A rare case of posterior uterine rupture with neonatal survival during trial of vaginal birth after cesarean section
Proceedings in Obstetrics and Gynecology
A rare case of posterior uterine rupture with neonatal survival during trial of vaginal birth after cesarean section
Ahmed M. Abbas 1
0 Faculty of Medicine; Assiut University , Assiut , Egypt
1 Department of Obstetrics and Gynecology, Faculty of Medicine; Assiut University , Assiut , Egypt
Posterior wall uterine rupture is a rare complication. Trial of vaginal birth after cesarean section (CS) is a predisposing factor especially when associated with augmentation of labor. Here we report a case of intrapartum uterine rupture during the second stage of labor in a multiparous woman trying vaginal birth after previous CS. Emergency laparotomy was done and the baby was saved. Repair of the site of the rupture in layers with complete hemostasis was achieved. Financial Disclosure: The authors report no conflict of interest.
Uterine rupture; maternal morbidity; cesarean section; VBAC; posterior uterine wall
Rupture of the uterus is a very rare
catastrophic peripartum complication
associated with severe morbidity and
mortality in the mother and the fetus.1
The chief risk factor for its occurrence is
a previous uterine scar especially
previous cesarean section (CS).2 It is
uncommon for an unscarred uterus is to
rupture.3 Vaginal birth after cesarean
(VBAC) is considered a safe mode of
delivery in women with one previous
lower segment CS (LSCS). When the
uterus ruptures in women with a
previous cesarean section, the rupture
generally involves the site of the
previous anteriorly placed scar. Rupture
of the posterior wall of in women
attempting VBAC has also been
described, although it's extremely rare.4
Outcomes of uterine rupture (UR)
depend on the time between diagnosis
of rupture and delivery. They include
fetal and maternal complications. Fetal
consequences are admission to the
neonatal intensive care unit, fetal
hypoxia or anoxia, and neonatal death.
Maternal consequences are
hemorrhage, hypovolemic shock,
bladder injury, need for hysterectomy,
and maternal death. Morbidity and
mortality following rupture of the uterus
depend on the level of medical care
Herein, we report a case of posterior
wall UR during a trial of vaginal delivery
after CS in a multiparous woman with
previous one CS followed by 2
A 29-year-old gravida 4 para 3 pregnant
at gestational age of 39.4 weeks was
admitted at our tertiary university
hospital early in labor. The patient had
regular antenatal visits in her pregnancy
with a primary care provider who had
discussed modes of delivery with her.
Transverse lower segment CS was
done 7 years ago due to late fetal
deceleration followed by 2 vaginal
deliveries (2 VBAC); first one was 5
years ago followed by the second
delivery 3 years later. There was no
history of other uterine surgery or
Abdominal ultrasonography had
revealed a single living male fetus,
placenta at the fundus of the uterus,
amniotic fluid was average and
estimated fetal weight was about 3100
grams. Vaginal examination revealed
the cervix about 4 cm, 50% effaced,
amniotic membrane intact, head station
at -1 and left occipito anterior position.
Mode of delivery with risks and benefits
associated with VBAC was discussed
with her and she chose vaginal delivery.
Cardiotocography (CTG) revealed a
fetal heart rate baseline about 130
beats/minute with 2 accelerations in 10
minutes, with no efficient uterine
contractions. Augmentation of labor was
done by artificial rupture of membrane,
but still no efficient uterine contractions
and failure of labor to progress for 2
hours was present. Therefore, 5 IU
oxytocin in 0.9% normal saline
intravenous infusion was initiated at a
rate of 20 drops per minute.
After that, the patient had a normal labor
progression reaching a fully dilated
cervix within 3 hours of oxytocin use.
However, 15 minutes after full dilatation
of the cervix, the patient developed
severe abdominal pain and fetal distress
with late decelerations up to 70 beats
per minute. Her vital parameters were
pulse 120 and blood pressure was
90/60 mmHg. There was no scar
tenderness. A decision for emergency
LSCS in view of fetal distress in the
second stage of labor was taken with a
high suspicion of UR.
Urgent abdominal exploration done
under general anesthesia revealed
marked intra peritoneal blood collection.
The scar of the previous LSCS was
intact and the baby was outside the
uterus. After delivering the baby, the
surgeon noted a longitudinal defect
about 4 cm in length at the lower
segment of the posterior wall of the
uterus with active bleeding. Repair was
done by absorbable sutures into 3
layers till hemostasis was achieved.
Estimated blood loss was about 1800
ml. The patient received 4 units of
packed cells and 2 units of fresh frozen
plasma intraoperatively. An
intraperitoneal drain was placed and
abdomen was closed after confirming
hemostasis. The neonatal Apgar score
at 1 min and 5 min was 1 and 4
respectively and a pediatric
resuscitation team handled him in the
pediatric care unit (PCU).
Vaginal exploration was done after the
procedure to rule out any unnoticed
vaginal tear. The anterior cervical lip
appeared normal, but the posterior lip
was pulled up due to suturing. The
patient was stable in the postoperative
period. She was discharged on day 4
with hemoglobin level 10.2 g/dl with a
healthy male infant after full recovery of
his general condition in the PCU.
UR is a rare but disastrous complication
mainly affecting women trying vaginal
birth after previous CS. The true
incidence of UR is unknown but in a
retrospective cohort analysis of 20,095
women, the incidence of UR in labor
with a previous uterine scar was 5.2 per
1000. The incidence increase in those
who received prostaglandin for induction
of labor to 24.5 per 1000.6
In women with a scarred uterus, most
cases of uterine dehiscence and
ruptures occur at the site of the previous
uterine scar due to fibrosis of the
myometrium at the site of the scar. In
very rare cases, as in our case, the
rupture occurs on the posterior wall of
the uterus. The hypothesis is that the
posterior wall may be excessively
stretched and thinned due to the rigid
anterior uterine scar that prevents equal
stretching, and may cause atypical UR
of healthy tissue.
The site of UR in such conditions isn’t
expected.4 This is similar to sacculation
in which the posterior uterine wall
softens allowing the posterior uterine
wall to swell like an aneurysm allowing
growth of the fetus into the abdomen
with increased risk of UR.
The risk factors for atypical UR include
previous unrecognized uterine
perforation during dilatation and
curettage or during insertion of an
intrauterine device. Risk factors are
magnified especially in the setting of
excessive uterine distension as the
myometrium is focally weakened.
However, in our case there was no
history of any of the previously
mentioned procedures and the patient
didn’t have any uterine intervention
Factors which predispose to uterine
rupture during VBAC are induction and
augmentation of labor, prolonged labor,
uterine anomalies, endometritis,
multiparty, fetal malpresentation or
malposition, and morbid adherence of
In cases of posterior UR in patients of
VBAC published between 1997 and
2007.10-14 It is possible that uterine over
distension predisposes weak thinned
out musculature to atypical UR. Hawe
and Olah and Figueroa et al. reported
two cases of posterior UR with the use
of prostaglandin for induction of
There are only five described cases in
the literature of posterior UR during
labor through “healthy” uterine tissue in
women with previous CS. However, in
the five instances of rupture through
posterior uterine wall in presence of
anterior scar, only in two cases was
labor induced by prostaglandin,
suggesting other factors may play a
role. In our view the presence of an
inelastic scar comprised of fibrous tissue
on the anterior wall prevents even
distribution of forces of contraction. As
the uterine muscle undergoes retraction
during the active phase of labor, the
healthy posterior wall may undergo
excessive shortening and thinning
compared to the inelastic anterior wall,
which could have predisposed to
rupture. In our case rupture of the
posterior wall occurred during the
second stage of labor but our patient
received oxytocin to augment labor not
The use of intrauterine pressure
catheters (IUPC) may indicate high
intrauterine pressure and diagnose UR
earlier. However Beckley et al.15 found
that in spite of use of IUPC, uterine
ruptures can occur at low pressure due
to increased compliance from the
previous cesarean scar. In our patient,
the uterine contraction and fetal heart
rate were monitored by CTG, there was
no excessive uterine contraction and
fetal bradycardia was the alarming sign
for possible UR, so urgent laparotomy
was performed that saved the baby.
Fetal distress and neonatal demise
resulting from UR are related to
placental abruption and hypovolemia
resulting in placental hypoperfusion,
which develops rapidly as evident from
previous instances of posterior rupture.
In our patient, prompt delivery resulted
in fetal rescue before fetal compromise
could develop. Smith et al.16 found that
the overall risk of perinatal death due to
UR was 1 in 2100 and UR was three
times more likely to result in death of the
infant if the delivery took place in a
hospital with <3000 births a year (1 in
1300) compared to 1 in 4700 in
hospitals with >3000 births a year.
The management of suspected UR
during trial of VBAC should be by early
surgical intervention to stop the bleeding
site and save the fetus' life. Repair of
the rupture site with or without tubal
sterilization should be carried out as the
most suitable intervention especially in
women with repairable tears. In
advanced cases, hysterectomy could be
the only suitable life-saving line of
management. Repair of UR carries a
risk of recurrence in subsequent
pregnancies between 4% & 19%.17 UR
was reported to account for 4% of
maternal mortality in our tertiary hospital
in a previous study.18 This high
percentage indicates the magnitude of
this problem if missed diagnosis or late
intervention was performed.
In conclusion, posterior uterine wall
rupture in a patient with previous CS
scar is very rare, but must be kept in
mind as early intervention is the only
way to save the mother and fetus.
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