Case Report

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Spontaneous prelabor uterine rupture in a primigravida:

a case report and review of the literature
Stefano Uccella, MD; Antonella Cromi, MD, PhD; Giorgio Bogani, MD; Eleonora Zaffaroni, MD; Fabio Ghezzi, MD

pontaneous uterine rupture (UR) is

a rare complication of pregnancy. Its
occurrence may implicate a high morbidity and mortality rate in both the fetus
and the mother. History of a uterine scar
performed for cesarean section, myomectomy, or partial uterine resection is a
well-known risk factor for UR during labor.1 UR is extremely uncommon before
the onset of labor and in nulliparous
women.

C ASE R EPORT
A 41-year-old nulliparous woman who
underwent oocyte donation became pregnant with a dichorionic-diamniotic twin
pregnancy. Her medical history was noteworthy for diagnostic hysteroscopy performed for primary infertility (10 years
before). During hysteroscopy, a 5-mm
uterine perforation occurred. No electrosurgical procedures were performed. At
the age of 35 years, premature ovarian failure was diagnosed; no hormone replacement therapy was prescribed. She then
decided to undergo in vitro fertilizationembryo transfer with oocyte donation at
the age of 41 years. The pregnancy was
uneventful, until the woman was admitted to the Obstetrics Department of the
University of Insubria, Varese, Italy,
because of diffuse itching at 35 weeks
of gestation. Laboratory evaluation reFrom the Department of Obstetrics and
Gynecology, University of Insubria, Del
Ponte Hospital, Varese, Italy (all authors),
and PhD Programme in Experimental
Medicine and Oncology (Dr Uccella).
Received July 29, 2011; revised Aug. 5, 2011;
accepted Aug. 15, 2011.
The authors report no conflict of interest.
Reprints: Stefano Uccella, MD, Department of
Obstetrics and Gynecology, University of
Insubria, Piazza Biroldi, 1-Varese, 21100 Italy.
stefucc@libero.it.
0002-9378/free
2011 Mosby, Inc. All rights reserved.
doi: 10.1016/j.ajog.2011.08.013

e6

A rare case of prelabor uterine rupture in a primigravida was reported. A woman with a
history of uterine perforation during hysteroscopy became pregnant after donor oocyte in
vitro fertilization. To provide more insight into the possible risk factors for prelabor uterine
rupture in primigravidae, a literature review was performed.
Key words: diagnostic hysteroscopy, in vitro fertilization, oocyte donation, premature
ovarian failure, uterine rupture

vealed normal findings. Clinical evaluation on admission showed an unfavorable cervix and a twin pregnancy with
viable fetuses. Nine hours after admission the patient suddenly reported severe
abdominal pain. Blood pressure decreased to 90/70 mm Hg with persistent
maternal tachycardia. Ultrasound scan
revealed bradycardia of the second twin.
Her hemoglobin level decreased from
13.8-7.4 g/dL. The patient had general
anesthesia and immediate laparotomy
was performed through a Joel-Cohen incision, for fetal nonreassuring status before labor and suspected UR. At surgical
exploration, massive hemoperitoneum
was evident.
Two male infants were found extruded
in the abdominal cavity and were extracted with no need for hysterotomic
incision. The first fetus was delivered
alive with Apgar scores of 2 and 7 at 1 and
5 minutes, respectively. The second fetus
was already dead at the time of extraction. After evacuation of the hemoperitoneum a 10-cm fundal UR was observed. The uterine defect was repaired
with a continuous double-layer closure
with 1-0 synthetic, monofilament medium-term absorbable suture. Total estimated blood loss was 3500 mL; the patient was transfused with 5 U of red cell
pack and 2 U of fresh frozen plasma.
The surviving infant was immediately
intubated and received positive pressure
ventilation for the first 24 hours. When
he was extubated no oxygen support was
needed. The woman and the infant were
discharged on the fifth postoperative day
in good condition.

American Journal of Obstetrics & Gynecology NOVEMBER 2011

D ISCUSSION
Traditionally, primigravidae and unscarred uteri are considered immune to
rupture.2 Uterine perforation during operative hysteroscopy has been associated
with the possibility of UR during subsequent pregnancies3; however, all the
cases described in a review on this issue
had hysteroscopic perforation due to excessive use of excisional electrosurgical
procedures. The current case describes a
prelabor UR 10 years after uterine perforation at diagnostic hysteroscopy with
no electrosurgical procedures.
To provide more insight in the possible risk factors for prelabor UR in primigravid women, we performed a review of
the literature. Twenty-four cases were
identified (Table). In almost half of
them, partial wall defect was the principal recognizable risk factor for UR before
the onset of labor.
It is interesting to note that 12 of the 23
(52.2%) women with specific available
information had a history of infertility. A
possible explanation could be that infertile patients more frequently undergo diagnostic/operative procedures on their
uterus during diagnostic investigation or
treatment resulting in a likelihood of iatrogenic damage.
Regarding our case report we were not
able to identify a clear condition as the
primum movens of UR. In our case we
hypothesize that possible contributing
factors to the rupture are the uterine
overdistension due to the presence of
twin pregnancy at term and the history
of uterine perforation. Moreover, our

Case Report

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TABLE

Third-trimester spontaneous prelabor uterine rupture in primigravid women

Author
Pedowitz et al

Year

Age, y

History of
infertility

Gestational
age, wk

Risk factor(s)

Hysterectomy

1952

31
34

NA
NA

33
Term

Myomectomy
Myomectomy

No
Yes

................................................................................................................................................................................................................................................................................................................................................................................
5

Felmus et al

1953

24

No

42

Adenomyosis

No

Taylor and Cumming

1979

28

Yes

35

Uterine damage due to trocar insertion, electrocautery

No

Olobo-Lalobo

1984

22

No

38

Uterine surgery

No

Martin et al

1990

33

No

32

Congenital abnormal uterus, abruptio placenta

No

Gonsoulin et al

1990

19

No

32

Placenta percreta, cocaine abuse

Yes

Harris

1992

24

Yes

34

Myomectomy, endometriosis

No

Dubuisson et al

1995

31

Yes

34

Myomectomy, uterine fistula

No

Grgan et al

1996

27

Yes

36

Uterine perforation during hysteroscopic synechiae

resection, electrocautery, genital tuberculosis

No

................................................................................................................................................................................................................................................................................................................................................................................
6
................................................................................................................................................................................................................................................................................................................................................................................
7
................................................................................................................................................................................................................................................................................................................................................................................
8
................................................................................................................................................................................................................................................................................................................................................................................
9
................................................................................................................................................................................................................................................................................................................................................................................
10
................................................................................................................................................................................................................................................................................................................................................................................
11
................................................................................................................................................................................................................................................................................................................................................................................
12

................................................................................................................................................................................................................................................................................................................................................................................
13

Abbi and Misra

1997

20

No

37

No risk factor

No

Pelosi and Pelosi

1997

39

No

33

Myomectomy

No

Welsh and Smith

1999

21

No

35

Uterine surgery

No

Dubuisson et al

2000

32

Yes

34

Tubocornual anastomosis, myomectomy

NA

Kieser and Baskett

2002

NA

Yes

NA

No risk factor

NA

Kazandi

2003

29

No

39

Placenta percreta

Yes

Asakura et al

2004

31

Yes

35

Myomectomy

No

Banas et al

2005

31

Yes

35

Myomectomy

No

Skrablin et al

2005

39

Yes

36

Myomectomy

No

Wada et al

2006

34

Yes

30

Adenomyomectomy

No

Walsh et al

2006

33

No

40

Ehlers-Danlos syndrome

No

Parker et al

2007

38

No

34

Myomectomy, electrosurgery

No

Matsubara et al

2011

27

No

38

Thin uterine wall

No

Yazawa et al

2011

37

Yes

33

Adenomyomectomy

No

Current case

2011

41

Yes

35

Uterine perforation during diagnostic hysteroscopy,

POF

No

................................................................................................................................................................................................................................................................................................................................................................................
14
................................................................................................................................................................................................................................................................................................................................................................................
15
................................................................................................................................................................................................................................................................................................................................................................................
16a
................................................................................................................................................................................................................................................................................................................................................................................
17
................................................................................................................................................................................................................................................................................................................................................................................
18
................................................................................................................................................................................................................................................................................................................................................................................
19b
................................................................................................................................................................................................................................................................................................................................................................................
20
................................................................................................................................................................................................................................................................................................................................................................................
21
................................................................................................................................................................................................................................................................................................................................................................................
22
................................................................................................................................................................................................................................................................................................................................................................................
23
................................................................................................................................................................................................................................................................................................................................................................................
24
................................................................................................................................................................................................................................................................................................................................................................................
25c
................................................................................................................................................................................................................................................................................................................................................................................
26
................................................................................................................................................................................................................................................................................................................................................................................

................................................................................................................................................................................................................................................................................................................................................................................

We performed English-language literature review. PubMed was searched for records from January 1, 1950 through May 31, 2011, using terms: uterine rupture, uterine dehiscence, unscarred
uterus, primigravida, nullipara, and emergency cesarean section alone or in combination. References of relevant studies were hand searched. Studies reporting unclear information about
gestational age or diagnosis of labor were excluded.
NA, not available; POF, premature ovarian failure.
a

Uterine rupture was revealed at the right cornual anastomosis, whereas the myomectomy scar was intact; b Patient suffered threatened premature delivery at 341 wk; c No complete uterine
rupture.

Uccella. Spontaneous prelabor uterine rupture in a primigravida. Am J Obstet Gynecol 2011.

patient was diagnosed with premature

ovarian failure. We can speculate that a
wasting of myometrial tissue due to aging and gonadal hormone depletion may
have played a role in determining uterine
dehiscence.
In conclusion, UR is a rare complication
especially in nulliparous women and before labor. However, clinical suspicion and
early diagnosis may represent the only possibilities to preserve maternal and perinatal

outcomes. Due to the rarity of its occurrence, more evidence should be registered
to increase the knowledge about this potentially lethal complication.
f
REFERENCES
1. Turner MJ. Uterine rupture. Best Pract Res
Clin Obstet Gynaecol 2002;16:69-79.
2. Walsh CA, Baxi LV. Rupture of the primigravid uterus: a review of the literature. Obstet
Gynecol Surv 2007;62:327-34.

3. Sentilhes L, Sergent F, Roman H, Verspyck

E, Marpeau L. Late complications of operative
hysteroscopy: predicting patients at risk of
uterine rupture during subsequent pregnancy. Eur J Obstet Gynecol Reprod Biol
2005;120:134-8.
4. Pedowitz P, Felmus LB. Rupture of myomectomy scars during subsequent pregnancies; a
review. Obstet Gynecol Surv 1952;7:305-13.
5. Felmus LB, Pedowitz P, Nassberg S. Spontaneous rupture of the apparently normal uterus
during pregnancy; a review. Obstet Gynecol
Surv 1953;8:155-72.

NOVEMBER 2011 American Journal of Obstetrics & Gynecology

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Case Report
6. Taylor PJ, Cumming DC. Spontaneous rupture of a primigravid uterus. J Reprod Med
1979;22:168-70.
7. Olobo-Lalobo JH. A hole in a primigravid
uterusan unusual finding at elective cesarean
section. Postgrad Med J 1984;60:559-60.
8. Martin JN Jr, Brewer DW, Rush LV Jr, et al.
Successful pregnancy outcome following midgestational uterine rupture and repair using
Gore-Tex soft tissue patch. Obstet Gynecol
1990;75:518-21.
9. Gonsoulin W, Borge D, Moise KJ Jr. Rupture
of unscarred uterus in primigravid woman in association with cocaine abuse. Am J Obstet Gynecol 1990;163:526-7.
10. Harris WJ. Uterine dehiscence following
laparoscopic myomectomy. Obstet Gynecol
1992;80:545-6.
11. Dubuisson JB, Chavet X, Chapron C,
Gregorakis SS, Morice P. Uterine rupture during
pregnancy after laparoscopic myomectomy.
Hum Reprod 1995;10:1475-7.
12. Grgan T, Yarali H, Urman B, Dagli V,
Dogan L. Uterine rupture following hysteroscopic lysis of synechiae due to tuberculosis
and uterine perforation. Hum Reprod 1996;11:
291-3.
13. Abbi M, Misra R. Rupture of uterus in a primigravida prior to onset of labor. Int J Fertil Womens Med 1997;42:418-20.

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14. Pelosi MA III, Pelosi MA. Spontaneous uterine rupture at thirty-three weeks subsequent to
previous superficial laparoscopic myomectomy. Am J Obstet Gynecol 1997;177:1547-9.
15. Welsh AW, Smith J. Antenatal uterine rupture in a primigravida (associated with undisclosed previous uterine surgery). Aust N Z J
Obstet Gynaecol 1999;39:368-70.
16. Dubuisson JB, Fauconnier A, Deffarges JV,
Norgaard C, Kreiker G, Chapron C. Pregnancy
outcome and deliveries following laparoscopic
myomectomy. Hum Reprod 2000;15:869-73.
17. Kieser KE, Baskett TF. A 10-year population-based study of uterine rupture. Obstet Gynecol 2002;100:749-53.
18. Kazandi M. Placenta percreta: report of two
cases and review of the literature. Clin Exp Obstet Gynecol 2003;30:70-2.
19. Asakura H, Oda T, Tsunoda Y, Matsushima
T, Kaseki H, Takeshita T. A case report: change
in fetal heart rate pattern on spontaneous uterine rupture at 35 weeks gestation after laparoscopically assisted myomectomy. J Nippon
Med Sch 2004;71:69-72.
20. Banas T, Klimek M, Fugiel A, Skotniczny K.
Spontaneous uterine rupture at 35 weeks gestation, 3 years after laparoscopic myomectomy,
without signs of fetal distress. J Obstet Gynaecol Res 2005;31:527-30.

American Journal of Obstetrics & Gynecology NOVEMBER 2011

21. Skrablin S, Banovic V, Kuvacic I. Successful pregnancy after spontaneous rupture of

scarred uterus following fundal myomectomy.
Eur J Obstet Gynecol Reprod Biol 2005;121:
251-2.
22. Wada S, Kudo M, Minakami H. Spontaneous uterine rupture of a twin pregnancy after
a laparoscopic adenomyomectomy: a case
report. J Minim Invasive Gynecol 2006;13:
166-8.
23. Walsh CA, OSullivan RJ, Foley ME.
Unexplained prelabor uterine rupture in a
term primigravida. Obstet Gynecol 2006;108:
725-7.
24. Parker WH, Iacampo K, Long T. Uterine
rupture after laparoscopic removal of a pedunculated myoma. J Minim Invasive Gynecol
2007;14:362-4.
25. Matsubara S, Shimada K, Kuwata T, Usui
R, Suzuki M. Thin anterior uterine wall with
incomplete uterine rupture in a primigravida
detected by palpation and ultrasound: a case
report. J Med Case Rep 2011;5:14.
26. Yazawa H, Endo S, Hayashi S, Suzuki S, Ito
A, Fujimori K. Spontaneous uterine rupture in
the 33rd week of IVF pregnancy after laparoscopically assisted enucleation of uterine adenomatoid tumor. J Obstet Gynaecol Res
2011;37:452-7.