Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2015 Oct 26.
Published in final edited form as: Am J Obstet Gynecol. 2015 Jun 10;213(4):590.e1–590.e2. doi: 10.1016/j.ajog.2015.06.017

Asymptomatic uterine dehiscence in a second-trimester twin pregnancy

Sally R Greenwald 1, Juan M Gonzalez 1, Ruth G Goldstein 1, Melissa G Rosenstein 1
PMCID: PMC4620992  NIHMSID: NIHMS728895  PMID: 26071921

Case notes

A 22-year-old woman with dichorionic-diamniotic twins and a history of cesarean delivery for breech presentation presented for routine anatomy ultrasound. She was found to have a 2-cm defect in the lower uterine segment at the cervical junction, likely at the site of her previous hysterotomy (Figure 1). On endovaginal scan, there was sludge within the defect that extended through the myometrium, covered only by serosa. A fetal foot intermittently kicked through the defect (Video). Magnetic resonance imaging confirmed the dehiscence at least 3 cm from the inferior margin of her anterior placenta adjacent to the normal-appearing bladder; there was no maternal free fluid (Figure 2). She was asymptomatic, however she was admitted at 19 weeks and 4 days for observation given concern for catastrophic rupture as the pregnancy progressed. At 21 weeks and 2 days, she ruptured her membranes, began painfully contracting, and a fetal foot was protruding through the cervical os. The patient was hemodynamically stable, however, due to her tightly contracted cervix around the fetal foot, the decision was made to perform an emergent exploratory laparotomy. A classic hysterotomy was performed to deliver the twins, who were not resuscitated due to their early gestational age. This defect was repaired with a single layer of 0-Vicryl (Ethicon Inc., Blue Ash, OH) in a running locked fashion to reapproximate the myometrium.

FIGURE 1. Ultrasound images.

FIGURE 1

FIGURE 1

Open in a new tab

A, Dichorionic-diamniotic twin pregnancy with anterior placenta (a). Transvaginal ultrasound showing B, uterine dehiscence with amniotic membrane protruding through defect (d) and C, defect (d) in relation to cervix (e). D, Membranes protruding through defect (d).

b, bladder; c, fetal foot.

FIGURE 2. Magnetic resonance imaging.

FIGURE 2

Open in a new tab

T2 weighted, showing twin pregnancy with defect (d).

a, presenting fetus; b, bladder; c, nonpresenting fetus.

Conclusions

Uterine rupture prior to labor is rare, as women who plan a repeat cesarean delivery have a risk of uterine rupture without labor of approximately 0.16%.1 The largest series of women who experienced second-trimester uterine dehiscence consists of 6 women who underwent surgical repair using collagen fleece, and delivered at ≥33 weeks.2 These women were all symptomatic with rupture, favoring intervention over expectant management. There is no consensus on management of asymptomatic second-trimester rupture. The limited available data describe a spectrum of management options including pregnancy termination, expectant management, or surgical repair.3,4 There are few reports of uterine dehiscence in twin pregnancies, and little evidence to suggest the possibility of predicting recurrence of uterine rupture, but subsequent pregnancies can be uncomplicated if delivered before the onset of labor.5,6

Supplementary Material

Video
Download video file (2MB, mp4)

Footnotes

The authors report no conflict of interest.

References

  • 1.Lydon-Rochelle M, Holt VL, Easterling TR, Martin DP. Risk of uterine rupture during labor among women with prior cesarean delivery. N Engl J Med. 2001;345:3–8. doi: 10.1056/NEJM200107053450101. [DOI] [PubMed] [Google Scholar]
  • 2.Sugawara T, Ogawa M, Tanaka T. Repair of uterine rupture during second trimester leading to successful pregnancy outcome: case study and literature’s review. AJP Rep. 2014;4:9–12. doi: 10.1055/s-0033-1361926. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.Shirata I, Fujiwaki R, Takubo K, Shibukawa T, Sawada K. Successful continuation of pregnancy after repair of a midgestational uterine rupture with the use of a fibrin-coated collagen fleece (TachoComb) in a primigravid woman with no known risk factors. Am J Obstet Gynecol. 2007;197:e7–9. doi: 10.1016/j.ajog.2007.07.039. [DOI] [PubMed] [Google Scholar]
  • 4.Hamar BD, Levine D, Katz NL, Lim KH. Expectant management of uterine dehiscence in the second trimester of pregnancy. Obstet Gynecol. 2003;102:1139–42. doi: 10.1016/s0029-7844(03)00162-5. [DOI] [PubMed] [Google Scholar]
  • 5.Combs CA, Murphy EL, Laros RK., Jr Factors associated with post-partum hemorrhage with vaginal birth. Obstet Gynecol. 1991;77:69–76. [PubMed] [Google Scholar]
  • 6.Chibber R, El-Saleh E, Al Fadhli R, Al Jassar W, Al Harmi J. Uterine rupture and subsequent pregnancy outcome–how safe is it? A 25-year study. J Matern Fetal Neonatal Med. 2010;23:421–4. doi: 10.3109/14767050903440489. [DOI] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Video
Download video file (2MB, mp4)

RESOURCES