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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 9  |  Issue : 2  |  Page : 293-298

Expectant management of an asymptomatic complete uterine rupture presenting as a herniated amniotic sac


1 Department of Obstetrics and Gynaecology, University of Abuja Teaching Hospital, Nigeria
2 Department of Obstetrics and Gynaecology, 063, Nigeria Air Force Hospital, Bill Clinton Road, Nigeria
3 Department of Obstetrics and Gynaecology, University of Abuja Teaching Hospital; Faculty of Clinical Sciences, University of Abuja, Nigeria

Date of Submission03-Apr-2021
Date of Decision27-Oct-2021
Date of Acceptance30-Oct-2021
Date of Web Publication29-Dec-2021

Correspondence Address:
Dr. Anthony Dennis Isah
Department of Obstetrics and Gynaecology, University of Abuja Teaching Hospital, Abuja/University of Abuja
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/amhs.amhs_77_21

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  Abstract 


When there is a defect in the uterine wall, it serves as a weakness through which the fetal membrane may herniate into abdominal cavity during pregnancy. This may manifest as either a silent (partial) or complete uterine rupture. Any silent (partial) uterine rupture has a potential of becoming complete. When a uterine rupture becomes complete, it may lead to acute life-threatening complications to both the mother and her fetus. As of today, there seems to be no consensus as to whether to manage silent or complete uterine rupture expectantly or surgically, including repair of the uterine wall or termination of the pregnancy, especially when this happens in the early second trimester, especially in Nigeria where the age of viability is still 28 weeks of gestation.

Keywords: Asymptomatic, complete uterine rupture, expectant, herniated amniotic sac


How to cite this article:
Nongo BH, Ojah OS, Agida TE, Isah AD. Expectant management of an asymptomatic complete uterine rupture presenting as a herniated amniotic sac. Arch Med Health Sci 2021;9:293-8

How to cite this URL:
Nongo BH, Ojah OS, Agida TE, Isah AD. Expectant management of an asymptomatic complete uterine rupture presenting as a herniated amniotic sac. Arch Med Health Sci [serial online] 2021 [cited 2022 Oct 6];9:293-8. Available from: https://www.amhsjournal.org/text.asp?2021/9/2/293/334026




  Introduction Top


Herniation is defined as an abnormal protrusion of an organ or other body structure(s) through a defect or natural opening in a covering, membrane, muscle, or bone.[1] When the uterus ruptures during pregnancy, the end can be a catastrophe, that may result increased maternal and perinatal morbidity and mortality. In patients with previous cesarean section, the incidence is about 1%.[2] Uterine rupture at the site of previous iatrogenic perforation which healed spontaneously or was repaired primarily is less reported.[3] Many uterine perforations are not recognized, most commonly those that follow dilatation and curettage. There is as of today no agreement as to whether to carry out expectant or immediate surgical termination of silent uterine rupture much less complete uterine rupture, especially when this occurs in the first or second trimester.[4]

When a diagnosis of a silent uterine rupture is made, there is a need to measure the myometrial thickness around it and how the uterine wall changes as the pregnancy advances.[4] It is even more of a dilemma when a diagnosis of a complete uterine rupture is made in the second trimester and the patient is hemodynamically stable or unstable. A literature search carried out by us revealed six previously documented cases of conservative management of complete uterine rupture, after surgical repair of the site of uterine rupture. We describe, here, a case of a large herniated amniotic sac, through a complete uterine rupture at the anterior part of the uterine fundus, first detected incidentally at 22 weeks and 2 days of gestation in a then G8P3+4 (3 alive), with previous history of evacuation of retained products of conception following primary postpartum hemorrhage (PPH). A sharp curettage was done. Emergency laparotomy with attempt at returning the amniotic sac into the uterus and uterine repair, was unsuccessful due to tension on the amniotic sac which may lead to rupture. The pregnancy was monitored with twice weekly ultrasound scan, bed rest, and fetal kick chart. Delivery of the fetus was successfully deferred until at 31 weeks of gestation, when following preterm prelabor rupture of membranes, with ultrasound scan confirmation of a live fetus and presence of free fluid in the peritoneum, an emergency laparotomy was done, with the delivery of a live fetus. This article traces the pathogenesis and management of complete uterine rupture with a herniated amniotic sac and live fetus before 34 weeks of gestation.


  Case Report Top


A 35-years-old then G8P3+4 (3 alive) was transferred to our teaching hospital, for evaluation and expert management of complete uterine rupture with herniated amniotic sac. Her last child birth was 5 years ago, delivery was complicated with secondary PPH, due to retained products of conception. She had evacuation of retained products of conception by uterine curettage using a sharp curette, in a peripheral hospital. This apparently was complicated by an asymptomatic uterine perforation.

In the index pregnancy, she went for her antenatal booking clinic at 22 weeks, 2 days gestation, at the referring hospital where a routine ultrasound scan [Figure 1] revealed a complete uterine rupture with a herniated amniotic sac. Upon admission in our hospital, she remained asymptomatic and her vital signs were within normal range. The fundal height was 20 cm and ultrasound examination showed a complete uterine rupture, with a large herniated sac at the uterine fundus that measured 77 mm × 85 mm, it was herniating into the maternal peritoneal cavity. There was a singleton viable intrauterine fetus with an average gestational age of 22 weeks and 2 days. The placenta was posteriorly located at the uterine fundus. The liquor in the uterine cavity was grossly reduced, and the amniotic fluid volume in the uterine cavity was 1.77 cm. There was a large collection of the amniotic fluid in the herniated amniotic sac with an approximate volume of 178.34 cm3. It was communicating with the amniotic fluid in the uterine cavity. The diameter of the site of perforation was 40 mm × 40 mm. There was no gross fetal congenital anomaly. The cervical length was 3.5 cm and the cervical internal OS was closed [Figure 1], [Figure 2], [Figure 3]. A joint meeting of the three gynecologists above was held. It was decided that a laparotomy with return of the amniotic sac into the intrauterine cavity and primary closure of the uterine rupture be carried out.
Figure 1: Antenatal ultrasound findings of 4 cm × 4 cm defect in the fundus of the uterus (inverted arrow), with herniation of the amniotic sac. The viable fetus is situated normally within the uterine cavity

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Figure 2: The findings at the first laparotomy, with tensed herniated amniotic sac at the uterine fundus. The left  Fallopian tube More Details was held down by filmy adhesions

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Figure 3: The collapsed herniated amniotic sac at the second emergency laparotomy after delivery of the fetus

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The patient was well counselled about the potential risks of maternal and fetal morbidity and mortality, due to possible onset of intraperitoneal hemorrhage and preterm prelabor rupture of membranes. Due to the fact that she had a prolonged inter-pregnancy interval of 5 years, and this pregnancy was for a new husband, she had a strong desire to continue the pregnancy. Laparotomy was done 3 days after with the finding of a complete uterine rupture, herniated amniotic sac and site of rupture measuring 4 cm × 4 cm [Figures 4]. There was no hemoperitoneum. Attempt at return of the herniated amniotic sac was abandoned because it was so much under tension. As such any attempt at return of the herniated sac into the uterine cavity would have ended up with prelabor rupture of membrane. The anterior abdominal was closed up. Expectant management was conducted. She was admitted into the ward. Bed rest was initiated. The fetal limbs remained inside the intra-uterine cavity. The patient remained asymptomatic, with reassuring fetal status and the fetal growth remained appropriate for gestational age. Twice weekly ultrasound scan showed that though the amniotic fluid in the herniated amniotic sac was increasing, the amniotic sac remained intact and there was no hemoperitoneum. Blood was grouped and cross-matched and made available in our blood bank all through the period of the expectant management. Expectant management was sustained until at 31 weeks of gestation (7 weeks 5 days of expectant management). It is important to note that despite extensive counseling on family planning, she declined a cesarian bilateral tubal ligation since she was in a new marriage. When she complained of sudden onset of generalized abdominal pains, an emergency ultrasound scan revealed that the amniotic sac had ruptured, the fetus was viable. An emergency laparotomy was therefore carried out and a live male baby was delivered with Apgar scores of 8 at one minute and 9 at 5 min, with a birth weight of 1.76 kg. The Placenta was delivered by traction on the cord, was inspected and found to be complete. The lower uterine segment was found to be well formed. Subsequent examination of the uterus revealed the site of the complete uterine rupture, which was at the fundus, and measured about 4 cm × 4 cm [Figure 4]. The edges were freshened and the site of the rupture was closed primarily with Vicryl 1. Estimated blood loss was 600 ml. The patient had an uncomplicated postoperative course; the baby was transferred to our special care baby unit, however, he died after 24 h, cause of death was pulmonary hypoplasia. The patient was counselled extensively about the risk to future pregnancies.
Figure 4: The exact point of the uterine perforation at the uterine fundus, prior to surgical closure, after delivery of the fetus at the second emergency laparotomy

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  Discussion Top


The leading cause of uterine scan dehiscence is that following cesarean section, followed by that after myomectomy.[5] The incidence of uterine perforation from dilatation and curettage is quoted to be 0.16%.[6]

Uterine perforation occurring at the uterine fundus account for about 13% of all the sites, with the anterior uterine wall accounting for about 40%, this being the highest.[7] There is an increase in partial uterine rupture as of today as the number of postcesarean section pregnancies has increased.[8],[9],[10]

The standard practice following complete uterine rupture has been to effect delivery or terminate the pregnancy, repair the site of uterine rupture, or carry out a hysterectomy. However, when complete, uterine rupture occurs remote from term (second trimester), there is the possibility of uterine repair and prolongation of the pregnancy and consequently this may lead to a favorable outcome for both the pregnant woman, her fetus and the neonatal outcome.[11] Prior to term, there seems to be no consensus as to the best approach when managing a complete uterine rupture, should it be emergency laparotomy with uterine repair, or hysterectomy.[12]

A computer search was done using the term “uterine rupture”, “second trimester” and “expectant management”, this did not yield any case of complete uterine rupture in the second trimester of pregnancy that was managed expectantly into the third trimester without uterine repair.

However, six cases of complete uterine rupture in second trimester, uterine repair, and expectant management into the third trimester with successful outcome were seen. The information gathered from each of the six cases above is summarized in [Table 1] and [Table 2].[11]
Table 1: Outline of our case (number 1) and six other cases

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Table 2: Treatment and perinatal outcome of our case (case number 1) and six previous cases

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In all the previous six cases reported, as shown in [Table 1] and [Table 2], all presented with acute abdomen. This is in sharp contrast to our case, where the complete uterine rupture was discovered incidentally during routine antenatal ultrasonography. This may be because, the symptoms were mild that the patient didn't bother to present. Also, even though there was complete uterine rupture, there was no hemoperitoneum. In the other six cases shown above, four out of the six cases had hemoperitoneum.[11] Our patient's vital signs were stable, this was because there was no ongoing acute hemorrhage. This is in contrast to four of the six cases previously reported, who all presented in hypovolemic shock.[11] The fetus in our case was alive, this also was the fetal outcome in all the previously documented six cases.[11] Our patient had an emergency laparotomy at 22 weeks 6 days of pregnancy with the aim of returning the amniotic sac into the uterine cavity and repairing the site of uterine rupture. However, this attempt at uterine repair was abandoned, when at laparotomy we discovered that the herniated amniotic sac was under tension and any attempt at manipulating would have likely led to a preterm prelabor rupture of membrane. The size of the uterine rupture was also 4 cm which would have made it virtually impossible to return a 7.7 cm × 8.5 cm herniated amniotic sac. All the cases seen in the literature, as reported in [Table 1] had successful uterine repair.[11] With no hemoperitoneum seen at laparotomy, the amniotic sac been intact and the patient hemodynamically stable, a decision was taken to abandon attempt at returning the amniotic sac into the uterine cavity and repair of the site of rupture. The anterior abdominal wall was repaired. The patient was returned back to the ward. There were no post-operative complications.

The optimal management of cases with a complete uterine rupture and a herniated amniotic sac has yet to be defined, especially in the first and early second trimesters.[4] The management of complete uterine rupture with a live fetus will depend on the gestational age, the degree of severity of abdominal pain and the strong desire of the couple to continue with the pregnancy.[4] Our patient had a complete uterine rupture at 22 weeks to 2 days gestation, she was asymptomatic and had a strong desire to continue with the pregnancy. An emergency laparotomy and delivery should however be done if the fetus is at a gestational age that is ascertained it can survive outside the uterus. Expectant management should be considered when a patient is asymptomatic as in our case or shows temporary abdominal pain without fetal distress.[4] In all cases, the couple should have extensive counselling as to the potential risks for expectant management, including preterm prelabor rupture of membranes, as occurred in our case, placenta accreta,[18],[19] hysterectomy,[18],[19] and preterm birth.[20]

When the amniotic sac herniates into the peritoneal cavity, whether from a silent or complete uterine rupture, it is important to discriminate cases that require surgical repairs and subsequent expectant management or those that require outright termination of the pregnancy.

Twice weekly ultrasonographic assessment of the pregnancy to ensure that the herniated membrane had not ruptured, to confirm fetal viability and to rule out hemoperitoneum, was one of the key factors that made this expectant management possible. Also, at laparotomy, we were able to rule out placenta accreta which may also cause hemoperitoneum. A herniated amniotic sac, whether through a partial or complete uterine rupture mostly occurs in pregnancies with a history of cesarean delivery, instrumental perforation or myomectomy and in twin gestation.[4] Our case resulted from previous evacuation of retained products of conception using a sharp curette. Therefore, the likely cause of a herniated amniotic sac is from decreased elasticity in focal sites of myometrial scar tissue or excessive intrauterine pressure.[4]

Following the above literature review that revealed six other published cases, the case reported by Sugawara et al. had the longest latency interval of 20 weeks. This is in contrast to ours that had a total conservative management period of 9 weeks. This is most likely so because we could not repair the site of complete uterine rupture before the commencement of expectant management, thus as the liquor volume increased with increasing gestational age, there was preterm prelabor rupture of membrane necessitating the emergency laparotomy at 31 weeks of gestation.

In all the previously reported six cases above, all the neonates were discharged from the hospital. The neonate in this case ended up as an early neonatal death. The cause of the neonatal death was pulmonary hypoplasia. This perhaps is because the neonatal services in our hospital being a developing country is not yet as advanced as those in the developed world where all the six cases above were managed.

Pulmonary hypoplasia is a significant cause of neonatal mortality. Oligohydramnios is said to be one of the most commonly associated abnormalities.[21] Factors such as intrauterine space, lung liquid volume and pressure influence lung growth.[21] The liquor volume in the intra-uterine cavity in our case was markedly reduced, thus this led to a reduced intrauterine space, less fluid to the fetal lungs, and pressure on the lung, thus leading to pulmonary hypoplasia. Oligohydramnios reduces the intrathoracic cavity size, leading to a disruption in fetal lung growth and leading to pulmonary hypoplasia.[21] However, the exact mechanism by which oligohydramnios affects the respiratory system and the long-term effect on respiratory outcomes by Oligohydramnios still remain unknown.[21]

What not to do in a similar scenario especially in developing countries where the resources, manpower, monitoring, and interventions are limited, when this occurs, after the age of viability, emergency cesarean section should be considered after administration of corticosteroids. However, when it occurs before the age of viability, hysterostomy should be considered, because the risk associated with expectant management could be high.

In conclusion, complete uterine rupture with a herniated amniotic sac and fetal viability can be managed expectantly when this occurs in the second trimester. This could follow attempt at repair of the ruptured uterus or where unsuccessful as in our case, hospital admission and close maternal and fetal monitoring.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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21.
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]



 

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