Perinatal morbidity among women with a previous caesarean delivery (PRISMA trial): a cluster-randomised trial.

BACKGROUND: Women with a previous caesarean delivery face a difficult choice in their next pregnancy: planning another caesarean or attempting vaginal delivery, both of which are associated with potential maternal and perinatal complications. This trial aimed to assess whether a multifaceted intervention, which promoted person-centred decision making and best practices, would reduce the risk of major perinatal morbidity among women with one previous caesarean delivery. METHODS: We conducted an open, multicentre, cluster-randomised, controlled trial of a multifaceted 2-year intervention in 40 hospitals in Quebec among women with one previous caesarean delivery, in which hospitals were the units of randomisation and women the units of analysis. Randomisation was stratified according to level of care, using blocked randomisation. Hospitals were randomly assigned (1:1) to the intervention group (implementation of best practices and provision of tools that aimed to support decision making about mode of delivery, including an estimation of the probability of vaginal delivery and an ultrasound estimation of the risk of uterine rupture), or the control group (no intervention). The primary outcome was a composite risk of major perinatal morbidity. This trial was registered with ISRCTN, ISRCTN15346559. FINDINGS: 21 281 eligible women delivered during the study period, from April 1, 2016 to Dec 13, 2019 (10 514 in the intervention group and 10 767 in the control group). None were lost to follow-up. There was a significant reduction in the rate of major perinatal morbidity from the baseline period to the intervention period in the intervention group as compared with the control group (adjusted odds ratio [OR] for incremental change over time, 0·72 [95% CI 0·52-0·99]; p=0·042; adjusted risk difference -1·2% [95% CI -2·0 to -0·1]). Major maternal morbidity was significantly reduced in the intervention group as compared with the control group (adjusted OR 0·54 [95% CI 0·33-0·89]; p=0·016). Minor perinatal and maternal morbidity, caesarean delivery, and uterine rupture rates did not differ significantly between groups. INTERPRETATION: A multifaceted intervention supporting women in their choice of mode of delivery and promoting best practices resulted in a significant reduction in rates of major perinatal and maternal morbidity, without an increase in the rate of caesarean or uterine rupture. FUNDING: Canadian Institutes of Health Research (CIHR, MOP-142448).

Parturition at term: induction, second and third stages of labor, and optimal management of life-threatening complications-hemorrhage, infection, and uterine rupture.

Childbirth is a defining moment in anyone's life, and it occurs 140 million times per year. Largely a physiologic process, parturition does come with risks; one mother dies every two minutes. These deaths occur mostly among healthy women, and many are considered preventable. For each death, 20 to 30 mothers experience complications that compromise their short- and long-term health. The risk of birth extends to the newborn, and, in 2020, 2.4 million neonates died, 25% in the first day of life. Hence, intrapartum care is an important priority for society. The American Journal of Obstetrics & Gynecology has devoted two special Supplements in 2023 and 2024 to the clinical aspects of labor at term. This article describes the content of the Supplements and highlights new developments in the induction of labor (a comparison of methods, definition of failed induction, new pharmacologic agents), management of the second stage, the value of intrapartum sonography, new concepts on soft tissue dystocia, optimal care during the third stage, and common complications that account for maternal death, such as infection, hemorrhage, and uterine rupture. All articles are available to subscribers and non-subscribers and have supporting video content to enhance dissemination and improve intrapartum care. Our hope is that no mother suffers because of lack of information.

Trial of labor after cesarean, vaginal birth after cesarean, and the risk of uterine rupture: an expert review.

The decision to pursue a trial of labor after cesarean delivery is complex and depends on patient preference, the likelihood of successful vaginal birth after cesarean delivery, assessment of the risks vs benefits of trial of labor after cesarean delivery, and available resources to support safe trial of labor after cesarean delivery at the planned birthing center. The most feared complication of trial of labor after cesarean delivery is uterine rupture, which can have catastrophic consequences, including substantial maternal and perinatal morbidity and mortality. Although the absolute risk of uterine rupture is low, several clinical, historical, obstetrical, and intrapartum factors have been associated with increased risk. It is therefore critical for clinicians managing patients during trial of labor after cesarean delivery to be aware of these risk factors to appropriately select candidates for trial of labor after cesarean delivery and maximize the safety and benefits while minimizing the risks. Caution is advised when considering labor augmentation and induction in patients with a previous cesarean delivery. With established hospital safety protocols that dictate close maternal and fetal monitoring, avoidance of prostaglandins, and careful titration of oxytocin infusion when induction agents are needed, spontaneous and induced trial of labor after cesarean delivery are safe and should be offered to most patients with 1 previous low transverse, low vertical, or unknown uterine incision after appropriate evaluation, counseling, planning, and shared decision-making. Future research should focus on clarifying true risk factors and identifying the optimal approach to intrapartum and induction management, tools for antenatal prediction, and strategies for prevention of uterine rupture during trial of labor after cesarean delivery. A better understanding will facilitate patient counseling, support efforts to improve trial of labor after cesarean delivery and vaginal birth after cesarean delivery rates, and reduce the morbidity and mortality associated with uterine rupture during trial of labor after cesarean delivery.

Single-layer vs double-layer uterine closure during cesarean delivery: 3-year follow-up of a randomized controlled trial (2Close study).

BACKGROUND: The rising rate of cesarean deliveries has led to an increased incidence of long long-term complications, including niche formation in the uterine scar. Niche development is associated with various gynecologic complaints and complications in subsequent pregnancies, such as uterine rupture and placenta accreta spectrum disorders. Although uterine closure technique is considered a potential risk factor for niche development, consensus on the optimal technique remains elusive. OBJECTIVE: We aimed to evaluate the effect of single-layer vs double-layer closure of the uterine incision on live birth rate at a 3-year follow-up with secondary objectives focusing on gynecologic, fertility, and obstetrical outcomes at the same follow-up. STUDY DESIGN: A multicenter, double-blind, randomized controlled trial was performed at 32 hospitals in the Netherlands. Women ≥18 years old undergoing a first cesarean delivery were randomly assigned (1:1) to receive either single-layer or double-layer closure of the uterine incision. The primary outcome of the long-term follow-up was the live birth rate; with secondary outcomes, including pregnancy rate, the need for fertility treatment, mode of delivery, and obstetrical and gynecologic complications. This trial is registered on the International Clinical Trials Registry Platform www.who.int (NTR5480; trial finished). RESULTS: Between 2016 and 2018, the 2Close study randomly assigned 2292 women, with 830 of 1144 and 818 of 1148 responding to the 3-year questionnaire in the single-layer and double-layer closure. No differences were observed in live birth rates; also there were no differences in pregnancy rate, need for fertility treatments, mode of delivery, or uterine ruptures in subsequent pregnancies. High rates of gynecologic symptoms, including spotting (30%-32%), dysmenorrhea (47%-49%), and sexual dysfunction (Female Sexual Function Index score, 23) are reported in both groups. CONCLUSION: The study did not demonstrate the superiority of double-layer closure over single-layer closure in terms of reproductive outcomes after a first cesarean delivery. This challenges the current recommendation favoring double-layer closure, and we propose that surgeons can choose their preferred technique. Furthermore, the high risk of gynecologic symptoms after a cesarean delivery should be discussed with patients.

Vascular Ehlers-Danlos syndrome and pregnancy: A systematic review.

BACKGROUND: Vascular Ehlers-Danlos syndrome (vEDS) is a hereditary connective tissue disorder associated with an elevated risk of vascular, uterine and digestive complications. Managing pregnancy in this context can be a challenge. OBJECTIVES: To systematically review the literature data on the complications in pregnancy associated with vEDS. SEARCH STRATEGY: We searched the Pubmed Medline and Embase databases for articles using the following terms "vascular Ehlers-Danlos syndrome" or "vEDS" AND "pregnancy". SELECTION CRITERIA: Women with vEDS. DATA COLLECTION AND ANALYSIS: We searched the PubMed® MEDLINE® database for publications evaluating obstetric outcomes in women with vEDS. MAIN RESULTS: A total of 121 publications were screened, with six (accounting for 412 pregnancies) included in our review. Of the women included in this sample, 30% were infertile. The miscarriage rate was 13.8% (57/412) and 8.8% of the live births were premature. Obstetric anal sphincter injuries occurred in 11.3% (23/203) of the deliveries. The maternal mortality rate per pregnancy was 5.7%. CONCLUSIONS: Women with vEDS present an elevated risk of uterine rupture, vascular events, digestive events and death during pregnancy. Women appear to be most at risk during the peripartum period; to avoid expulsive efforts, a caesarean section should be scheduled at 37 weeks of gestation.

Clinical analysis of complete uterine rupture during pregnancy.

BACKGROUND: Uterine rupture in pregnant women can lead to serious adverse outcomes. This study aimed to explore the clinical characteristics, treatment, and prognosis of patients with complete uterine rupture. METHODS: Data from 33 cases of surgically confirmed complete uterine rupture at Chenzhou No.1 People's Hospital between January 2015 and December 2022 were analyzed retrospectively. RESULTS: In total, 31,555 pregnant women delivered in our hospital during the study period. Of these, approximately 1‰ (n = 33) had complete uterine rupture. The average gestational age at complete uterine rupture was 31+4 weeks (13+1-40+3 weeks), and the average bleeding volume was 1896.97 ml (200-6000 ml). Twenty-six patients (78.79%) had undergone more than two deliveries. Twenty-five women (75.76%) experienced uterine rupture after a cesarean section, two (6.06%) after fallopian tube surgery, one (3.03%) after laparoscopic cervical cerclage, and one (3.03%) after wedge resection of the uterine horn, and Fifteen women (45.45%) presented with uterine rupture at the original cesarean section incision scar. Thirteen patients (39.39%) were transferred to our hospital after their initial diagnosis. Seven patients (21.21%) had no obvious symptoms, and only four patients (12.12%) had typical persistent lower abdominal pain. There were 13 cases (39.39%, including eight cases ≥ 28 weeks old) of fetal death in utero and two cases (6.06%, both full term) of severe neonatal asphyxia. The rates of postpartum hemorrhage, blood transfusion, hysterectomy were 66.67%, 63.64%, and 21.21%. Maternal death occurred in one case (3.03%). CONCLUSIONS: The site of the uterine rupture was random, and was often located at the weakest point of the uterus. There is no effective means for detecting or predicting the weakest point of the uterus. Rapid recognition is key to the treatment of uterine rupture.

Trial of labour after two caesarean sections (TOLA2C) and risk of uterine rupture, a retrospective single centre study.

BACKGROUND: Most German hospitals do not offer a trial of labour after two caesarean sections (TOLA2C). TOLA2C is claimed to be associated with too many complications, above all the high risk of uterine rupture. The objective of this study is to review our experience with TOLA2C, with special attention paid to the risk and probability of uterine ruptures. Secondary outcomes include comparing neonatal and maternal outcomes in the group of TOLA2C with the group of elective repeat caesarean section (ERCS) and to assess the success rate for vaginal birth after two caesarean sections (VBAC-2). METHODS: The retrospective cohort study was conducted in a community hospital in North Rhine-Westphalia. Inclusion criteria were all pregnant women with two caesarean sections in their medical history, with a current vertex singleton pregnancy and the absence of morphological abnormalities of the foetus, who gave birth in our facility between January 2015 and June 2021. Descriptive statistics were calculated and Kolmogorov-Smirnov tests, Mann-Whitney U tests, Fishers exact tests, Chi2 -tests and t-tests for independent samples were performed. RESULTS: A total of 91 cases were included in the TOLA2C-group. These were compared to 99 cases that, within the same time frame, had an elective repeat caesarean section (ERCS-group). There was no statistically significant difference found in the neonatal outcome between the two groups (except for the neonatal pH-value: p 0.024). The hospital stay was significantly shorter in the TOLA2C-group, while maternal complication rates were almost similar (13.2% in the TOLA2C-Group, vs. 16.2% in the ERCS-Group). The success rate for TOLA2C was 55%. No complete uterine rupture was found, but in three cases an incomplete rupture (3.3% rate for incomplete uterine ruptures) occurred, but had no influence on the neonatal outcome. CONCLUSION: TOLA2C is not associated with a worse maternal or neonatal outcome compared to ERCS, and especially the risk of complete uterine ruptures seems to be low. TOLA2C should be more widely offered to suitable patients who are motivated for it.

Accidental uterine extensions in cesarean deliveries - outcome of subsequent pregnancy.

OBJECTIVES: To explore the obstetric, maternal and neonatal outcome in the subsequent pregnancy after a pregnancy with an accidental uterine extension (AUE) during cesarean delivery (CD), as well as the relationship between the different types of AUE (inferior, lateral and superior). METHODS: A retrospective cohort study of all CD with AUE in a tertiary medical center between 01/2011-01/2022. Women with a prior CD with AUE were compared to a 1:3 ratio matched control group of women with a prior CD without AUE. All AUE were defined in their direction, size and mode of suturing. CD with deliberate uterine extensions were excluded. We evaluated obstetric, maternal and neonatal outcomes in the subsequent pregnancy after a pregnancy with AUE during CD. RESULTS: Comparing women with a prior CD with AUE (n=177) to the matched control group of women with a prior CD without AUE (n=528), we found no significant differences in proportions of uterine rupture or any other major complication or adverse outcome between the groups. There were no significant differences in the outcomes of the subsequent pregnancy in relation to the characteristics of the AUE (direction, size and mode of suturing). CONCLUSIONS: Subsequent pregnancies after AUE are not associated with higher maternal or neonatal adverse outcomes including higher proportions of uterine rupture compared to pregnancies without previous AUE. Different characteristics of the AUE do not impact the outcome.

Updated criteria for the approval of subsequent pregnancy after cesarean section with a transverse uterine fundal incision based on 17 years of experience.

In the case of placenta previa-accreta when the placenta covers the entire anterior uterine wall, it is difficult to avoid transecting the placenta by traditional low-transverse cesarean section (CS), resulting in catastrophic hemorrhage and fetal anemia. To prevent this critical risk, we developed the CS with transverse uterine fundal incision (TUFI) and this technique has been widely used as a beneficial surgical method in clinical practice owing to its safety advantages for the mother and neonate since our first report. However, the risk of uterine rupture during a subsequent pregnancy remains unclear. Based on our 17 years of experience, patients who require TUFI do not need to avoid this beneficial operative method simply because of their desire to conceive again, as long as certain conditions can be met. To approve a post-TUFI pregnancy, an appropriate suture method, delay in conception for at least 12 months with evaluation of the TUFI scar, and cautious postoperative management are at a minimum essential. In this article, we showed our recommendation for operative procedure and discuss the current status of the management of post-TUFI pregnancies based on the evaluation of the TUFI wound scar and experience with postoperative pregnancies.

Elective Induction of Labor following Prior Cesarean Delivery.

OBJECTIVE: Following the release of A Randomized Trial of Induction versus Expectant Management (ARRIVE) trial, the induction of labor at 39 weeks has increased in the United States. The risk of uterine rupture and optimal timing of elective induction in those patients with a prior cesarean delivery is not well-described, and they were not included in the original trial. We aimed to determine the risk of uterine rupture in those patients undergoing elective induction of labor with prior cesarean delivery. STUDY DESIGN: This was a retrospective cohort of participants with prior cesarean delivery from 1996 to 2000. Participants were included if they had two or more prior cesareans. Participants were excluded if they had a history of an unknown prior incision, a classical incision, gestational age <39 weeks, any diabetes, chronic hypertension, twin gestation, collagen or vascular disease, or HIV. Those undergoing expectant management were compared with those undergoing elective induction with no medical or obstetrical indications for delivery. Analysis was performed at three gestational age groups: 39 weeks, 40 weeks, and 41 weeks. The primary outcomes were uterine rupture, rates of successful vaginal delivery, and a composite major morbidity risk. Multivariable logistic regression was performed. RESULTS: At 39 weeks, 618 (10.3%) elective inductions were compared with 5,365 (89.7%) undergoing expectant management; uterine rupture occurred more frequently (13 patients [2.1%] vs. 49 patients [0.9%]; adjusted odds ratio [aOR], 2.5; 95% confidence interval, 1.3-4.6) with fewer successful vaginal birth after cesarean [VBAC; 66.8 vs. 75%; aOR, 0.6; 95% confidence interval, 0.5-0.7]. The risk of uterine rupture was similar between groups at 40 weeks (5 patients [0.8%] vs. 21 patients [1.2%]; p = 0.387) and 41 weeks (7 patients [1.4%] vs. 2 patients (0.8%); p = 0.448). CONCLUSION: Patients undergoing elective induction of labor with a prior cesarean scar had an increased risk of uterine rupture when compared with expectant management at 39 weeks, with fewer successful VBAC. KEY POINTS: · TOLAC elective induction at 39 weeks has an increased risk of uterine rupture.. · TOLAC elective induction at 39 weeks has a less successful chance of vaginal delivery.. · Awaiting spontaneous labor in this cohort does not increase the risk of uterine rupture..

Risk factors for maternal complications following uterine rupture: a 12-year single-center experience.

PURPOSE: To determine maternal outcomes and risk factors for composite maternal morbidity following uterine rupture during pregnancy. METHODS: A retrospective cohort study including all women diagnosed with uterine rupture during pregnancy, between 2011 and 2023, at a single-center. Patients with partial uterine rupture or dehiscence were excluded. We compared women who had composite maternal morbidity following uterine rupture to those without. Composite maternal morbidity was defined as any of the following: maternal death; hysterectomy; severe postpartum hemorrhage; disseminated intravascular coagulation; injury to adjacent organs; admission to the intensive care unit; or the need for relaparotomy. The primary outcome was risk factors associated with composite maternal morbidity following uterine rupture. The secondary outcome was the incidence of maternal and neonatal complications following uterine rupture. RESULTS: During the study period, 147,037 women delivered. Of them, 120 were diagnosed with uterine rupture. Among these, 44 (36.7%) had composite maternal morbidity. There were no cases of maternal death and two cases of neonatal death (1.7%); packed cell transfusion was the major contributor to maternal morbidity [occurring in 36 patients (30%)]. Patients with composite maternal morbidity, compared to those without, were characterized by: increased maternal age (34.7 vs. 32.8 years, p = 0.03); lower gestational age at delivery (35 + 5 vs. 38 + 1 weeks, p = 0.01); a higher rate of unscarred uteri (22.7% vs. 2.6%, p < 0.01); and rupture occurring outside the lower uterine segment (52.3% vs. 10.5%, p < 0.01). CONCLUSION: Uterine rupture entails increased risk for several adverse maternal outcomes, though possibly more favorable than previously described. Numerous risk factors for composite maternal morbidity following rupture exist and should be carefully assessed in these patients.

Spontaneous second trimester rupture of a previous caesarean section scar: A case report.

Spontaneous uterine rupture before the onset of labour is rare in pregnancy especially before the third trimester. It is life threatening with devastating consequences to the mother and fetus. We report a case of spontaneous second trimester uterine rupture in a multipara with a previous uterine scar with the aim of creating awareness and sharing the challenges in diagnosis and management of this unusual complication of pregnancy. A 34-year-old woman with two previous deliveries presented at 16 weeks gestation with abdominal pain and vaginal bleeding of one day duration. At presentation, she was pale and in shock. There was generalized abdominal tenderness with guarding and rebound tenderness. At laparotomy, there was uterine rupture involving the lower segment with right lateral upward extension which was repaired. She remained stable at the follow up visit. In conclusion, Spontaneous uterine rupture of a previous caesarean section scar in the second trimester is rare. The diagnosis should be considered in a woman with previous caesarean section who experience an acute abdomen in the second trimester of pregnancy.

La rupture utérine spontanée avant le début du travail est rare pendant la grossesse, surtout avant le troisième trimestre. Elle met la vie en danger et entraîne des conséquences dévastatrices pour la mère et le fœtus. Nous rapportons un cas de rupture utérine spontanée au deuxième trimestre chez une multipare présentant une cicatrice utérine antérieure dans le but de sensibiliser et de partager les défis du diagnostic et de la prise en charge de cette complication inhabituelle de la grossesse. Une femme de 34 ans ayant déjà accouché deux fois s'est présentée à 16 semaines de gestation avec des douleurs abdominales et des saignements vaginaux d'une durée d'un jour. Lors de la présentation, elle était pâle et sous le choc. Il y avait une sensibilité abdominale généralisée avec une sensibilité de garde et de rebond. Lors de la laparotomie, il y a eu une rupture utérine impliquant le segment inférieur avec extension latérale droite vers le haut qui a été réparée. Elle est restée stable lors de la visite de suivi. En conclusion, la rupture utérine spontanée d'une cicatrice de césarienne antérieure au deuxième trimestre est rare. Le diagnostic doit être envisagé chez une femme ayant déjà subi une césarienne et présentant un abdomen aigu au cours du deuxième trimestre de la grossesse.

[Rudimentary horn pregnancy: clinical analysis of 12 cases and literature review].

Objective: To investigate the clinical characteristics, treatments and fertility recovery of rudimentary horn pregnancy (RHP). Methods: The clinical data of 12 cases with RHP diagnosed and treated in Peking University Third Hospital from January 1, 2010 to December 31, 2022 were retrospectively analyzed. Clinical informations, diagnosis and treatments of RHP and the pregnancy status after surgery were analyzed. Results: The median age of 12 RHP patients was 29 years (range: 24-37 years). Eight cases of pregnancy in residual horn of uterus occurred in type Ⅰ residual horn of uterus, 4 cases occurred in type Ⅱ residual horn of uterus; among which 5 cases were misdiagnosed by ultrasound before surgery. All patients underwent excision of residual horn of uterus and affected salpingectomy. After surgery, 9 patients expected future pregnancy, and 3 cases of natural pregnancy, 2 cases of successful pregnancy through assisted reproductive technology. Four pregnancies resulted in live birth with cesarean section, and 1 case resulted in spontaneous abortion during the first trimester of pregnancy. No uterine rupture or ectopic pregnancy occurred in subsequent pregnancies. Conclusions: Ultrasonography could aid early diagnosis of RHP while misdiagnosis occurred in certain cases. Thus, a comprehensive judgment and decision ought to be made based on medical history, physical examination and assisted examination. Surgical exploration is necessary for diagnosis and treatment of RHP. For infertile patients, assisted reproductive technology should be applied when necessary. Caution to prevent the occurrence of pregnancy complications such as uterine rupture, and application of cesarean section to terminate pregnancy are recommended.

[Trial of labor and gynecological uterine scars : a narrative review]. / Accouchement vaginal et cicatrices utérines d'origine gynécologique : revue narrative.

The increasing number of women of childbearing age with gynecological uterine scars presents a significant clinical challenge. -Planning the route of birth for a subsequent pregnancy necessitates -careful consideration and should be the subject of an informed -discussion. Unfortunately, the heterogeneity of data in the literature with regards to gynecological uterine scars makes this choice -debatable. Although the use of less invasive surgical procedures in this context is on the rise, there is currently a lack of robust data on their obstetric repercussions. This article -explores risk factors for uterine rupture in the view of gynecological uterine scars and -provides pragmatic recommendations for clinicians.

Le nombre de patientes en âge de procréer avec un utérus ­cicatriciel d'origine gynécologique est en augmentation du fait de l'avancée en âge médian des grossesses. Le choix de la voie d'accouchement pour la grossesse ultérieure doit faire l'objet d'une discussion éclairée. Malheureusement, les données de la littérature concernant les cicatrices utérines d'origine gynéco­logique sont hétérogènes rendant le choix de la voie d'accou­chement discutable. De nouvelles techniques chirurgicales moins invasives se développent mais peu de données sur le retentis­sement obstétrical existent. Cet article fait le point sur les facteurs de risque de rupture utérine dans le contexte des cicatrices utérines d'origine gynécologique et propose aux cliniciens une attitude pragmatique.

Incidence and outcomes of uterine rupture in women with unscarred, preterm or prelabour uteri: data from the international network of obstetric survey systems.

OBJECTIVE: Analysis of atypical cases of uterine rupture, namely, uterine rupture occurring in unscarred, preterm or prelabour uteri. DESIGN: Descriptive multi-country population-based study. SETTING: Ten high-income countries within the International Network of Obstetric Survey Systems. POPULATION: Women with unscarred, preterm or prelabour ruptured uteri. METHODS: We merged prospectively collected individual patient data in ten population-based studies of women with complete uterine rupture. In this analysis, we focused on women with uterine rupture of unscarred, preterm or prelabour ruptured uteri. MAIN OUTCOME MEASURES: Incidence, women's characteristics, presentation and maternal and perinatal outcome. RESULTS: We identified 357 atypical uterine ruptures in 3 064 923 women giving birth. Estimated incidence was 0.2 per 10 000 women (95% CI 0.2-0.3) in the unscarred uteri, 0.5 (95% CI 0.5-0.6) in the preterm uteri, 0.7 (95% CI 0.6-0.8) in the prelabour uteri, and 0.5 (95% CI 0.4-0.5) in the group with no previous caesarean. Atypical uterine rupture resulted in peripartum hysterectomy in 66 women (18.5%, 95% CI 14.3-23.5%), three maternal deaths (0.84%, 95% CI 0.17-2.5%) and perinatal death in 62 infants (19.7%, 95% CI 15.1-25.3%). CONCLUSIONS: Uterine rupture in preterm, prelabour or unscarred uteri are extremely uncommon but were associated with severe maternal and perinatal outcome. We found a mix of risk factors in unscarred uteri, most preterm uterine ruptures occurred in caesarean-scarred uteri and most prelabour uterine ruptures in 'otherwise' scarred uteri. This study may increase awareness among clinicians and raise suspicion of the possibility of uterine rupture under these less expected conditions.

Uterine rupture after high-intensity focused ultrasound ablation of adenomyosis: a case report and literature review.

AIM: High-intensity focused ultrasound (HIFU) is a non-invasive treatment of adenomyosis. Uterine rupture during pregnancy is a rare adverse event after HIFU treatment, because HIFU treatment results in tissue coagulative necrosis. METHODS: We reported a case of uterine rupture in a 34-year-old woman. The woman had HIFU treatment for adenomyosis eight months before unplanned pregnancy. She was closely monitored during the pregnancy and the antenatal course was uneventful. At the gestational age of 38 weeks and 2 days, an emergency lower segment cesarean section was performed because of inexplainable abdominal pain. After delivery of the fetus, a 2 × 2 cm serous membrane rupture was observed in the HIFU treatment area. CONCLUSION: Uterine rupture during pregnancy after HIFU is a rare adverse event, however, attention is required during the whole pregnancy in case of unexpected uterine rupture.

Conservative management of complete fetal expulsion into the abdominal cavity after silent uterine rupture - case report.

BACKGROUND: Clinically silent uterine rupture with complete fetal expulsion into the abdominal cavity is an extremely rare complication. Diagnosis can be difficult and the risk to the mother and fetus is high. Conservative management has been described only in a few cases of partial expulsion of the fetus so far. CASE PRESENTATION: We present a case of 43-year-old tercigravida with a history of previous laparotomic myomectomy and subsequent cesarean section. The subsequent pregnancy was complicated by uterine wall loosening and rupture at the site of the previous uterine scar after myomectomy and complete fetal expulsion into the abdominal cavity. The diagnosis was made at 24 + 6 weeks of gestation. Considering the absence of clinical symptomatology and the good condition of the fetus, a conservative approach was chosen with intensive monitoring of the maternal and fetal conditions. The pregnancy ended by elective cesarean section and hysterectomy at 28 + 0 weeks of gestation. The postpartum course was uneventful and the newborn was discharged to home care 63 days after delivery. CONCLUSIONS: Fetal expulsion into the abdominal cavity after silent uterine rupture of the scarred uterus may be accompanied by minimal symptomatology making early diagnosis difficult. This rare complication must be considered in the differential diagnosis in women after major uterine surgery. In selected cases and under conditions of intensive maternal and fetal monitoring, conservative management may be chosen to reduce the risks associated with prematurity.

Spontaneous uterine venous plexus complicated with ovarian rupture in the third trimester of pregnancy: a case report.

BACKGROUND: Spontaneous uterine venous rupture combined with ovarian rupture in late pregnancy is extremely rare. It often has an insidious onset and atypical symptoms, develops rapidly, and is easily misdiagnosed. Wewould like to discuss and share this case of spontaneous uterine venous plexus combined with ovarian rupture in the third trimester of pregnancy with colleagues. CASE PRESENTATION: A pregnant woman, G1P0 at 33+4 weeks of gestation,was admitted to the hospital due to threatened preterm labour on March 3, 2022. After admission, she was treated with tocolytic inhibitors and foetal lung maturation agents. The patient's symptoms did not improve during the treatment. After many examinations, tests, discussions, a diagnosis, and a caesarean section, the patient was finally diagnosed with atypical pregnancy complicated by spontaneous uterine venous plexus and ovarian rupture. CONCLUSIONS: Spontaneous rupture of the uterine venous plexus combined with ovarian rupture in late pregnancy is an occult and easily misdiagnosed condition, and the consequences are serious. Clinical attention should be given to the disease and prevention attempted to avoid adverse pregnancy outcomes.

Maternal outcomes of placental abruption with intrauterine fetal death and delivery routes: A nationwide observational study.

INTRODUCTION: Placental abruption is a serious complication, especially when accompanied by intrauterine fetal death. The optimal delivery route for placental abruption with intrauterine fetal death for reducing maternal complications is still unclear. In this study we aimed to compare the maternal outcomes between cesarean delivery and vaginal delivery in women with placental abruption with intrauterine fetal death. MATERIAL AND METHODS: Using the Japan Society of Obstetrics and Gynecology nationwide perinatal registry database, we identified pregnant women with placental abruption with intrauterine fetal death between 2013 and 2019. The following women were excluded: those with multiple pregnancies, placenta previa, placenta accreta spectrum, amniotic fluid embolism, or whose delivery route was missing data. The association between delivery routes (cesarean delivery and vaginal delivery) and the maternal outcome was examined using a linear regression model with inverse probability weighting. The primary outcome was the amount of bleeding during delivery. Missing data were imputed using multiple imputation. RESULTS: The number of women with placental abruption with intrauterine fetal death was 1218/1601932 (0.076%). Of 1134 women analyzed, 608 (53.6%) underwent cesarean delivery. Bleeding during delivery (median [interquartile range]) was 1650.00 (950.00-2450.00) (mL) and 1171.00 (500.00-2196.50) (mL) in cesarean and vaginal delivery, respectively. Bleeding during delivery (mL) was significantly greater in cesarean delivery than in vaginal delivery (regression coefficient, 1086.39; 95% confidence interval, 130.96-2041.81; p = 0.026). Maternal death and uterine rupture occurred in four (0.4%) and five (0.4%) women, respectively. The four maternal deaths were noted in the vaginal delivery group. CONCLUSIONS: Bleeding during delivery was significantly greater in cesarean delivery than that in vaginal delivery in women with placental abruption with intrauterine fetal death. However, severe complications, including maternal death and uterine rupture, occurred in vaginal delivery-related cases. The management of women with placental abruption with intrauterine fetal death should be cautious regardless of the delivery route.

Intestinal obstruction in pregnancy-a rare presentation of uterine perforation.

BACKGROUND: Intestinal obstruction is an uncommon non-obstetric condition during pregnancy which may cause maternal and fetal mortality. Clinicians are confronted with challenges in diagnosis and treatment of intestinal obstruction due to the overlapping symptoms, concerns over radiological evaluation, and surgical risks. CASE PRESENTATION: We reported a 39-year old, gravida 7, para 2, woman who suffered from acute intestinal obstruction at 34 weeks of gestation. Ultrasonography and abdominal computed tomography were applied for intestinal obstruction diagnose. Conservative treatment was initially attempted. But following ultrasound found the absence of fluid in the amniotic sac and the patient showed no improvement in clinical symptoms. An emergency caesarean section was then performed. Intra-operative assessment showed dense adhesion between the left wall of uterus and omentum, descending colon, and sigmoid colon. After adhesion dialysis, uterine rupture with complete opening of the uterine wall at the site of left uterine cornua was found without active bleeding. The uterine rupture was then repaired. CONCLUSIONS: Although uncommon during pregnancy, clinical suspicion of bowel obstruction is necessary especially in women with a history of abdominal surgery. Surgical intervention is indicated when conservative therapy fails and when there are signs of abnormal fetal conditions and worsened symptoms.