LETTER TO THE EDITOR

Repaired uterine rupture at mid gestation

Luciana Patrıcio • Diana Martins • Alexandra Henriques •

Helena Ferreira • Nuno Clode

Received: 11 November 2012 / Accepted: 15 January 2013 / Published online: 31 January 2013

� Springer-Verlag Berlin Heidelberg 2013

Uterine rupture is usually a catastrophic event, frequently

demanding emergent delivery followed by uterine repair or

post-cesarean hysterectomy [1]. If the pregnancy is very

premature at the time of rupture, the risk of neonatal

morbidity and mortality is high [2]. Although a sole uterine

repair may also delay delivery, this procedure can be sur-

gically challenging and easily complicated, leading to

significant maternal or fetal morbidity.

A 36-year-old gravida 3, para 1, presented, in her 20th

week of gestation, at the emergency department of her

local hospital with abdominal pain and rebound abdominal

tenderness.

She had underwent a left salpingectomy 4 years before

(to treat a tubal ectopic pregnancy) followed the year after

by an emergency cesarean (due to a spontaneous pre-labor

right-fundal uterine rupture at 37 weeks). During the latter

procedure, a stillborn was delivered and the uterine defect

was repaired with a double-layer suture.

Upon arrival, her blood pressure, heart rate, body tem-

perature and laboratory parameters were normal, except for

a slightly low hemoglobin level (8.6 g/dl). Ultrasound

scans revealed fetal bradycardia and no free fluid in the

maternal abdomen.

She was transferred to our hospital presumptively

diagnosed with acute appendicitis and underwent an

exploratory laparotomy, during which hematoperitoneum

and a 2.5-cm uterine fundus rupture (near the right

fallopian tube isthmus) were discovered (Fig. 1). The

rupture was first repaired with a double-layer suture and

then covered with Surgicel� (Ethicon, Inc-Johnson—

Johnson) (Fig. 2). Postoperatively, the patient remained

asymptomatic and hospitalized. During this time, ultra-

sound scans were performed on a monthly basis, revealing

normal fetal growth and amniotic fluid production, a

posterior fundal placenta and a thin fundal myometrium.

Corticosteroids were given for fetal pulmonary maturation

at 24 weeks of pregnancy and once more at 30 weeks.

Early in the third trimester, a magnetic resonance imaging

was performed to confirm the suspicion of placenta per-

creta through the sutured area of the uterus (Figs. 3, 4) and,

due to this suspicion and her obstetric history, we opted to

perform a cesarean section at 34 weeks under general

anesthesia, with delivery of a healthy 2,120 g female

newborn (Apgar scores of 5 and 8 at minutes 1 and 5). The

placenta was easily removed and the macroscopic uterine

examination confirmed that the fundal myometrium was

thin and covered by an epiploon adhesion. Finally, we

ligated the remaining right fallopian tube.

Uterine rupture must be considered during a differential

diagnosis of acute abdominal pain in pregnancy. Only a

few cases of successful mid gestation uterine rupture repair

with preservation pregnancy have been reported [2, 3] and,

in all cases, there was a previous uterine scar. We believe

that, as cesarean rates rise, so will events similar to this

one. Guidelines proposing the most adequate surgical

approach and pregnancy management are lacking. If the

rupture can be repaired and pregnancy maintained, we

believe the woman should remain in an obstetric ward until

delivery since the growing fetus potentiates the risk for

repeat uterine rupture. In all previous reports, patients

underwent cesarean section at 33–35 weeks of gestation

[2, 3] to avoid repeat uterine rupture.

L. Patrıcio � D. Martins � A. Henriques � H. Ferreira � N. Clode

Hospital Santa Maria, Av Prof. Egas Monis,

1649-035 Lisbon, Portugal

L. Patrıcio (&)

Rua das Vigias 4.25.01B, 88A, 1990-506 Sacavem, Portugal

e-mail: patricio.luciana@gmail.com

123

Arch Gynecol Obstet (2013) 288:457–458

DOI 10.1007/s00404-013-2724-0

Conflict of interest We declare that we have no conflict of interest.

References

1. Turner M (2002) Uterine rupture. Best Pract Res Clin Obstet

Gynaecol 16:69–79

2. Martin J Jr, Brewer D, Rush L Jr, Martin R, Hess L et al (1990)

Successful pregnancy outcome following mid-gestational uterine

rupture and repair using gore-tex soft tissue patch. Obstet

Gynaecol 75:518–520

3. Shirata I, Ritsuto F, Takubo K, Shibukawa T, Sawada K (2007)

Successful continuation of pregnancy after repair of a midgesta-

tional uterine rupture with the use of a fibrin coated collagen fleece

(TachoComb) in a primigravid woman with no known risk factors.

Am J Obstet Gynaecol 197:e7–e9

Fig. 1 Uterine rupture

Fig. 2 Appearance of the repaired uterus after double-layer suture

Fig. 3 Sagittal T2-weighted magnetic resonance imaging shows a

thin fundal myometrium

Fig. 4 Axial T2-weighted magnetic resonance imaging showing the

uterine suture

458 Arch Gynecol Obstet (2013) 288:457–458

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