Silent spontaneous posterior uterine rupture of a prior caesarean delivery at 36 weeks of gestation
In caesarean section patients, the spontaneous rupture of the posterior wall of the uterus is extremely rare, with nonspecific signs and symptoms being present. Perinatal and maternal morbidity and mortality are high.
A 28-year-old woman at 36 + 6 weeks of gestation presented with mild uterine contractions and developed a sudden abdominal distension. An emergency laparotomy was performed, and the posterior wall of the uterus had ruptured. A baby boy was born.
Silent uterine rupture is very rare and easy to ignore due to nonspecific clinical symptoms, unexplained haemoglobin reduction and haemoperitoneum, but these features caution us to more closely consider uterine rupture in patients.
KeywordsUterine rupture Pregnancy Caesarean section
Uterine rupture is an obstetric complication that causes significant maternal and foetal morbidity and mortality . Silent uterine rupture is very difficult to diagnose, as the clinical features of uterine rupture, including abdominal pain, vaginal bleeding, maternal hypovolemic shock, or haemorrhage may be absent . We present the spontaneous rupture of the posterior wall of the uterus at 36 weeks of gestation; the uterine rupture was found during the operation.
Spontaneous rupture of the posterior wall of the uterus in pregnancy is rare and potentially a catastrophic event for both the mother and the foetus [3, 4]. Nonspecific signs and symptoms lead to misdiagnosis and delayed treatment. In this case, no predisposing factors, classic signs and symptoms, including decreased foetal heart rate, uterine contraction, abdominal pain, changes in the station of the presenting part, bleeding or shock were found. The patient felt only uterine contraction aggravations and abdominal swelling. We performed an urgent laparotomy based on the previous caesarean delivery history in breech presentation. Both the patient and the newborn were fortunate to have a good outcome.
In 2011, Stefano Uccella  wrote a review of spontaneous pre-labour uterine rupture in a primigravida. Some risks in those cases included a history of uterine surgeries, such as caesarean section or myomectomy, uterine damage due to trocar insertion, uterine perforation and other risk factors, such as uterine anomaly, uterine curettage, uterine diverticula, and Ehlers-Danlos syndrome. The patient had only a history of caesarean section, with no other uterine operations, but the rupture site was not found in the uterine scar. She had no other risk factors.
Le-Ming Wang  reported a spontaneous uterine rupture on the posterior wall due to placenta percreta. In this case, the placenta was located on the right lateral and anterior wall of the uterus so that its occurrence should not be related to placenta factors. Unscarred uterus multiparity is one of the most important factors in uterine rupture. The stretching, tearing or bruising of repeated childbirth makes the uterine wall very weak, so the chances of rupture increase with every subsequent pregnancy. The patient had a medical termination of a missed miscarriage at seven weeks and a caesarean section. It was not clear if this rare event of spontaneous rupture may be attributed to the weakening of the uterine wall.
Traditionally, spontaneous rupture of the posterior wall of the uterus is rare, and the rupture is often easily covered by the intestinal loop and omentum so that some minor symptoms are ignored. Ultrasonography plays a critical role in diagnosing uterine rupture based on the demonstration of a myometrial defect associated with intraperitoneal and extraperitoneal haemorrhage . In this case, we failed to find extraperitoneal haemorrhage. However, it is important to maintain a high index of suspicion for uterine rupture in women presenting with some or all of these features, regardless of any known risk factor . Prompt recognition of uterine rupture, early diagnosis and expeditious recourse to laparotomy are critical to influencing perinatal and maternal morbidity.
Silent uterine rupture, especially that occurring in the posterior wall, is very rare and easy to ignore due to nonspecific clinical symptoms. Haemoglobin reduction and haemoperitoneum in patients caution us to closely consider uterine rupture.
No financial support was received for this study.
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The surgery was performed by CSH and DXP. CSH collected data and wrote the article. CSH and DXP read and approved the final version of the manuscript.
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