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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 17  |  Issue : 2  |  Page : 86-88

Incidental finding of uterine scar dehiscence at elective repeat caesarean section at term


Department of Obstetrics, Gynaecology and Perinatology, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun, Nigeria

Date of Submission15-Aug-2018
Date of Decision12-Jun-2019
Date of Acceptance05-Jun-2019
Date of Web Publication29-Nov-2019

Correspondence Address:
Dr. O A Ijarotimi
Department of Obstetrics, Gynaecology and Perinatology, College of Health Sciences, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njhs.njhs_9_18

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  Abstract 


The risk of adverse outcome for the mother and/or baby is high in the setting of uterine rupture and its possibility should be entertained in a pregnant woman with previous uterine surgery and recent onset lower abdominal pain in advanced gestation. In the absence of symptoms, uterine scar dehiscence may occur unnoticed until complications set in. Women with short inter-pregnancy interval, caesarean wound morbidity and classical caesarean section are at increased risk. Each case should be individualised and those at high risk of uterine rupture should be offered appropriate care. We report a case of antepartum scar dehiscence found incidentally at elective repeat caesarean section at term.

Keywords: Caesarean section, inter-pregnancy interval, scar dehiscence


How to cite this article:
Ijarotimi O A, Sowemimo O O, Dare O A, Ibuola P O. Incidental finding of uterine scar dehiscence at elective repeat caesarean section at term. Niger J Health Sci 2017;17:86-8

How to cite this URL:
Ijarotimi O A, Sowemimo O O, Dare O A, Ibuola P O. Incidental finding of uterine scar dehiscence at elective repeat caesarean section at term. Niger J Health Sci [serial online] 2017 [cited 2019 Dec 7];17:86-8. Available from: http://www.chs-journal.com/text.asp?2017/17/2/86/272039




  Introduction Top


Uterine rupture is an obstetric emergency and should be suspected in a pregnant woman with lower abdominal pain in the background of a previous caesarean section. In the absence of obvious risk factors and clinical signs/symptoms to heighten suspicion, uterine rupture/scar dehiscence may occur unnoticed till complications set in. We report a case of antepartum scar dehiscence found incidentally at repeat elective caesarean section at term.


  Case Report Top


The patient is a 27 year old G4P1+2 (with 2 previous spontaneous complete miscarriages and 1 Caesarean section, none alive). She had a previous emergency caesarean section 5months before index conception at gestational age of 32weeks on account of severe preeclampsia with intrauterine growth restriction resulting in an early neonatal death. She had a poorly formed lower uterine segment, and a transversely placed incision was employed at the lower uterine segment. She had an uneventful postoperative period and was discharged home on the sixth postoperative day.

She, however, presented at the booking clinic 8months later at the gestational age of 13weeks and had a normal course of antenatal care. In view of the short inter-pregnancy interval of 5months following the previous caesarean section, bad obstetric history and maternal request, a joint decision was made for an elective caesarean section at 38th week of gestation. At admission, the maternal and foetal conditions were satisfactory with no abdominal pain or scar tenderness, and labour had not set in. She had caesarean section under spinal anaesthetic block with intraoperative finding of clean pelvis with well-formed lower uterine segment bearing a complete scar dehiscence at the upper margin of the lower uterine segment and bulging tense foetal membranes with foetal head closely apposed to the scar margins [Figure1].
Figure 1: Uterine scar dehiscence with foetal membranes bulging through the gap

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The foetal membranes were ruptured, and a live male baby with Apgar score of 9 at 1min and 10 at 5min and birth weight of 3.6kg was delivered. The third stage was managed actively, and the thinned-out dehisced myometrium was repaired in two layers with Vicryl number 2 suture in interlocking and simple continuous fashion, respectively.

She had satisfactory postoperative recovery and was counselled along with the husband on the intraoperative findings and implication on subsequent conception. Contraceptive counselling was offered, and the need for adequate observation of inter-pregnancy interval of up to 3years was advised. She was seen at the postnatal clinic with the baby in satisfactory condition. She opted for long-acting reversible contraception in the form of progesterone implant.


  Discussion Top


Rupture of the gravid uterus is an obstetric emergency that could result in mortality for the foetus and mother. It often occurs as an intrapartum event with the background of a previous uterine scar, either caesarean or myomectomy.[1],[2] The risk of antepartum uterine rupture is higher following classical caesarean section at 2.2% as against 0.5% following single lower segment caesarean section.[3],[4]

A previous Caesarean section performed at 32 weeks gestation when the lower uterine segment was not yet properly formed and a short inter-pregnancy interval w{Figure1}ere the identifiable risk factors for scar dehiscence in this case. She did not have uterine contraction and attempted vaginal delivery or oxytocic use before surgery, which are known predisposing factors to uterine rupture. Similar silent spontaneous uterine rupture was reported by Woo etal. in a patient with two classical caesarean section scars.[5]

Antepartum diagnosis of scar dehiscence may be challenging as it is often asymptomatic. There is a global increase in caesarean section rate making previous caesarean section the most common indication for caesarean section.[6],[7],[8] With this development of incidental finding or risk of scar dehiscence without prior symptom/sign as in our case, a reduction in the frequency of trial of vaginal birth after caesarean section(VBAC) is being reported.[9] Measures to predict those at increased risk of uterine ruptured are being developed, including ultrasound estimation of thickness of the lower uterine segment.[10] A lower uterine segment thickness cutoff of 3.5mm has been proposed as safe for VBAC with a varying cutoff from various studies.[10],[11] Myometrial thickness measured by transabdominal or transvaginal scan has also been considered.[12] Within the purview of our literature search, there is no conclusive evidence on the role of bed rest and hospitalisation in advanced pregnancy for those at risk of scar dehiscence in pregnancy.


  Conclusion Top


This case report points to the possibility of asymptomatic uterine scar dehiscence in pregnancy. While antepartum uterine rupture in the previous single nonclassical caesarean section is uncommon, consideration of the inter-pregnancy interval and gestational age at the previous caesarean section may inform the need to institute surveillance for women at risk.

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

1.
HofmeyrGJ, SayL, Gülmezoglu AM. WHO systematic review of maternal mortality and morbidity: The prevalence of uterine rupture. BJOG 2005;112:1221-8.  Back to cited text no. 1
    
2.
BernardiTS, RadosaMP, WeisheitA, DiebolderH, SchneiderU, SchleussnerE, etal. Laparoscopic myomectomy: A6-year follow-up single-center cohort analysis of fertility and obstetric outcome measures. Arch Gynecol Obstet 2014;290:87-91.  Back to cited text no. 2
    
3.
American College of Obstetricians and Gynecologists. ACOG practice bulletin no115: Vaginal birth after previous cesarean delivery. Obstet Gynecol 2010;116:450-63.  Back to cited text no. 3
    
4.
EzechiOC, MabayojeP, ObiesieLO. Ruptured uterus in South Western Nigeria: Areappraisal. Singapore Med J 2004;45:113-6.  Back to cited text no. 4
    
5.
WooJY, TateL, RothS, EkeAC. Silent spontaneous uterine rupture at 36weeks of gestation. Case Rep Obstet Gynecol 2015;2015:596826.  Back to cited text no. 5
    
6.
BakerPN. Operative intervention in Obstetric. In: BakerPN, KennyLC, editors. Obstetrics by Ten Teachers. 19thed. London: Hodder Arnold; 2011. p.224-40.  Back to cited text no. 6
    
7.
IgberaseGO, EbeigbePN, AndrewBO. High caesarean section rate: Aten year experience in a tertiary hospital in the Niger Delta, Nigeria. Niger J Clin Pract 2009;12:294-7.  Back to cited text no. 7
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8.
ChanrachakulB, HerabutyaY, UdomsubpayakulU. Epidemic of cesarean section at the general, private and university hospitals in Thailand. JObstet Gynaecol Res 2000;26:357-61.  Back to cited text no. 8
    
9.
YehJ, Wactawski-WendeJ, SheltonJA, ReschkeJ. Temporal trends in the rates of trial of labor in low-risk pregnancies and their impact on the rates and success of vaginal birth after cesarean delivery. Am J Obstet Gynecol 2006;194:144.  Back to cited text no. 9
    
10.
RozenbergP, GoffinetF, PhillippeHJ, NisandI. Ultrasonographic measurement of lower uterine segment to assess risk of defects of scarred uterus. Lancet 1996;347:281-4.  Back to cited text no. 10
    
11.
JastrowN, AntonelliE, RobyrR, IrionO, BoulvainM. Inter-and intraobserver variability in sonographic measurement of the lower uterine segment after a previous cesarean section. Ultrasound Obstet Gynecol 2006;27:420-4.  Back to cited text no. 11
    
12.
SharmaC, SuryaM, SoniA, SoniPK, VermaA, VermaS. Sonographic prediction of scar dehiscence in women with previous cesarean section. JObstet Gynaecol India 2015;65:97-103.  Back to cited text no. 12
    


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