Spontaneous and complete uterine scar rupture occurred 26 days after caesarean section: A case report

 Kartina Ariffin, Jumaida Abu Bakar, Aruku Naidu

 Department of obstetrics & Gynaecology, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia

Abstract:

Caesarean section rates have increased worldwide. Following this, the rate of uterine scar dehiscence or rupture is also increased in pregnancy. Rupture of lower uterine segment incision at post-partum is extremely rare clinical condition. We present a 25 year old patient at day 26 post caesarean section, presented with lower abdominal pain with copious vaginal discharge. The examination was unremarkable. On Pelvic ultrasound and Computerized Tomography, an anterior hyperechoic mass with fat attenuation with the mass was visible, measuring 3.3x 7.2x 7.7cm , an anterior uterine wall defect was also noted.  The patient underwent an exploratory laparotomy. There was a spontaneous and complete rupture of the lower uterine segment with omentum enclosing the defect. The debris, clot & fluids were evacuated, followed by repair of the defects in 2 layers with polyglactin suture material size 1. The patient’s post-operative recovery was uneventful. In conclusion, the diagnosis of post-partum caesarean scar dehiscence or rupture is difficult clinically, but radiological modality is essential to establish the diagnosis. As this patient is young, primiparous and with future reproduction function in mind, an exploratory laparotomy was performed as it is both diagnostic & therapeutic in this rare case.

Key words: post- partum, caesarean scar, rupture uterus

Introduction

The post-partum lower abdominal pain and per vaginal discharge is common presentation in patients after caesarean section or childbirth. The common cause is urinary tract infection, endomyometritis and retained placenta. Spontaneous caesarean scar dehiscence or rupture at post-partum is unusual and difficult to diagnose clinically. Radiological modality is a usual tool to help in the diagnosis. Scar dehiscence or rupture not only can be missed but can be potentially life-threatening in her subsequent pregnancy if not address properly. Preoperative diagnosis is usually difficult, thus exploratory laparotomy is both diagnostic and therapeutic for this rare condition. We report a case of spontaneous and complete rupture of a caesarean scar at day 26 post-partum.

Case Report:

The patient was a 25-year-old primiparous woman who underwent emergency caesarean section for deep transverse arrest. The course of her pregnancy had been normal and uneventful. She had no significant medical or surgical history. The labour was spontaneous and progress smoothly until she reach the second stage. The second was prolonged for 1 and half hours with OS fully. Caesarean section was decided as there was large caput & it was not suitable for instrumental delivery. Her caesarean section operation was complicated with bilateral extended uterine tear, the tears was extended and involved the broad ligaments. These tears were repaired in two layers using polyglactin suture size 1. The uterine incision was also sutured in two layers using the same material by a specialist. There were no active bleeding. The abdomen was closed in layers.

She was clinically stable, with normal vital signs throughout her hospital stay and was discharged well on day 2 post-operative day. She was perfectly well during her post-delivery visits. On the Day 26 postpartum, she presented with lower abdominal pain and foul smelling lochia/discharge. She had no fever, any evidence of sepsis or any excessive per vaginal bleeding.

On examination, she was afebrile, her blood pressure was 104/62mmHg, pulse rate was 100bpm and abdomen was soft, but mild tender on palpation. Uterus was contracted well at 16 weeks. Vaginal examination revealed copious amount of yellowish vaginal discharge, and draining from the OS. A pelvic ultrasound showed irregular and hyperechoic mass above the uterine incision. The mass appeared like haematoma measuring 4.1x 6.7x7.0cm. Computerized Tomography was carried out, which also reported the same finding and a possibility of caesarean scar rupture with blood or abscess collection. An anterior hyperechoic mass with fat attenuation with the mass was visible, measuring 3.3x 7.2x 7.7cm. The bladder wall was separate and well defined. The hemoglobin concentration was 10.9 g/L, the total white blood cell was 9.0x 10⁹ /L. The high vaginal swab was no growth detected.  Histology report suggest acute on chronic inflammation with granulation tissue formation.

As the patient was young and primiparous, a decision was made to perform an exploratory laparotomy and repair of the ruptured uterine defect.  The patient & her husband was adequately counseled prior to the operation. At laparotomy, there was minimal pus in peritoneum. The omentum was adhered to anterior uterine wall. The omentum was released from the scar. There was a complete scar rupture of the lower segment uterine incision. The margins of the incision were unhealthy, with some collection of blood and pus. The scar was debrided until a fresh layer of uterine wall. The uterine cavity was normal. The bladder wall was intact.

Uterine defect margins were refashioned and approximated in 2 layers with continuous closure and interrupted suture respectively using polyglactin suture material size 1. Thorough abdominal lavage done and abdominal drain was inserted. The integrity of the bladder and ureters was confirmed prior abdominal closure. Her blood pressure remained stable throughout the surgery.

The patient’s postoperative course was uneventful and she received broad spectrum antibiotics for 14 days. She was discharged well on the 3rd day postoperative day and remained well thereafter. She was reviewed 6 weeks after the laparotomy. The abdominal wound has healed well. A repeat pelvic Ultrasound reveal well define uterine margins.

Ultrasound picture:

Intraoperative picture

Discussion

Abdominal pain and per vaginal discharge after post caesarean delivery is a common complaint. The common causes for such symptoms are urinary tract infection, endomyometritis and retained placenta However, pain secondary to uterine dehiscence or rupture are a rare clinical condition. The incidence of post-partum uterine scar dehiscence or rupture is between 0.6% - 3.8%¹. Delayed presentation of caesarean scar rupture up until 6 weeks postpartum period has been reported in literature². Postpartum scar dehiscence or rupture can present as secondary post-partum hemorrhage, localized or generalized pain and peritonitis, sepsis or even shock. In our case, the presenting complaint was only tenderness at the lower abdomen associated with copious vaginal discharge, which may suggested a possibility of endomyometritis. This case report shows that it is important to have high index of suspicion to exclude uterine dehiscence or rupture in patients who present with localized tenderness or even pelvic haematoma or abscess. Risk factors for lower segment uterine incision rupture during the post-partum period are advance age, multiparity, diabetes, immune compromised, wound infection and hematoma. In our case, we postulated that the extended tear may have led to haematoma and subsequently developed infection that caused tissue necrosis and scar dehiscence. This was evident by presence of copious vaginal discharge vaginally. Among other factor that is associated with poor wound healing is malnutrition. The body mass index of the patient during booking was 16. Whether this has a direct relationship with uterine dehiscence, is unknown.

Ultrasound is the commonly used imaging modality to help with the diagnosis. On ultrasonography, the uterine incision site may show full thickness defect, some hypoechoiec area along the uterine incision line or in some cases some blood or abscess collection anterior to the incision site. Other imaging modality that we can use to aid in our diagnosis is computed tomography (CT) an magnetic resonance imaging ( MRI). An MRI with a heavily T2 weighted image may show a bright fluid filled tract³. However, the clinical usefulness using this modality in acute setting needs to be defined.

Management of these patient’s will depend on the clinical situation taking into account the haemodynamic stability, the severity of infection and patient future reproductive potentials. The management includes conservative or surgical management. In conservative management, broad spectrum antibiotics should be considered and long term follow is need. Patient uterine integrity is difficult to test if this patients plan for further pregnancies and deliveries. In those patients who are unstable, exploratory laparotomy is recommended. Option between refashioning of the edges of the uterine incision or hysterectomy should depend on the intraoperative findings and patient future needs. In our case, the scar margins was intact, hence re-suturing of the incision site was carried out. If the edges are necrotic and irregular, hysterectomy may be considered.

The consequence of this complication for a future pregnancy remains unknown. Mode of delivery in next pregnancy is preferably a repeat caesarean section. For our patient, we have recommended for an elective caesarean delivery at around 37 weeks. 

Disclosure

None of the authors has anything to disclose

Consent Taken from Patient to use the pictures & publish this article

References:

1. El-Agwany AS et al. Conservative management of infected post partum uterine dehiscence after   c   cesarean section. J Med Ultrasound. 2018;26(1):59. doi:10.4103/jmu.jmu_5_18.

2. Wagner MS, Bédard MJ. Postpartum Uterine Wound Dehiscence: A Case Report. J Obstet Gynaecol Canada. 2006;28(8):713–5.doi:10.1016/s1701-2163(16)32236-8

3. Jastrow N, Chaillet N, Roberge S, Morency AM, Lacasse Y, Bujold E. Sonographic lower uterine segment thickness and risk of uterine scar defect: a systemic review. J Obstet Gynaecol Can 2010;32:321-7

4.  Sengupta Dhar R, Misra R. Postpartum uterine wound dehiscence leading to secondary PPH: Unusual sequelae. Case Rep Obstet Gynecol 2012;2012:154685.