Keywords
fleece-coated fibrin glue - second trimester - uterine rupture
Rupture of the pregnant uterus caused by separation of uterine myometrium is thought
to be a life-threatening condition for the mother and fetus. For management of this
condition, cesarean delivery may be suitable during the viable term of the fetus,
followed by repair of the uterus. Hysterectomy may be appropriate if bleeding is uncontrolled.[1] However, during the previable term, we do not have any knowledge about what approach
is better, cesarean section, repair, or hysterectomy.[1]
We encountered a case of rupture of the pregnant uterus that occurred during the early
second trimester. Repair of the rupture site using collagen fleece led to successful
pregnancy prolongation. In this case series study, we have reviewed our case and five
previously reported cases, and have evaluated how repair of the pregnant ruptured
uterus occurring in the second trimester would be managed.
Materials and Methods
Case
A 28-year-old Japanese woman, gravida 3 and para 2, was referred to our hospital with
progressive abdominal pain after coitus at 14 + 5 weeks of gestation. Her pregnant
history was (1) interruption, (2) cesarean section with low transverse incision due
to breech presentation, and (3) cesarean section with high transverse incision due
to placental previa accreta, which needed intravenous methotrexate therapy and uterine
arterial embolization. At admission, her vital signs were normal; blood pressure:
81/42 mm Hg; pulse: 66/min. Her hematocrit was 34.8%, hemoglobin 9.5 g/dL, and white
blood cell count 7,400/µL. Ultrasonography revealed echo-free space in the vesicouterine
pouch, suggesting hemoperitoneum. Six hours later, intra-abdominal bleeding increased,
and signs of shock index were not observed, so minilaparotomy was performed. Hemoperitoneum
(1,300 g of blood loss) was found with a myometrium defect on the uterine anterior
wall, suggesting rupture of scarred uterus ([Fig. 1a]). Her family did not give consent for total hysterectomy. Repair of the ruptured
uterus was performed with three-layered separate stitches suture of 3–0 polyglactin
910 (Coated Vicryl, Ethicon, Inc., Somerville, NJ), subsequently covered using fleece-coated
fibrin glue (TachoComb, CSL Behring, King of Prussia, PA). Her total blood loss was
1,745 g, for which she received four units of red blood cells. To prevent uterine
rupture, she received continuous infusion of a tocolytic agent, ritodrine, with bed
rest. We planned a laparotomy, as a second-look operation, to rule out placental percreta,
and it was performed at 28 weeks of gestation. The rupture site was completely covered
with white tissue. No evidence of placenta percreta was noted ([Fig. 1b]). A healthy baby weighing 2,600 g was delivered by elective cesarean section with
normal Apgar scores at 34 + 6 gestational weeks.
Fig. 1 (a) Myometrium defect revealed on uterine surface (white arrows) at 14 + 5 weeks
gestation and the placenta with continuous bleeding were represented. (b) White tissue
(white arrows) derived from collagen fleece coated with fibrin glue covered the previous
uterine wall defect at diagnostic laparotomy at 28th week.
Five Other Cases
A computer search was done using the terms “uterine rupture,” “second trimester,”
and “repair” through the PubMed engine.[2] Twenty-seven articles were checked and five documents were extracted. The information
from each is summarized in [Tables 1] and [2].
Table 1
Outline of our case and five previous cases
|
No.
|
Age/G/P
|
Cause
|
Onset (GW)
|
Symptom
|
Shock vital
|
Hemoperitoneum (g)
|
Rupture site
|
Rupture size (cm)
|
Active bleeding from rupture site
|
Placental location
|
Complete rupture or incomplete rupture
|
|
1
|
28/3/2
|
Previous cesarean
|
14
|
Acute abdomen
|
Absent
|
1,300
|
Anterior
|
3
|
Continuously
|
Beneath
|
Complete
|
|
2
|
33/1/0
|
Previous cesarean
|
19
|
Acute abdomen
|
–
|
–
|
Right lateral
|
2
|
Present
|
Beneath
|
Complete
|
|
3
|
35/3/2
|
Previous cesarean
|
20
|
Acute abdomen
|
Present
|
–
|
Anterior
|
5
|
Continuously
|
Beneath
|
Incomplete
|
|
4
|
31/1/0
|
Unknown
|
21
|
Acute abdomen
|
Present
|
3,000
|
Fundal anterior
|
0.5
|
Present
|
Other
|
Complete
|
|
5
|
30/0/0
|
Unknown
|
24
|
Acute abdomen
|
Present
|
2,200
|
Fundal posterior
|
3
|
Continuously
|
Beneath
|
Complete
|
|
6
|
29/0/0
|
Unknown
|
26
|
Acute abdomen
|
–
|
Present
|
Fundal
|
3
|
Present
|
Other
|
Complete
|
Abbreviations: G, gravidity; GW, gestational weeks; P, parity.
Note: No. 1 is from our presented case, No. 2 from Martin et al,[11] No. 3 from Palacios-Jaraquemada et al,[12] No. 4 from Wang et al,[13] No. 5 from Shirata et al,[9] and No. 6 from Chen.[14]
Table 2
Treatment and perinatal outcome of our case and five previous cases
|
No.
|
Repair
|
Delivery (GW)
|
Delivery route
|
Birth weight (g)
|
Apgar scores
|
Authors
|
|
1
|
Sutured with 3–0 Vicryl, patched by TachoComb
|
34
|
Cesarean
|
2,600
|
8/9
|
Present case
|
|
2
|
Sutured with Chromic Catgut and Ethibond, patched by GoreTex
|
33
|
Cesarean
|
2,220
|
8/9
|
Martin et al (1990)
|
|
3
|
Sutured with 5–0 Vicryl, patched by Vicryl Mesh
|
34
|
Cesarean
|
1,700
|
7/9
|
Palacios-Jaraquemada et al (2009)
|
|
4
|
Double layer sutured with 1–0 Monocryl, single layer sutured with 3–0 Vicryl
|
33
|
Cesarean
|
2,345
|
6/8/9
|
Wang et al (1999)
|
|
5
|
Sutured with Vicryl, patched by TachoComb
|
35
|
Cesarean
|
2,612
|
8/9
|
Shirata et al (2007)
|
|
6
|
Continuously sutured with 1 Chromic Catgut
|
37
|
Cesarean
|
2,842
|
–
|
Roeters et al (2007)
|
Abbreviation: GW, gestational weeks.
Note: No. 1 is from our presented case, No. 2 from Martin et al,[11] No. 3 from Palacios-Jaraquemada et al,[12] No. 4 from Wang et al,[13] No. 5 from Shirata et al,[9] and No. 6 from Chen.[14]
Discussion
Rupture of the pregnant uterus was thought to be a rare disorder, that is, less than
0.05% of pregnancies.[3] There has been an upward trend in threatened uterine rupture recently as the number
of postcesarean section pregnancies has increased.[4]
[5]
[6] Eden et al[7] reported that rupture due to previous cesarean, referred to as scarred uterus, accounted
for approximately 20% of all uterine ruptures in the 1980s. Furthermore, Rachagan
et al[8] emphasized its frequency was over 50% in 1986. Pregnancy termination was indicated
if uterine rupture occurred; hysterectomy may be needed in some instances. Repair
of the ruptured uterus could possibly lead to pregnancy prolongation, and consequently
could yield favorable maternal and fetal or neonatal outcomes.
Shirata et al[9] reported an interesting case of unscarred uterine rupture that occurred at 24 gestational
weeks with massive hemoperitoneum of 2,200 g, which was repaired by combined therapy
of absorbable suture and covering with fleece-coated fibrin glue, and then subsequently
yielded favorable pregnancy prolongation until 35 gestational weeks. Their management
was similar to our case. These two cases may suggest the utility of a collagen sheet
for repair of uterine dehiscence. Collagen fleece has recently been used in many surgeries
as a hemostatic agent, such as to treat pneumothorax. Collagen fleece maintains the
strength of tissue by adhering to the tissue and forming a three-dimensional structure.
Matsutani and Ozeki[10] examined the efficacy of overlapping of collagen fleece to repair pleural defects.
They concluded that pleural circular defects 6 mm in diameter with overlapping of
collagen fleece could withstand airway pressure of 40 cmH2O. They explained that collagen fleece resulted in adhesion of pleura. Therefore,
collagen fleece may reinforce the uterine defect.
There have been several reports,[9]
[11]
[12]
[13]
[14] concerning repair of uterine ruptures in the second trimester using suture and/or
patching. These five cases and our case are reviewed and summarized in [Tables 1] and [2]. The putative cause of uterine rupture was mainly previous cesarean in early mid-trimester.
The initial symptom was lower abdominal pain caused by hemoperitoneum. In complete
rupture, rupture size was larger than in cases with incomplete rupture. All cases
achieved sufficient pregnancy prolongation of more than 33 gestational weeks. In four
cases, the placenta was located just beneath the rupture site. In these cases, it
was impossible to distinguish uterine rupture and placenta percreta. Roeters et al[15] reported a case in which placenta percreta at 14 gestational weeks was repaired
and subsequently resulted in pregnancy prolongation until the 35th week. However,
they criticized their management because it did not rule out the possibility of a
severe complication, that is, recurrence of hemoperitoneum due to placenta percreta.
In our case, we performed diagnostic laparotomy to rule out placenta percreta. Repeated
ultrasonographic examination may needed for diagnosis of percreta.
In conclusion, uterine rupture in mid-trimester could be repaired with suture and
overlapping of collagen fleece, if placenta percreta is absent. When placenta percreta
is suspected, precise ultrasound monitoring or diagnostic laparotomy might be necessary
after repair.
