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10 Uterine Rupture andPerforation
when oxytocin exposure is considered. However,
both induction and augmentation of labor are
associated with an increased risk of UR compared to women who labor spontaneously. The
initial cervical examination impacts this nding;
an unfavorable initial cervical examination
(<4 cm dilation) results in an increased risk of
UR compared to spontaneous labor [105].
The benet of intrauterine pressure catheter
(IUPC) monitoring of uterine contractions in
VBAC trials is unclear. Only a small case series
failed to detect differences in fetal or maternal morbidity/mortality associated with UR when an IUPC
was used instead of external tocodynamometry.
The intrauterine pressure catheter allows
careful titration of oxytocin dosing, espe-
cially when maternal habitus limits the
accurate external monitoring of uterine
contractions in women undergoing a
TOLAC.
Cesarean Section andInduction ofLabor
Labor induction is an increasingly common practice in the USA and accounts for at least 20% of
births. While oxytocin is an effective drug in
patients with favorable Bishop Scores, other pharmacological or mechanical agents are frequently
utilized with an unripe cervix. Induction of labor
after a prior CS appears to be associated with an
increased risk of UR.The rate of UR that underwent labor induction after a single previous CS was
1.4–4% compared with 0.34–0.72% for women
who had labored spontaneously [101, 102]. These
ndings suggest a fourfold to 12-fold increased
risk of UR for labor induction after previous CS,
dependent on the labor induction method.
Several studies found a several fold (3–5%
compared to <1%) increased risk for UR using
prostaglandins in gravidas who underwent a
TOLAC [100, 101]. In contrast, the two studies
did not show a signicant difference, but in both
studies, patients with the induction of labor had a
higher percentage of spontaneous URs [106,
107]. Landon et al. reported no URs [88].
Although the study was underpowered to detect
slight differences, the particular type of prostaglandin administered did not signicantly affect
the UR rate (misoprostol; dinoprostone; PGE2
gel; and combined prostaglandins) [88].
Misoprostol induction in patients with a previous
CS results in the calculated risk of UR of 4.7%
compared to 1% associated with a vaginal birth
without misoprostol after a previous CS (fourfold
increase) [108, 109].
Myometrial contractions in women with previous CS are associated with decreased total myometrial collagen and possibly connective tissue
content. The incubation with misoprostol accentuates such an effect, while exposure to dinoprostone
does not. The more pronounced contractile
response and a decrease in collagen content
observed with misoprostol may explain the higher
incidence of UR observed in women with previous
CS.They usually experience UR at the site of their
old scar when treated with PGs for cervical ripening compared to other agents [21]. The milder
effects of dinoprostone on collagen content suggest that it may represent a safer choice for labor
induction in the setting of a previous CD [110].
Among women with a prior CS undergoing
second-trimester abortion using misoprostol, the
risk of UR was less than 0.3%. Women with a
history of low-transverse segment CS and women
induced with misoprostol alone were not found
to be at risk for UR [111].
Prostaglandins
The use of misoprostol in women with prior
cesarean delivery or major uterine surgery
has been associated with an increase in UR
and, therefore, should be avoided in the
third trimester. (ACOG [82]).
Mechanical Methods
It is difcult to estimate the risk of UR with the
use of mechanical methods of labor induction for
cervical ripening because additional induction
methods, such as oxytocin, are concomitantly
used [112, 113]. The mechanical method with the
mere use of a transcervical Foley catheter is a
safe and effective method of VBAC in women
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refusing the use of ecbolics [114]. A randomized
controlled trial found that adding oxytocin to the
use of a transcervical Foley catheter for labor
induction does not shorten the time to delivery
and has no effect on the likelihood of delivery
within 24h or the vaginal delivery rate [115].
Induction of labor with a transcervical
Foley catheter alone may be a reasonable
option for women undergoing a TOLAC
with an unfavorable cervix.
Cesarean Section withPrevious Successful
Vaginal Delivery
There is a protective association between previous vaginal birth on UR risk in subsequent
attempts at vaginal birth after previous CS, with
one-fourth to one-fth of the risk [116]. In
women with no prior vaginal delivery who underwent a TOLAC, there is an increased risk of UR
with induction versus spontaneous labor (1.5%
vs. 0.8%). In contrast, no statistically signicant
difference was shown for women with a prior
vaginal delivery who underwent spontaneous
TOLAC compared with labor induction (0.6%
vs. 0.4%) [117].
Cesarean Section withSubsequent
Successful VBACs
A prior successful VBAC has a protective effect
on the UR rate. Multiple potential explanations
exist. The two most prominent are that a successful prior VBAC attempt assures that (1) the maternal bony pelvis is adequate to permit passage of
the fetus, and (2) the integrity of the uterine scar
under the stress/strain conditions during labor and
delivery was adequate to result in vaginal delivery
without UR.The UR rate decreases after the rst
successful VBAC, but there is no additional protective effect after that the UR rate was 0.87%
with no prior VBACs, 0.45% for those with one
successful prior VBAC, and 0.43% for those with
two or more successful prior VBACs [118].
Pooled data indicate an increased UR rate of 1.4%
in failed VBAC attempts that required a repeat CS
in labor [88, 102].
Interdelivery Interval
With an interpregnancy interval between CS and
subsequent pregnancy of <18 months, UR is
nearly three to four times more frequent than
controls [119, 120]. A Canadian study on women
who underwent a TOLAC after a single lowtransverse CS found that 2.8% of patients who
had an interdelivery interval of ≤24months had a
UR compared with 0.9% for those with an interdelivery interval of >24months (OR 2.65) [121].
In a follow-up study, the same authors examined
the risk of UR between 18 and 24months. After
adjustment for confounding factors, an interdelivery interval shorter than 18months was associated with a signicant increase of UR (OR 3),
whereas an interdelivery interval of 18–24months
was not (OR 1.1) [122].
After a previous CS, an interdelivery inter-
val shorter than 18months but not between
18 and 24months should be considered a
risk factor for UR.
A prolonged interpregnancy interval might
allow the previous CS scar to reach its maximal
tensile strength before the scar undergoes
mechanical stress and strain with a subsequent
intrauterine pregnancy. A short interdelivery
interval of ≤24months and a single-layer hysterotomy closure are associated with a 5.6% UR
rate—a rate threefold higher than patients without this combination. This is comparable to the
rate of UR for patients undergoing a TOLAC
with a previous classic midline CS scar [121].
There were no comparisons of single- or twolayer sutures.
Single-Layer vs. Two-Layer Hysterotomy
Closure
Myometrium closure techniques include interrupted, locked, and unlocked continuous sutures
with single- or double-layer closure [123, 124].
Single-layer locked, continuous suturing, popularized in North America during the late 1980s, is
part of the Misgav–Ladach technique developed
by Stark etal. [124, 125]. A single-layer closure
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10 Uterine Rupture andPerforation
might have several short-term benets, including
reduced operating time, decreased blood loss,
reduced tissue disruption, and the reduced introduction of foreign suture material into the wound.
Most studies [126, 127] compared a locked
single- layer closure with a double-layer closure;
it is, therefore, possible that many benets are
related to tissue strangulation by locked sutures,
which results in better and faster hemostasis.
However, few conclusions can be drawn about
the short-term benets of locked versus unlocked
single-layer closures because studies comparing
these two closure types are lacking [128]. One
large randomized controlled trial did not conrm
the reduced operating time and blood loss of a
single-layer closure [129].
There is a four- to vefold increased risk of
UR after a previous single-layer uterine lowtransverse closure (3.1%) compared to a twolayer closure (0.5%) for CS [130]. The
recommendation is to avoid single-layer closure
in women contemplating future VBAC delivery
[130, 131]. Locked but not unlocked single-layer
closures were associated with a higher UR risk
than two-layer closures in women attempting a
TOLAC [126]. An unlocked single-layer closure
probably leads to better uterine scar healing,
unlike locked sutures that increase pressure at the
suture–tissue interface, leading to ischemic
necrosis and impairing coaptation. Meanwhile,
unlocked sutures provide coaptation, hemostasis,
and wound strength in the immediate postoperative period [132]. Should the wound be exposed
to additional pressure, an unlocked suture would
provide more strength than a locked suture.
Conclusions cannot be drawn because information on the suture type (locked or unlocked) for
the rst or second layer of a double-layer closure
was unavailable. This parameter could have inuenced the comparison between single- and
double- layer closures. In addition, other factors
such as suture material, the inclusion or exclusion of decidua in the uterine suture, and certain
risk factors for UR, including fetal macrosomia,
labor dystocia, and labor induction, were not
considered. Decidua inclusion in sutures or eversion of the edges could result in a weaker scar
and explain the difference between single-layer
locked, continuous, and double-layer closure [96,
133, 134].
Single-layer locked, continuous closure
may increase UR risk in women attempting
TOLAC in a future pregnancy. The risk of
UR after an unlocked single-layer closure
seems comparable to that after a doublelayer closure.
Uterine closure with chromic catgut alone,
irrespective of the number of layers, also resulted
in a higher incidence of the abnormal lower uterine segment [96]. The rapid proteolytic degradation of chromic catgut, especially in the presence
of infection, could be the reason [135].
Multiple Cesarean Sections
Multiple CS carry a higher risk for UR than a previous single CS. Studies from 1993 to 2010
showed that UR risk in a subsequent pregnancy
ranged from 0.9% to 6.0% (1/17–1/108). This
risk is increased 2–16 times compared to women
with only a single previous CS [136–138].
Women with a previous vaginal delivery were
one-fourth as likely to have a UR as women without it (OR 0.26) [116]. The 2010 ACOG recommendation suggests that women with two
previous low-transverse CS may be considered
for TOLAC regardless of their prior vaginal
delivery status [82].
Placenta Percreta
The suggested incidence of abnormal placentation, including placenta percreta, varies between
1/540 and 1/93,000, with an average of 1/700.
Recently, the incidence of placenta accreta has
been rising due to the increased rate of CS [139].
Spontaneous UR due to placenta percreta is one
of the most urgent obstetrical complications
resulting in rapid exsanguination with high mortality. It is commonly seen in the third trimester
and rarely in the second trimester [139]. It is
rarely recognized as intrapartum and is very difcult to diagnose. The precise etiology of all
cases of placenta accreta is unknown; however,
35
DURATION OF PREGNANCY AT TIME OF RUPTURE
NO. OF PATIENTS
WN
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there are known factors that increase the risk.
Most signicant include scarring of the endometrial cavity with previous CS, uterine curettage,
myomectomy, Asherman’s syndrome, iatrogenic
uterine perforation, and advanced maternal age.
These risk factors are frequent with IVF/embryo
transfer. Placenta accreta is mainly caused by a
combination of factors, and its occurrence is
unlikely to be attributed to a single factor. A placenta percreta is common with a previously
scarred uterus [140, 141]. It was present with an
unscarred uterus but with previous uterine instrumentations (including IVF procedures) [142].
UR caused by placenta percreta mainly occurs
during advanced pregnancy, with very few reports
during the rst trimester [143, 144]. In most URs
during delivery, the affected site is the lower uterine segment; however, the fundus is the most
common site in UR during the rst trimester
[143, 144].
Sexual Intercourse
Several case reports described the UR of the
scarred uterus following sexual intercourse [77,
145]. The issue is whether it should be labeled
spontaneous or traumatic URs. Also, it is
unknown whether intercourse was accused as a
cause in other reports of spontaneous UR without
mentioning etiology.
Gestational Age
In both scarred and unscarred uteri, URs
extremely rarely appear before 30weeks of pregnancy. The incidence related to gestational age is
presented in Fig.10.7.
10.1.5.2 Unscarred Uterus
Back in 1845, Jackson conrmed M’Keever’s
observations about risk factors for UR: “I can
fully bear out the opinion of Dr. M’Keever, in his
Essay [147], that this dreadful accident occurs
more frequently amongst the lower ranks than the
higher; and I would suggest whether this result
does not arise from the greater frequency of
deformity of the pelvis as the consequence of
rachitis or scrofula in the former class; and
hence, it is highly probable that in large towns,
where poverty and unhealthy occupants prevail,
and especially where children are engaged in
cramped or restrained positions, as in cotton factories, we shall nd a higher ratio of this kind of
difcult and dangerous parturition” [148].
The anterior wall, particularly in the lower
segment, is a typical site of rupture of an unscarred uterus [42, 43, 149]. Spontaneous rupture
usually involves the lower segment and occurs
during labor, while women with upper segment
scars should deliver by CS before the onset of
labor [150].
Fig. 10.7 Rupture of
the uterus related to the
stage of gestation.
Uterine rupture is the
most frequent at or near
term. (Reproduced with
permission from [146])
30
25
20
15
10
5
20-23 30-31 32-33 34-35 36-37 38-39
WEEKS
40-41 42-43
Previous Scar
INTACT UTERUS
Traumatic
Spontaneous
44-45 45+ UNKNO
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10 Uterine Rupture andPerforation
Oxytocin andProstaglandins
For the stimulation of inert labor, the postulates for
safe administration of oxytocin include (1) labor
should be true, not false; (2) the inertia should be
of the hypotonic variety; (3) wait until the cervix is
two ngerbreadths dilated; (4) the oxytocin should
be adequately diluted or divided and given over a
safe period; (5) there should be no disproportion
and no scar in the uterus; (6) constant attendance
of medical staff is mandatory for administration a
suitable anesthetic if the uterus should react violently; (7) the fetal heart should be frequently auscultated; (8) hesitate to use oxytocin if the patient
has had more than four babies; (9) if there should
be, any doubt, do not use it at all [22]. Feeney published the rst cases of spontaneous UR receiving
5 units of oxytocin in 1956 [22].
Misoprostol (Cytotec®; Searle and Co, Chicago,
IL) is a synthetic prostaglandin E1 (PGE1) analog.
Owing to its uterotonic effect, it has been used as
an abortifacient [151] for cervical ripening (placed
in posterior vaginal fornix), labor induction, and
the treatment of postpartum hemorrhage due to
uterine atony [152]. UR with misoprostol induction has been reported in the English literature in
20 instances up to 2001. Seven ruptures occurred
in the unscarred uterus, whereas 13 cases had CS
scars [109]. In many cases, previous dilation and
curettage, fetal macrosomia, external cephalic version, multiparity, shoulder dystocia, or oxytocin
use might have contributed to UR. Misoprostol
was used in a dose of 25–100μg, or even 600μg
every 3–6h with a maximum of four doses. An
odds ratio of 2.7 for tachysystole with misoprostol
compared to other medications used for labor
induction was observed [153].
PGE2 (dinoprostone) is a potent oxytocic
agent, and rupture of the unscarred uterus has
been reported with vaginal and intracervical
applications [29, 75] in doses up to 6mIU/min.
PGE2 should be used cautiously, particularly in
multiparous patients and oxytocin use. Uterine
hyperstimulation was not observed, and UR
occurred >4h after administration [12].
Assisted Vaginal Delivery
Application of external force in the second stage
of labor [9], vacuum forceps, and breech extrac-
tion are possible causes of UR [75]. Midforceps
delivery and breech version extraction have been
implicated as potential causes of UR [154].
Whether the manipulation results in UR is
unclear.
Parity, Age, andRace
High multiparity carries with it certain inherent
risks … it can be very unforgiving of any carelessness, incapacity, or neglect.
(John Kevin Feeney, 1935)
There could be a signicant difference in the
inuence of parity on the term and preterm
UR.The high parity, rst observed by John Kevin
Feeney (Professor of Gynecology and Obstetrics
at University College Dublin and Master of the
Coombe Hospital in Dublin) in 1953, is recognized as a major risk factor of spontaneous UR in
an unscarred uterus [22, 155]. The uterus may
have been weakened by thinning and stretching
muscle bers during labor, especially with aging
and repeated childbearing [12]. The mean parity
at the time of UR is 5–6 [156, 157]. Some
reported that 56–75.6% of URs occurred with a
parity of 1–4 and 38% with a parity of 5–9 [158,
159]. The precise inuence of parity comes from
the reports of cumulative incidence of the scarred
and unscarred uterus [43, 146]. Some claim that
the incidence rises until the third delivery and
then decreases [43]. Grand multiparity predisposes to malpresentation and unstable lie, a signicant risk factor for UR [64, 66]. Grand
multiparas attend antenatal clinics sparsely (due
to heavy domestic commitments), and consequently, malpresentation is diagnosed late during
labor. Nevertheless, with proper antenatal care,
modern obstetrics, and advanced neonatal services, there is no difference in outcome between
grand multiparous women and women with low
parity [160]. Only 0.005% of UR among 39,529
multigravidas developed without previous uterine scar [69]. Uterine overdistension from twin
pregnancy was not proven as a risk factor. Fetal
weight in singleton pregnancy is a risk only when
it contributes to cephalopelvic disproportion
[41]. Age and parity are interrelated risk factors.
Preterm UR is most common in primigravidas, resulting from traumatic events due to uter-
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ine instrumentation [23]. Congenital
abnormalities, connective tissue disorders, and
abnormally invasive placenta are known risk factors for UR in a primigravida [62].
Women older than 35 and having their fth
or later birth are at the greatest risk for
spontaneous term UR.
The peak incidence differs from country to
country and depends on the average age of the
rst pregnancy and the number of pregnancies.
Therefore, some claim peak incidence in the
26- to 35-year age range [158], while others
showed a peak incidence in the 25- to 29-year
age group. In Qatar, where repeated pregnancies continue into middle age, 56.9% of URs
were grand multiparas (para 5 or more), and
39% were over 35. The factors contributing to
a rupture of the unscarred uterus are presented
in Table10.1. Connective tissue diseases [161]
may also induce UR.In some cases, the gravid
UR has no apparent cause even before labor
[15, 162].
A major factor for UR is obstructed labor.
Black African women have a high incidence of
the contracted pelvis [163].
An unscarred prelabor primigravid uterus
can show a very thin uterine wall, compatible
with incomplete UR, without apparent etiological or risk factors. There have been 36 [164]
and 22 [165, 166] cases of primigravid URs
found over the last 65years (1946–2013). Of 21
cases found by Matsubara et al., 15 were
reported in Nepal [167], with all ruptures occurring after labor duration of >48h, and 12 had
received no antenatal care. Of all these 58
(36+ 21 +1) cases, 55 had some discernible
etiological or risk factors for UR, including a
history of uterine surgery, congenital uterine
anomaly, adherent placenta, labor, or oxytocin
or prostaglandin use [161, 164, 166]. The etiology was indiscernible in the remaining two
[168, 169], while in one, there was a history of
curettage [165], but without the evidence being
a cause.
Congenital Uterine Anomalies
Congenital uterine anomalies affect approximately 1/200 women [170]. In such cases, the
walls of the abnormal uteri tend to become abnormally thin as pregnancies advance, and the thickness can be inconsistent over different aspects of
the myometrium [171], predisposing it to rupture
(Fig. 10.8). The reported incidence of UR in
women with congenitally malformed uteri is 8%
compared to 0.61% in those with normal uteri
attempting VBAC [173]. Cases of UR in women
with uterine anomalies involved labor induction
with prostaglandin E2. In contrast, a study of 165
patients with Müllerian duct anomalies who
underwent spontaneous labor after one prior CS
reported no cases of UR [174]. In this study, 36%
had only a minor uterine anomaly (arcuate or
septate uterus), and 64% had a major uterine
anomaly (unicornuate, didelphys, or bicornuate
uterus). Moreover, only 6% with Müllerian duct
anomalies underwent induction of labor.
Rudimentary Horn
See Chap. 9.
Uterine Sacculation
A thin uterine wall resulting from uterine sacculation [175, 176] may induce UR.Uterine sacculation is a transitory pouch or sac-like structure
developing from a portion of the gravid uterus
[175]. The typical form of sacculation results
from an incarcerated retroverted uterus [175,
Fig. 10.8 Fundal uterine rupture in the left part of the
bicornuate uterus in a 12-week pregnancy. (Reproduced
with permission from [172] under the CC BY Attribution
License)
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10 Uterine Rupture andPerforation
176]. A ventrally located cervical ostium and
vagina may cause physicians to suspect this diagnosis. In this condition, the anterior uterine wall
becomes stretched and thin. Other conditions,
such as previous surgery, a primary myometrial
defect, uterine malformation, or placental abnormalities, are listed as possible causes of uterine
sacculation [175].
Uterine Diverticulum
The diverticulum can result from a developmental malformation (true diverticulum) or weakening of the uterine wall from prior uterine surgery
(iatrogenic or secondary diverticulum) [177]. A
uterine diverticulum is frequently misunderstood
and reported as uterine sacculation [177]. On the
other hand, uterine sacculation is typically a
larger outpouching that contracts after delivery. It
occurs during pregnancy as the uterus is distended by the destruction of the uterine wall by
trophoblastic tissue [177]. The hypothesis is that
abnormal development of the paramesonephric
duct may cause a congenital uterine deformity,
leading to the formation of the diverticulum
[178]. The uterine diverticulum has a narrow
connection with the uterine cavity and a thicker
wall than uterine sacculation [177]. While uterine
sacculation is usually observed during pregnancy
[175], the diverticulum is usually detected in
nonpregnant women. Uterine diverticula as complications during pregnancy are rare. An asymptomatic diverticulum in pregnancy indicates
elective CS before uterine contractions and labor.
Extreme caution is needed because there are
cases of UR before uterine contractions as a start
of labor [177, 179]. Also, if the gestational sac is
implanted in a diverticulum [178], there is a signicant risk of UR and other obstetric complications, and the pregnancy should be terminated.
Genetic Susceptibility forRupture
Loeys–Dietz syndrome is caused by heterozygous mutations in the genes encoding type 1 or 2
transforming growth factor β receptor
(TGF-βR1/2). It carries a risk of gravid UR and
the arteries during pregnancy or in the immediate
postpartum period and damage to the vagina, the
perineum, and the colon [180].
Antenatal Care
Prenatal care in some undeveloped countries
such as Yemen or Uganda is indigent. Only 44%
of pregnant women had ever been to any prenatal
clinic, with visits ranging from one to four during
a pregnancy. Women visit antenatal clinics mostly
when they encounter complications and rarely
for routine antenatal care (13%). In Yemen, 56%
of pregnant women have never had antenatal
care. Home delivery is still typical. About 78% of
women deliver at home, 16% at state hospitals,
and 5% at private hospitals. Home deliveries are
usually attended by midwives with minimal
training or relatives with some labor experience.
Some of the women will still deliver at home
alone [41]. In Uganda, the majority (67%) of the
women did not attend antenatal care [20].
Epidural Anesthesia
Epidural anesthesia has been linked to UR [60,
181]. Plauché etal. suggested that “the propriety
of the sitting position for the induction of epidural or spinal anesthetic procedures for delivery
created an increase in intra-abdominal pressures
that may be sufcient to produce a uterine rupture” [181]. However, epidural use is low in
patients with UR, ranging from 6% to 21% [60,
181, 182].
Uterine Fibroids
Fibroids are associated with numerous pregnancy
complications (see Chap. 12), including pain,
miscarriage, premature labor and delivery, malpresentation, and placental abruption [183–185].
Approximately 10–40% of complications are in
this group [186]. UR occurs after myomectomies, not with uterine broids. Uterine broid
rupture during pregnancy or puerperium presents
with bleeding. Two cases of uterine broid rupture with UR were detected during labor [187,
188].
10.1.5.3 Operative Procedure
Prepregnancy Uterine Myomectomy
Most URs with myomectomy scars occur during
the third trimester of pregnancy or labor [189–
194], with several cases during the second [195–
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198] or even the rst trimester [199]. Some claim
a 3–4% UR rate in women with scars from a previous myomectomy—open or laparoscopic [146,
189]. Such reports often do not delineate the
important factors for assessing the risk of subsequent UR (e.g., number, size, and locations of
leiomyomas; number and locations of uterine
incisions; entry of the uterine cavity; and type of
closure technique). The risk is signicantly lower
with these factors included in the analysis, 0.26–
1% [189, 190].
Because the neuropeptide substance P and
vasoactive intestinal peptide in the pseudocapsule of uterine myomas may affect wound healing and myometrial function in a subsequent
pregnancy, the pseudocapsule with neurovascular
bundle should be respected to prevent damage by
excision or extensive coagulation [200, 201].
Therefore, intracapsular laparoscopic myomectomy, which preserves these neuropeptides and
enables proper myometrial healing, is recommended [202]. Compared to open myomectomy,
laparoscopic myomectomy could increase the
risk because the rate of 2-layer closure is lower,
with higher use of tissue coagulation [201, 203].
Other studies did not nd the inuential role of
laparoscopic myomectomy in association with
UR [204]. Other UR preventive measures after
prepregnancy myomectomy include (1) elective
CS for numerous and deeply placed broids, (2)
opened endometrium, (3) accurate apposition of
the wound edges and hemostasis had not been
secured, (4) recovery had been complicated by
fever, and (5) the placenta has been implanted on
ultrasound (US) examination upon an endometrial scar [22]. An interval of contraception after
myomectomy to ensure adequate wound healing
might be necessary. Evaluation of changes in
uterine structure (resolution of hematoma,
absorption of suture materials, decrease in scar
size, etc.) during the recovery process after myomectomy using MRI [205], US [206], and 3D
Doppler US [207] leads to the conclusion that the
wound healing process completes by 3months.
Cases 8 years after laparoscopic myomectomy
exist [208], meaning that prolongation of contraception alone may not reduce the risk of UR and
such an interval is not a denitive risk factor for
UR [209, 210]. In conclusion, at least 3months is
needed for uterine wound healing, while some
recommend 6 months of contraception [201].
The most rigorous recommendation can follow
the recommendation that pregnancy and vaginal
delivery are safe 18months after CS.
These measures (including vasoconstrictors
instead of coagulation) can minimize UR [192,
202, 204, 211–215]. These outcomes should be
cautiously analyzed because some studies did not
nd UR, but the uterine dehiscence rate was 1.8–
4.9% [209, 216]. Prepregnancy myomectomies
should be recorded, so that if the UR or uterine
dehiscence occurs, the locations could be compared (Figs.10.9 and 10.10).
Women who have undergone laparoscopic
myomectomy would best avoid multiple
pregnancies because of the potentially
increased risk of UR. This is extremely
important when assisted reproduction tech-
niques are used in these women; single
embryo transfer would be preferable,
whereas intrauterine insemination could be
managed without any ovarian stimulation
[203].
Medical Abortion
Medical abortion was started in the late 1980s,
becoming more widely used in the late 1990s,
with mifepristone and misoprostol being the
most used. It came as an alternative to dilation
and curettage, which caused more complications,
resulting in 50,000–100,000 maternal deaths
yearly [217, 218]. No randomized controlled trial
has been powerful enough to compare medical
and surgical abortions concerning the adverse
effects. Misoprostol (partial progesterone receptor agonist which also antagonizes cortisol action
competitively on the receptor level) alone for the
termination of pregnancy was described in 1994.
It has been used widely in the normal uterus [217,
218]. The absence of previously reported cases of
gemeprost-associated UR may reect the rarity
of this pregnancy termination method in the second trimester. Initially, higher doses were admin-
268
bc
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a
def
10 Uterine Rupture andPerforation
Fig. 10.9 Sixteen months prepregnancy laparoscopic
myomectomy. (a, b) The subserosal myoma in the fundus
was removed by cutting its narrow stalk. (c, d) another
subserosal myoma on the anterior wall was removed by
istered, and the conclusion was that smaller doses
might lessen the risk of uterine hypertonus and
decrease the risk of UR [219]. The additional risk
factor in such cases is scarred uterus [220–222],
but there are even cases with an unscarred uterus
[109, 223]. The systematic review from 2009
found a seven times higher incidence of UR in
the scarred uterus (0.28%) in comparison with
the unscarred uterus (0.04%), but the authors
found the incidence acceptable [111]. UR in an
unscarred uterus is possibly related to the dose,
dose interval, gestation, and parity. Based on the
pharmacokinetics of misoprostol, a dosage interval is 6h (range 3–12h) [224]. UR occurred in
one case with a lower accumulated dose of misoprostol (1200 μg/30 h) than in some reported
regimens (2400μg/24h) [224]. A case of spontaneous UR of the unscarred uterus in the rst trimester using mifepristone/misoprostol for
medical termination of pregnancy exists [225].
Corticosteroid therapy is a contraindication to
mifepristone (but not misoprostol) because of the
glucocorticoid antagonistic effect. Whether pro-
cutting its stalk. (e, f) the intramural myoma on the anterior wall was enucleated. (Reproduced with permission
from [201])
longed corticosteroid therapy can result in a
weakened myometrium susceptible to rupture
remains to be determined. The incidence of UR
among women with a prior CS during
second- trimester pregnancy termination with
prostaglandin E2 or oxytocin is 3.8% [226]. The
risk is even higher when oxytocin is used with
prostaglandins [227]. There was no set regimen
protocol for intravaginal misoprostol in secondtrimester pregnancy termination. Mostly the initial dose was 400μg repeated every 4–6h, up to
a maximum of 1200–1600μg/24h. Some studies
have augmented misoprostol with either oxytocin
or mifepristone [220, 223, 226]. FIGO has recommended the protocol for second-trimester
pregnancy termination with 100–200 μg intravaginal misoprostol, repeated every 6 h till a
maximum of four doses/24h [227]. Its use should
be with care in a previously scarred uterus. Four
cases of rupture of an unscarred uterus in the second trimester following MTOP were reported.
Only two of these cases used mifepristone and
misoprostol [228]. The other women found do
cd
10.1 Spontaneous Uterine Rupture
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269
a
b
Fig. 10.10 Uterine rupture was identied during the
emergent Cesarean section at 33weeks of gestation (the
same patient from Fig.10.9). (a, b) The myometrial defect
reached the endometrial cavity. It was 2×3cm in size and
located near the right uterine horn on the anterior uterine
not follow the MTOP protocol but contain information relevant to this case. The rst was an
MTOP using mifepristone and gemeprost. The
rupture was found by US the morning after commencing prostaglandins [229]. The second case
was a grand multiparous patient [222]. An US
found the UR following one dose of misoprostol
(200 μg) followed by oxytocin 12 h later.
Although high doses of prostaglandins are a
known risk factor, the above two women were
treated for over 24h, raising the possibility that
the duration of prostaglandin treatment is a risk
factor. Other agents, such as ethacridine lactate,
have been linked to UR, although this is very
rare, and the case was related to the second tri-
wall. (c) Debridement and 2-layer myometrial suturing.
(d) Macroscopic picture of resected tissues in the ruptured
site of the myometrium. The pathological diagnosis of the
removed myometrial specimen was focal myometrial
necrosis. (Reproduced with permission from [201])
mester [230]. Cases of UR have been reported
involving small doses of misoprostol. One case
involved an endocervical rupture in the second
trimester following two doses [231]. Another was
a scarred uterus [232], and a similar case was the
rst-trimester UR following one dose of misoprostol in preparation for surgical termination
[199].
There is no evidence that pretreatment with
mifepristone might increase the chance of
UR.The chance might be reduced as mifepristone increases cervical compliance; however, as
it increases uterine sensitivity to the action of
exogenous prostaglandins [229], the risk–benet
is unknown. Previous CS could be a risk factor
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