Live birth after uterine rupture with fetus in herniated amniotic sac

Background:

Uterine rupture during pregnancy is a serious obstetrical complication. The presence of a previous uterine scar is the most important risk factor, whereas ruptures in an unscarred uterus are very rare.

Case report:

We report the case of a 26 year-old primigravid woman with fundal uterine rupture at 22+2 weeks of gestation. She had undergone hysteroscopy and chromolaparoscopy because of dyspareunia, dysmenorrhea and infertility two years prior to this pregnancy.

The patient presented to the emergency department with lower abdominal pain and vaginal bleeding. Ultrasonography showed the amniotic sac with the fetus' lower body part protruding into the left side of the mother's abdomen with a anterior/fundal placenta. Intravenous tocolysis with β-agonists was started because of painful contractions. The patient was confined to bedrest with continuous tocolysis. An MRI obtained at 22+5 weeks confirmed fundal rupture with an intact amniotic sac. The anterior/fundal placenta did not reach the scar. Only the head and right arm of the fetus remained inside the uterus.

A steroid course with 12 mg of Dexamethason was started at 23+3 weeks of gestation and magnesium sulfate at 23+5 weeks for fetal neuroprotection.

At 27+2 weeks of gestation, the patient complained of lower abdominal discomfort. An ultrasound showed that also the head of the fetus had dislocated through the uterine scar into the mother's abdomen. The amniotic sac was still intact. Doppler of the umbilical artery showed normal perfusion and a normal CTG was obtained. Later that same day, the patient experienced severe lower abdominal pain, ultrasound showed fetal bradycardia. An emergency c-section was performed delivering a boy of 990 g. The fundal rupture was closed using a single-stitch technique. The child was admitted to the neonatal care unit and was discharged home 10 weeks after birth.

Conclusion:

Uterine ruptures during pregnancy are serious emergencies that usually require immediate laparatomy leading to termination of the pregnancy to reduce maternal morbidity. In this case, the fundal rupture occurred gradually and allowed for a conservative approach leading to the delivery of a preterm but otherwise healthy child.

Even though a previous uterine scar is the most important risk factor, uterine ruptures also need to be considered in a presumably unscarred uterus. The patient had most probably suffered unnoticed uterine damage from the previous hysteroscopy and chromolaparoscopy with a uterine manipulator. The risk for uterine rupture may be increased after any uterine surgery.