Year: 2003
Type: article
Abstract: The spontaneous rupture of an unscarred uterus is rare. We followed a pregnancy which had a normal course in spite of a spontaneous rupture of the uterus which was diagnosed in the postpartum period. In reviewing the case it was apparent that rupture had occurred by the 21-week scan (Figure 1a – 1c). (a) Ultrasound examination (sagittal view) at 21 weeks' gestation suggests the presence of a septum with the placenta inserted on it. (b) A further examination (sagittal view) at 21 weeks reveals that the septum is the Fallopian tube inserted on a cotyledon. (c) The transaxial view at 21 weeks shows the placenta, septum (tube) and cotyledon. Fetal development is normal. At the initial ultrasound examination in the first trimester, the presence of a uterine septum with placental insertion was suspected. The woman, who had two previous normal deliveries, denied having a first-trimester abortion, currettage, artificial delivery or a uterine procedure. The pregnancy proceeded ueventfully until term when the woman underwent spontaneous labor and delivered a healthy baby. Three days after delivery, she developed acute pelvic pain and an exploratory laparotomy was performed to exclude appendicitis or cholecystis. Intrapelvic hemorrhage and intestinal agglutination had occurred. Following adhesiolysis, we noticed the presence of an old perforation in the uterine fundus. The left tube was found to pass through the uterus (Figure 2a). The ampulla was fixed on the placental cotyledon within the uterine cavity (Figure 2a and 2b). (a) At postpartum surgery the Fallopian tube could be seen to have penetrated the uterine cavity through a hole which seemed to be old. (b) After removal of the tube from the uterus it appeared that the tube had been attached within the cavity by the cotyledon which can be seen on the ampulla. Because of the presence of ectopic trophoblast around the tube we decided to perform a salpingectomy and the perforation was repaired. Pathological examination of the tube revealed edematous adventitia and neovascularization. Necrotic chorionic villi were found to have invaded the tubal adventitia. A 7 × 4-cm aberrant cotyledon showed tubal tissue on adventitia. The patient in our case did not have a history of uterine injury or pelvic irradiation1-3. The rupture that was noted in the fundus of the uterus after delivery appeared to have occurred in the first or second trimester. The tissue around the perforation had healed, indicating that it was not recent. Moreover, the tube was within the uterine cavity and attached to a placental cotyledon. Microscopic examination revealed that placental villi had invaded the tubal adventitia, indicating that the tube was already within the cavity when the placenta began its invasion. There are several hypotheses to explain the findings in our case. First, the perforation was old and was caused by a uterine procedure that the patient did not disclose and the rupture was large enough for the tube to enter the uterine cavity. The placenta of the subsequent pregnancy developed on the tube and the tube was seen as the ‘septum’ suspected at the initial ultrasound examination. Second, this was an ectopic pregnancy that had aborted and eroded through the myometrium of the fundus and implanted in the endometrial cavity. The pregnancy progressed normally in spite of this rupture and pressure within the amniotic cavity had plugged the hole in the uterus. Third, this was a normal intrauterine pregnancy with placenta percreta attaching to the tube and resulting in the operative findings. However, findings on microscopic examination did not support this hypothesis nor did those of the first ultrasound examination. Moreover, the diagnosis was made after a normal term delivery which did not result in catastrophic hemorrhage. In conclusion, this pregnancy progressed normally in spite of a uterine fundal rupture. It seems that a uterine rupture can be revealed after a normal pregnancy and delivery following subsequent acute intraperitoneal hemorrage. G. Porcu*, V. Roger , R. Sakr*, X. Carcopino , J. L. Feugeas , M. Gamerre*, * Service de Gynécologie Obstétrique et Médecine de la Reproduction, Hôpital La Conception, 147 Boulevard Baille, 13385 Marseille cedex 5, France, Service de Gynécologie Obstétrique (Pr Bernard Blanc), Hôpital La Conception, 147 Boulevard Baille, 13385 Marseille cedex 5, France, Département d'Anesthésie–Réanimation (Pr Jean-Claude Manelli), Hôpital La Conception, 147 Boulevard Baille, 13385 Marseille cedex 5, France
DOI: 10.1002/uog.886
Institution: Hôpital de la Conception
Language: English
Subfield: Obstetrics and Gynecology
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W2019526779