesquisa bibliográfica em diferentes bases de dados eletrônicos. Foram encontrados 31 artigos, todavia apenas 13 estudos foram incluídos no presente estudo após avaliação criteriosa. A técnica de fechamento uterino é um dos fatores de risco possível de prevenir, sendo que a sutura em camada simples é associada a maior chance de se desenvolver a istmocele. A sutura de camada simples (ancorada) incluindo o endométrio está relacionada a menor espessura miometrial residual, associada a probabilidade de ruptura uterina e a istmocele, que a camada dupla não ancorada com a exclusão do endométrio.(AU)

The isthmocele is an anatomical alteration in the uterine wall responsible for forming a "niche", which is visualized as a hypoechoic area by hysterography or other imaging methods, due to inappropriate healing of a previous cesarean section. This modification leads to gynecological and obstetric complications. This study aimed to analyze among the risk factors the relation of isthmocele and the uterine closure technique comparing the single- and double-layer suture. It was conducted an electronic based search in different electronic databases. The research led to the retrieval of 31 articles; however only 13 studies were included in the present research after careful reading. The uterine closure technique is one of the possible risk factors to be modified; the single-layer suture is associated with a greater chance of developing isthmocele. The locked single-layer suture including the decidua is related to the decreased residual myometrial thickness, associated with the likelihood of uterine rupture and the isthmocele, than the double-layer unlocked excluding the decidua.(AU)

Ruptura uterina por placenta percreta en el tercer trimestre del embarazo: reporte de un caso / Uterine rupture by placenta percreta in the third quarter of pregnancy: case report

Resumen ANTECEDENTES: La placenta percreta es la forma más rara e invasiva del acretismo placentario: supone el 5% de estos casos y concentra la mayor morbilidad y mortalidad materna y perinatal. Además, es la principal causa de ruptura uterina, por ello su diagnóstico y atención temprana son decisivos. Hoy día, el ultrasonido es la herramienta esencial y de elección para identificar el alto riesgo de acretismo placentario. CASO CLÍNICO: Paciente con 32.5 semanas de embarazo, ingresada a Urgencias con signos sugerentes de choque hipovolémico e inconsciente. Se decidió la cesárea de urgencia, con histerectomía abdominal y salpingooferectomía izquierda, por ruptura uterina en torno del cuerno izquierdo, con exposición parcial de la placenta, de aspecto percreta, con salida de vellosidades, laceraciones en el intestino y sangrado de 3500 mL. Nació una niña y se salvó la vida de la madre. CONCLUSIONES: La disponibilidad de personal capacitado y experimentado permite la actuación rápida ante estas urgencias médicas. Los bancos de sangre y las unidades de cuidados intensivos son indispensables para ofrecer una atención médica completa y de calidad que responda a las necesidades de la población.

Abstract BACKGROUD: Placenta percreta is the rarest and most invasive form of accreta placenta spectrum disorders, accounts for 5% of these cases, and concentrates the highest maternal and perinatal morbidity and mortality, in addition to being the main cause of uterine rupture, due to This diagnosis and early attention are decisive. Ultrasound has become the essential and choice tool to identify women at high risk of placental accreta. CLINICAL CASE: Patient with a pregnancy of 32.5 weeks of gestation is admitted to the emergency department with suggestive signs of hypovolemic shock and unconscious, an emergency body caesarean section was performed with abdominal hysterectomy and left salpingooferectomy due to uterine rupture at the level of the left horn with partial exposure of placental appearance Percreta with exit of villi, lacerations in intestine and a total bleeding of 3500 mL. Thanks to the appropriate and timely action of the staff, a unique live product of the female sex was obtained and safeguard the life of the mother. CONCLUSIONS: The importance of having highly trained staff who act quickly in this kind of medical emergency, in addition to having a blood bank and an intensive care unit makes possible a complete and quality medical care that meets the needs of the population.

Menor opción de parto en cesáreas repetidas: estudio de caracterización / Minor option for vaginal delivery in repeat cesarean sections: characterization study

Resumen OBJETIVO: Describir las características de las pacientes con cesárea por indicación de cesárea anterior. MATERIALES Y METODOS: Estudio cuantitativo, descriptivo, observacional y retrospectivo llevado a cabo en el Hospital Regional de Medicina Tropical Julio César Demarini Caro, Chanchamayo, Junín, Perú, entre enero de 2020 y junio de 2021. La información se recopiló de las historias clínicas completas y legibles de los sujetos de investigación y se reunió en una base de datos de Excel y se procesó en el programa SPSS versión 25. Se aplicaron estadística descriptiva, medidas de tendencia central y de frecuencias simples. RESULTADOS: La muestra estudiada fue de 200 mujeres que finalizaron el último embarazo por cesárea; la indicación fue, precisamente, cesárea previa. El 40% no tuvo otra indicación secundaria para la cesárea y 19% tuvo como indicación adicional el sufrimiento fetal agudo. Características obstétricas: multíparas (83.5%), con periodo intergenésico adecuado (62.5%), con atención prenatal adecuada (69%), y con pelvis ginecoide (84.5%). Complicaciones de las madres: anemia moderada y severa (64.5%), rotura uterina (10.5%) y atonía uterina (5%). Complicaciones perinatales: Apgar menor a 7 (15%), asfixia neonatal (11%) y síndrome de insuficiencia respiratoria (9%). CONCLUSIONES: Las indicaciones de las cesáreas previas fueron: sufrimiento fetal agudo, desproporción cefalopélvica, trastornos funiculares, trastornos hipertensivos, oligohidramnios severo y distocias de presentación. Las principales complicaciones materno-perinatales fueron: anemia moderada y severa, rotura uterina, atonía uterina, Apgar del recién nacido menor o igual a 7, asfixia neonatal, síndrome de insuficiencia respiratoria y recién nacido prematuro.

Abstract OBJECTIVE: To determine the main characteristics of patients with previous cesarean section. MATERIALS AND METHODS: Quantitative, descriptive, observational and retrospective study carried out at the Regional Hospital of Tropical Medicine Julio César Demarini Caro, Chanchamayo, Junín, Peru, between January 2020 and June 2021. The information was collected from the complete and legible medical records of the research subjects and was collected in an Excel database and processed in SPSS version 25. Descriptive statistics, measures of central tendency and simple frequencies were applied. RESULTS: The sample studied consisted of 200 women whose last gestation was terminated by cesarean section; the indication was, precisely, previous cesarean section. Forty percent had no other secondary indication for cesarean section and 19% had acute fetal distress as an additional indication. Obstetric characteristics: multiparous (83.5%), with adequate inter-gestational period (62.5%), with adequate prenatal care (69%), and with gynecoid pelvis (84.5%). Maternal complications: moderate and severe anemia (64.5%), uterine rupture (10.5%) and uterine atony (5%). Perinatal complications: Apgar less than 7 (15%), neonatal asphyxia (11%) and respiratory failure syndrome (9%). CONCLUSIONS: Indications for previous cesarean sections were acute fetal distress, cephalopelvic disproportion, funicular disorders, hypertensive disorders, severe oligohydramnios and presentation dystocias. The main maternal and perinatal complications were moderate and severe anemia, uterine rupture, uterine atony, newborn Apgar less than 7, neonatal asphyxia, respiratory distress syndrome and premature newborn.

Rotura uterina: da suspeita ao tratamento / Uterine rupture: from suspicion to treatment

A rotura uterina durante a gravidez ou trabalho de parto é uma grave complicação obstétrica ainda responsável por elevada morbimortalidade materna e perinatal. É importante o diagnóstico diferencial de outras hemorragias da segunda metade da gravidez, como o descolamento prematuro da placenta e a placenta prévia. O diagnóstico é feito baseado em uma associação de sinais bem comuns da rotura uterina. O tratamento sempre é cirúrgico, mas varia de acordo com a classificação da emergência. A prevenção é realizada por meio da atenção obstétrica cuidadosa e com implementação das boas práticas de assistência ao parto.(AU)

Uterine rupture during pregnancy or labor is a serious obstetric complication still responsible for high maternal and perinatal morbidity and mortality. Differential diagnosis of other hemorrhages in the second half of pregnancy, such as placental abruption and placenta previa, is important. The diagnosis is made based on an association of very common signs of uterine rupture. Treatment is always surgical but varies according to the classification of the emergency. Prevention is carried out through careful obstetric care and the implementation of good childbirth care practices.(AU)

Prediction and analysis of adverse pregnancy outcomes in pregnant women with cesarean scar diverticulum / 中华妇产科杂志

Objective:To investigate the pregnancy outcomes of pregnant women with cesarean scar diverticulum (CSD) and to find the relevant factors that predict the occurrence of adverse pregnancy outcomes.Methods:From January 2015 to March 2019, 501 singleton pregnant women with a history of cesarean section who underwent regular prenatal examination in early pregnancy and eventually delivered in Peking University First Hospital were prospectively collected. According to the presence or absence of CSD in the first trimester of pregnancy, the pregnant women were divided into the CSD group ( n=127, 25.3%) and the non-CSD group ( n=374, 74.7%). According to the mode of delivery and the classification of the lower uterine segment seen during cesarean section, the CSD group was further divided into the non-rupture group (including spontaneous delivery and lower uterine segment grade Ⅰ; n=108, 85.0%) and rupture group (including lower uterine segment grade Ⅱ-Ⅳ; n=19, 15.0%). The general clinical data, pregnancy outcomes, diverticulum-related indexes [including length, width, depth (D), average diameter, volume, and residual myometrial thickness (RMT)] were compared. The predictive values of D/adjacent myometrial thickness≥50%, RMT≤2.2 mm and D/RMT>1.3 for uterine rupture in CSD pregnant women were verified. Results:(1) Comparison between CSD group and non-CSD group: the lower uterine segment thickness in the third trimester of pregnancy in the CSD group was lower than that in the non-CSD group [(1.2±0.5) vs (1.4±0.6) mm, respectively], and the incidence of uterine rupture was higher than that in the non-CSD group [15.0% (19/127) vs 8.0% (30/374), respectively], and the differences were statistically significant (both P<0.05). There were no significant differences in other clinical data and pregnancy outcomes between the two groups (all P>0.05). (2) Comparison of rupture group and non-rupture group: the lower uterine segment thickness in the third trimester of pregnancy in rupture group [(0.6±0.5) mm] was lower than that in non-rupture group [(1.2±0.6) mm], and the difference was statistically significant ( t=3.486, P=0.001). There were no significant differences in diverticulum-related indexes between the two groups (all P>0.05). (3) Relationship between high risk predictors of uterine rupture and actual uterine rupture: the sensitivity of D/adjacent muscle thickness ≥50%, RMT≤2.2 mm and D/RMT>1.3 in predicting the high risk of uterine rupture were 94.7%, 57.9% and 73.6%, the specificity were 12.0%, 40.7% and 24.1%, the positive predictive value were 15.9%, 14.7%, 14.6%, and the negative predictive value were 92.8%, 84.6%, 83.9%, respectively. Conclusions:The risk of uterine rupture in pregnant women with CSD is higher than that in those without CSD. There is no significant correlation between CSD related indexes and uterine rupture in the first trimester. Monitoring the lower uterine segment thickness in the third trimester might be helpful to predict the occurrence of adverse pregnancy outcomes.

Facteurs de risque et prise en charge de la rupture utérine dans une structure de 1ere référence du Mali: cas du district sanitaire de Bougouni / Risk factors and management of uterine rupture in a 1st reference structure in Mali: case of the Bougouni health district

L'objectif était d'évaluer les facteurs de risque de la RU et de proposer les aspects thérapeutiques. Matériels et méthodes : Nous avons réalisé une étude cas-témoins au centre de santé de Référence de Bougouni en 2019. Résultats : De janvier au 31 décembre 2019; sur 1161 accouchements 43 RU ont été enregistrées soit 3,7% correspondant à une RU pour 27 accouchements. Les patientes de 35 ans et plus ont été plus touchée par la RU (44,2%) avec ORaIC95%= 6,3 [1,5 - 26,3]. Les évacuations obstétricales avaient un ORaIC95%=25,6 [7,8- 83,7]. La totalité des patientes étaient des femmes au foyer (97,7%) des cas versus (82,3%) des témoins avec ORaIC95%= 8,9 (1,1-69). Les Paucipares et multipares avaient respectivement un ORaIC95%= 6,2 [1,8 - 20,3] et 4,1[1,3 - 12,9]. La cicatrice utérine (20,9%) des cas contre 8,1 % les témoins avait un ORaIC95%= 2,9 [1,1 - 8,7]. En effet l'absence de CPN étaient un facteur de risque, ORaIC95%= 3,0 [1,3 ­ 6,9]. Le délai de la RU était ˂ 6 heures chez 95%. En effet 34 RU complètes (79,1%) et 9 RU incomplètes (20,9%) ont été notées. Seulement 2,3 % des cas avaient accouché par voie basse. Le traitement de la RU reposait sur la chirurgie (100%) complétée par celui du choc (51,2%) des cas et de l'infection (100%) des cas. Conclusion: La RU est fréquente dans nos pays sous médicalisés. Sa prévention efficace passe par des stratégies visant à agir sur les facteurs de risque

The objective was to assess the risk factors for and to suggest therapeutic aspects. Materials and methods: We carried out a case-control study at the Bougouni Reference health center in 2019. Results: From January to December 31, 2019; out of 1161 deliveries, 43 uterine rupture were recorded, 3.7% corresponding to one uterine rupture for 27 deliveries. Patients 35 years and older were more affected by uterine rupture (44.2%) with ORaIC95% = 6.3 [1.5 - 26.3]. Obstetric evacuations had an ORaIC95% = 25.6 [7.8-83.7]. All of the patients were housewives (97.7%) versus (82.3%) controls with ORaIC95% = 8.9 (1.1-69). Pauciparous and multiparous had an ORaIC95% = 6.2 [1.8 - 20.3] and 4.1 [1.3 - 12.9], respectively. The uterine scar (20.9%) of cases versus 8.1% of controls had a 95% ORaIC95% = 2.9 [1.1 - 8.7]. Indeed the absence of ANC was a risk factor, ORaIC95% = 3.0 [1.3 - 6.9]. The time to uterine rupture was ˂ 6 hours in 95%. In fact 34 complete uterine rupture (79.1%) and 9 incomplete uterine rupture (20.9) were noted. Only 2.3% of cases gave birth vaginally. Treatment of uterine rupture was based on surgery (100%) supplemented by shock (51.2%) of cases and infection (100%) of cases. Conclusion: Uterine rupture is common in our countries under medical care. Its effective prevention involves strategies aimed at acting on risk factors.

A propósito de un caso: presentación atípica de rotura uterina / A case report: unusual presentation of uterine rupture

RESUMEN La rotura del útero gestante se define como una solución de continuidad patológica de la pared uterina, situada con mayor frecuencia en el segmento inferior. La rotura de un útero intacto es muy rara, su incidencia está estimada entre 1/5700 y 1/20000 embarazos. Su prevalencia ha aumentado dado el incremento de parto vaginal con cesárea anterior. Actualmente oscila entre el 0.3 y el 1 %, siendo mayor en mujeres en las que tiene lugar un intento de parto vaginal tras cesárea (0,78%) que en aquellas en las que se lleva a cabo una cesárea electiva (0,22%). En cuanto a su diagnóstico, suele ser precoz, dada la clínica de gravedad con la que debutan. En este caso se presenta una evolución atípica de rotura uterina, donde la paciente se mantiene asintomática hasta que acude a urgencias cinco días después del parto con fiebre y dolor abdominal; gracias a la ecografía abdominal y trans-vaginal se pudo establecer rápidamente el diagnóstico y así proceder a su inmediata reparación quirúrgica.

ABSTRACT Rupture of the pregnant uterus is defined as a solution of pathological continuity of the uterine wall, most often located in the lower segment. The rupture of an intact uterus is very rare, its incidence is estimated between 1/5700 and 1/20000 pregnancies. Its prevalence has increased given the increase in vaginal delivery with previous caesarean section. Currently, it ranges between 0.3 and 1%, being higher in women with a vaginal delivery after caesarean section (0.78%) than in those who undergo an elective caesarean section (0.22%). Their diagnosis is usually early given by the severity of the debut. In this case, there is an atypical evolution of uterine rupture where the patient remains asymptomatic until she goes to the emergency room five days after delivery with fever and abdominal pain; Because of the abdominal and transvaginal ultrasound, the diagnosis could be quickly established and thus proceed to immediate surgical repair.

Uterine scar rupture at the site of the placenta accreta presenting as a case of sudden death

Uterine rupture during pregnancy is a known complication of placenta accreta. This paper presents a case of sudden maternal death in the 27th week of gestation due to a ruptured uterine scar at the site of placenta accreta with a short inter-pregnancy period of 6 months with previous two C-sections. Autopsy findings revealed a massive hemoperitoneum and a thinned out anterolateral uterine wall. Internal examination revealed clotted and fluid blood in the peritoneal cavity with rupture of the anterior uterine wall at the site of the placenta accreta in a healed cesarean section scar. Placenta accreta is a rare complication of pregnancy. However, it is becoming more frequent and a significant risk factor with the increasing rate of C-section.

Maternal and Fetal Outcomes in Caesarean Sectıons Repeated Fourth and Fıfth Tımes

ABSTRACT Objective: To evaluate the maternal and fetal outcomes associated with caesarean sections (CS) repeated fourth and fifth times. Methods: We performed a retrospective study of 110 patients undergoing CS repeated fourth and fifth times between May 2014 and May 2015. The patients were divided into two groups: group 1 had CS repeated four times (n = 90) and group 2 had CS repeated five times (n = 20), and the maternal and fetal outcomes of the groups were retrospectively evaluated. Results: There were no statistically significant differences between fourth and fifth CS groups with regard to the maternal age, gravida, body mass index, gestational age at birth, birth-weight, and Apgar scores at 5 minutes (p > 0.05). We found no significant differences between the fourth and fifth CS groups in terms of injury to peripheral organs, intra-abdominal adhesions, caesarean hysterectomy, uterine dehiscence or rupture, time during operation, length of hospital stay, and need for blood transfusions (p > 0.05). Compared with the elective cases, perioperative complications and length of hospital stay were significantly higher in the urgent group (p = 0.034 and p = 0.005). Conclusion: Women with CS repeated four or five times have increased risks for perioperative complications. Placenta previa with or without accreta and intra-abdominal adhesions seem to be the major causes of increased morbidity.

Silent uterine rupture in second trimester: a differential diagnosis to remember

Spontaneous silent uterine rupture is a life-threatening emergency situation requiring immediate laparotomy. High index of suspicion is key to prevent maternal mortality as at times the presentation can be nonspecific. Authors herein present a case of spontaneous silent uterine rupture during second trimester of pregnancy wherein the diagnosis was initially missed. To the best of authors knowledge, only a few cases with spontaneous fundal second trimester uterine rupture have been recorded so far.

Management of caesarean scar ectopic pregnancy: a case report

Caesarean scar ectopic involves an abnormal implantation of the embryo within the myometrium of previous caesarean scar. It is a rare and serious entity involving maternal complication like abnormal placentation, hemorrhage or death due to uterine rupture. Authors present a case report of 32 years old female diagnosed as a case of caesarean scar ectopic pregnancy on TVS and MRI and managed conservatively by USG guided D and C.

A rare case of lower segment scar pregnancy

Caesarean scar ectopic is one of the rarest of all ectopic pregnancies. The incidence of caesarean scar ectopic has increased due to increase in number of caesarean deliveries. A 31-year-old woman (G4P3003) presented from an outside facility to Sola Civil Hospital with vaginal bleeding and discharge with no abdominal pain or any discomfort. The gestational sac was located in an anterior position toward the anterior lower uterine segment at the level of prior caesarean scar with little visible myometrium noted anterior to the gestational sac in the lower uterine segment and Tissue was sent for histopathological examination and diagnosis of caesarean scar ectopic pregnancy was confirmed. Reports found that It is life threatening condition, causes excessive hemorrhage and risk of uterine rupture. The diagnosis of this type of ectopic pregnancy is very difficult and false negative diagnosis can lead to major complications.

Abdomen agudo por coriocarcinoma accidentado. Reporte de un caso clínico / Acute abdomen by accidented coriocarcinoma. Report of a clinical case

Introducción: El coriocarcinoma es una neoplasia gestacional trofoblástica maligna que puede ocurrir después de una mola hidatiforme, embarazo ectópico, aborto e incluso de un embarazo normal. Se trata de una patología poco frecuente que en ocasiones puede pasar desapercibida. Entre las complicaciones clínicas se destaca la metástasis, pero es excepcional la ruptura uterina, siendo esta la que se presenta en el presente caso denotando la importancia del seguimiento. Presentación de caso: Paciente femenina de 49 años que presenta dolor en hipogastrio y vómito, tiene antecedente de mola hidatiforme no controlada. Examen complementario muestra beta-gonadotropina coriónica humana (B-HCG) cualitativa positiva y culdoscentesis positiva. Se realiza tratamiento quirúrgico por laparotomía exploratoria evidenciándose hemoperitoneo más tumor que perfora útero. Se realiza histerectomía abdominal total. Se confirma diagnóstico presuntivo a través de estudio histopatológico que determina coriocarcinoma. Paciente no continua con tratamiento conociéndose posteriormente su deceso. Conclusiones: Se presenta este caso por ser una patología infrecuente con una complicación poco habitual como es la ruptura uterina por coriocarcinoma, al ser considerada una rareza su importancia radica en el diagnóstico oportuno y adecuado seguimiento del caso.

Uterine rupture: a preventable obstetric catastrophe

Background: Maternal health has long been acknowledged to be the cornerstone in public health. The objective of this study was to determine the incidence, etiology, risk factors, complications, treatment strategies, maternal and fetal outcome associated with uterine rupture and to determine how to decrease the maternal morbidity and mortality pertaining to it, as it is indeed a preventable obstetric catastrophe!Methods: This is a retrospective study which was carried out in our institute. Analysis of 45 cases of uterine rupture including scar dehiscence, registered/emergency, rupture occurring in the antepartum or intrapartum period, irrespective of previous vaginal or cesarean delivery was done between July 2017 to June 2019 out of 16,330 deliveries. None of the cases were excluded. Statistical analysis was done comparing the mortality in general population and study population and it was determined that it contributes to the maternal mortality significantly hence making it essential to promptly diagnose and treat the cases.Results: The incidence of rupture of uterus is average 0.27% (1 in 362). Out of 45 cases 9 (20%) were registered, and 36 (80%) were referred patients. The 20-30 years age group is the most vulnerable. Scarred uterus undergoing rupture were 34 (75.55%) as compared to rupture in intact uterus which were 11 (24.44%). The commonest modality of treatment used is suturing of tear which was done in 34 (75.55%) followed by total hysterectomy. There were 2 maternal deaths giving maternal mortality rate of 4.44% and perinatal mortality occurred in 18 (40%) cases.Conclusions: Uterine rupture is a dire emergency with a high incidence of maternal and fetal morbidity and mortality. Skilled attendance with accessible obstetric care, focused antenatal care, strict intrapartum monitoring and good surgical approach are key elements for the prevention and management of uterine rupture.

Hemorragia obstétrica y rotura uterina por un embarazo intersticial. Reporte de un caso / Obstetric hemorrhage and uterine rupture due to an interstitial pregnancy. Report of a case

Resumen: ANTECEDENTES: El embarazo ectópico intersticial ocurre en 2.4% de los casos, quizá debido a la rotura uterina, con lo que se incrementa la morbilidad y mortalidad por hemorragia obstétrica. Los factores de riesgo son los mismos que para el embarazo ectópico tubárico. El tratamiento se establece en función del escenario clínico y deseo genésico de la paciente. CASO CLÍNICO: Paciente de 31 años, que ingresó al servicio de Urgencias por dolor abdominal severo e incapacitante en el hipogastrio, con índice de choque de 1.3 y signos de irritación peritoneal. La ecografía reportó líquido libre en el hueco pélvico y el espacio de Morrison; el saco gestacional extrauterino se encontraba en el anexo izquierdo, el feto sin latido cardiaco, con longitud craneocaudal de 11 semanas de gestación. La laparotomía exploradora evidenció: hemoperitoneo de 2800 cc, rotura uterina en el cuerno derecho, de aproximadamente 8 x 6 cm, visualización del feto e integridad de la bolsa amniótica. Puesto que la paciente manifestó no desear más embarazos se decidió efectuar la histerectomía total abdominal. CONCLUSIONES: El embarazo ectópico intersticial comparte los mismos factores de riesgo que el embarazo tubárico. Hoy día se dispone de diversos métodos de diagnóstico; sin embargo, la detección oportuna permite implementar el tratamiento conservador a seguir y, así, disminuir la morbilidad y mortalidad materna.

Abstract: BACKGROUND: Interstitial ectopic pregnancy occurs in approximately 2.4% of all cases, this tubal portion is located in the proximal segment and shares the muscular portion of the uterus, due to its great myometrial compliance, it facilitates late diagnosis and its clinical presentation is By means of uterine rupture and with it an increase in morbidity and mortality due to obstetric hemorrhage, the risk factors are the same as for tubal ectopic pregnancy, treatment is assessed based on preserving fertility and according to the patient's clinical setting. CLINICAL CASE: A 31-year-old patient who went to the emergency department for severe and disabling abdominal pain in the hypogastrium, shock index 1.3, with signs of peritoneal irritation, ultrasound was performed, which reported free fluid in the pelvic cavity and Morrison space, extrauterine gestational sac at the level of the left annex, embryo without heartbeat, craniocaudal length of 11 weeks of gestation, exploratory laparotomy was performed, in which hemoperitoneum of 2800 cc was observed, uterine rupture in the right cornual region of approximately 8x6cm, with fetus e integrity of the amniotic sac adjacent to the uterine rupture, the patient reported satisfied parity, and therefore a total abdominal hysterectomy was decided. CONCLUSIONS: Interstitial ectopic pregnancy shares the same risk factors as tubal pregnancy. Today, we have various diagnostic aids, so the cornerstone is timely detection, which will allow conservative treatments to decrease maternal morbidity and mortality.

Útero didelfo como causa de ruptura uterina espontánea. Reporte de un caso / Didelphys uterus as a cause of spontaneous uterine rupture. A case report

Resumen: ANTECEDENTES: Las malformaciones müllerianas son un grupo de alteraciones congénitas que resultan del inadecuado desarrollo de los conductos de Müller durante la embriogénesis. El 25% de las mujeres con malformaciones müllerianas tiene problemas obstétricos. La rotura espontánea del útero didelfo durante el embarazo es un accidente poco frecuente y de difícil diagnóstico. La importancia del estudio de estas malformaciones radica en las posibilidades diagnósticas y terapéuticas, además del pronóstico reproductivo de las pacientes. CASO CLÍNICO: Paciente de 27 años, acudió a consulta por dolor abdominal intenso súbito. A la exploración física se encontraron: tensión arterial de 90-50 mmHg, palidez cutáneo-mucosa, hipotensión e hipotermia, abdomen doloroso, fondo uterino no delimitable y datos de irritación peritoneal; cuello uterino cerrado, sin sangrado transvaginal. En la ecografía: feto único extrauterino, con ausencia de actividad cardiaca, de 21.2 semanas de gestación y líquido libre en la cavidad abdominal. La laparotomía exploradora reportó: útero didelfo con ruptura uterina, por lo que se procedió a la metroplastia de Strassman, con resultados satisfactorios. CONCLUSIÓN: Aún con la escasa frecuencia de estos casos siempre será conveniente tenerlos en mente en el diagnóstico diferencial de mujeres embarazadas que en el segundo trimestre manifiestan dolor abdominal. Este caso sirve como precedente para la atención y tratamiento temprano, con la intención de evitar complicaciones, como la ruptura uterina.

Abstract: BACKGROUND: Mullerian malformations are a group of congenital pathologies resulting from from an inadequate development of the Mullerian ducts during embryogenesis. The 25% of women with mullerian malformations have obstetric problems. Spontaneous rupture of the didelphys uterus during pregnancy is a rare and difficult- to- diagnose accident. The fundamental importance of the study of these malformations lies in the various diagnostic and therapeutic possibilities employed, in addition to the improvement in the reproductive prognosis of the patients. CLINICAL CASE: 27-year-old patient, who starts suddenly with severe abdominal pain. She arrives at the emergency department with blood pressure of 90/50 mmHg, pale-mucous paleness, coldness, hypotension and hypothermia, painful abdomen, non-delimitable uterine fundus, with data of peritoneal irritation; closed cervix, without transvaginal bleeding. On ultrasound: single extrauterine fetus, with absence of cardiac activity, 21.2 weeks, presence of free fluid in abdominal cavity. An exploratory laparotomy is performed by finding a didelphys uterus with uterine rupture and a Strassman metroplasty is performed. CONCLUSION: Despite the low frequency of the clinical case presented, we believe that it should be considered in the differential diagnosis of pregnant women with abdominal pain in the second trimester. Likewise, we consider it important to make it known to contribute to early approach and treatment, avoiding complications such as uterine rupture.