Review Received: November 5, 2014 Accept after revision: April 6, 2015 Published online: May 13, 2015
Gynecol Obstet Invest DOI: 10.1159/000398795
Spontaneous Rupture of the Pregnant Uterus following Salpingectomy: A Literature Review Paweł Jan Stanirowski Seweryn Trojanowski Anna Słomka Krzysztof Cendrowski Włodzimierz Sawicki Department of Obstetrics, Gynecology and Oncology, Second Faculty of Medicine, Medical University of Warsaw, Mazovian Bródno Hospital, Warsaw, Poland
Abstract Background: Spontaneous rupture of the uterus is a lifethreatening obstetric complication in rare cases associated with previously performed salpingectomy. Aim: This paper presents an analysis of uterine rupture cases during pregnancy in patients after surgical removal of the fallopian tubes. Methods: The English and Polish language literature was reviewed for studies published between January 1, 1980 and September 30, 2014 to identify articles that described rupture of the uterus in women with a previous history of salpingectomy. Results: Thirteen case reports and case series studies in 18 women were identified. 33% of cases of uterine rupture following salpingectomy occurred during intrauterine pregnancy, whereas the rest was associated with interstitial ectopic pregnancy. Laparoscopic salpingectomy more often resulted in rupture of the uterus during non-ectopic pregnancy as compared to laparotomy (4 vs. 2 cases, respectively). When interstitial pregnancies were excluded, uterine rupture was a cause of fetal death in 67% of reported gestations. There were no cases of maternal mortality. Con-
© 2015 S. Karger AG, Basel 0378–7346/15/0000–0000$39.50/0 E-Mail [email protected] www.karger.com/goi
servative treatment was the preferred management option, and total hysterectomy was performed in only 2 patients. Conclusion: Particular attention should be paid to patients with a previous history of salpingectomy due to the risk of uterine rupture throughout the entire pregnancy. © 2015 S. Karger AG, Basel
Introduction
Spontaneous rupture of the uterus is a rare, life-threatening obstetric complication associated with increased morbidity and mortality rates in both mother and fetus. The overall incidence of uterine rupture is approximately 0.04–0.09% in the general population, and women with a previous history of uterine surgery, including cesarean section or myomectomy, are considered the highest-risk group [1–4]. Few reports suggests there is an association between uterine rupture during pregnancy with previously performed salpingectomy. This paper presents a review of the available literature on uterine rupture in patients subject to salpingectomy and discusses current methods of tubal surgery, as well as pregnancy outcomes and mortality rate among mothers and fetuses. The analysis was based on a rare case of sponPaweł Jan Stanirowski Mazovian Bródno Hospital Kondratowicza 8 PL–03-242 Warsaw (Poland) E-Mail stanirowski @ gmail.com
Downloaded by: NYU Medical Center Library 128.122.253.228 - 5/30/2015 7:43:16 PM
Key Words Uterine rupture · Salpingectomy · Interstitial pregnancy · Laparoscopy
Case Presentation A 29-year-old Caucasian woman (gravida 2, para 1) at 38 gestational weeks of uncomplicated pregnancy was admitted to our department in August 2014 with regular uterine contractions. She had no history of previous surgery, except for laparoscopic salpingectomy for a ruptured tubal pregnancy in June 2013. According to the postoperative protocol the patient underwent total surgical resection of the left fallopian tube using bipolar electrosurgical coagulation. The woman was in a good general health at physical examination on admission. The only abnormalities detected on abdominal examination were non-specific and included muscular guarding associated with a mild, dull pain in the lower and middle abdomen. Cardiotocography demonstrated normal uterine activity, regular contractions and a fetal heart rate of about 140 bpm. Antepartum ultrasound scan showed breech presentation, normal fetal biometry and placenta located at the fundus of the uterus with no evidence of preterm abruption. The amount of amniotic fluid was significantly decreased, although no clinical signs of external leakage were observed. Due to the breech presentation of the fetus in a primiparous woman, a cesarean section was performed via the Pfannenstiel skin incision. Intraoperatively, a large (about 1,000 ml) collection of colorless fluid was found within the peritoneal cavity and a 50-ml sample was obtained for cytological analysis. A horizontal incision was performed in the lower uterine segment, and a single living male fetus was extracted from the uterus. The newborn weighted 3,750 g and was in good health on initial assessment. Although the placenta appeared normal on macroscopic inspection, tissue samples together with the umbilical cord were taken for histological examination. Then both ovaries, the parietal peritoneum and the liver were visually inspected and no abnormal findings were observed. Finally, a 1-cm-long tear was found in the uterine wall at the scar site from the previous tubal surgery. The rupture was closed with two layers of absorbable sutures. The early postpartum period was uneventful and the patient was discharged from hospital on the 4th day after surgery. Histological examination of the placenta revealed no evidence of intrauterine infection or focal lesions, whereas cytological analysis of peritoneal fluid showed the presence of protein, red blood cells and lysed squamous epithelial cells, indicating amniotic origin and unequivocally confirming spontaneous rupture of the uterus.
Methods A review of the English and Polish language literature was undertaken for studies published between January 1, 1980 and September 30, 2014 to identify articles that described rupture of the
2
Gynecol Obstet Invest DOI: 10.1159/000398795
uterus in women with a history of previous salpingectomy. Studies were identified via PubMed and EMBASE databases using the key words ‘uterine rupture’ and ‘salpingectomy’ by three authors (P.S., K.C., W.S.) independently. The reference lists of retrieved articles were reviewed to locate additional studies. Publications eligible for the study included full-text randomized controlled trials, cohort studies, letters to the editor, case reports and case series studies. Abstracts, conference supplements and reviews were excluded from the analysis. 164 potentially useful publications were retained, and during further selection 13 case reports and case series studies on uterine rupture in 18 pregnant women with a previous history of surgical removal of the fallopian tubes were identified. A summary of the selected publications is provided in table 1 [5–17]. The following data were collected: patient age, signs and symptoms associated with uterine rupture, indication for as well as mode and technique of salpingectomy, time interval between salpingectomy and conception, gestational age, pregnancy management and maternofetal final outcomes.
Results and Discussion
Spontaneous rupture of the uterus defined as a partial or full-thickness separation of the uterine wall before the onset of myometrial contractions is a rare obstetric complication that occurs primarily in the third trimester of pregnancy when the intrauterine volume and pressure are increased to the highest possible levels. The risk of rupture is greatest in patients with a previous history of uterine surgery, including cesarean section or myomectomy, and extremely low in those with intact and unscarred uterus [1–4]. Possible causes of uterine rupture in the latter group include e.g. abnormal placentation or interstitial pregnancy defined as ectopic gestation, in which an embryo implants outside of the uterine cavity within the cornual portion of the fallopian tube [11–19]. Labor induction with prostaglandins or oxytocin, fetal malpresentation, labor dystocia, delivery after ≥42 gestational weeks, fetal birth weight ≥4,000 g or advanced maternal age constitute other factors responsible for increased risk of uterine rupture [1–3]. The only identified risk factors in our patient were breech presentation of the fetus and laparoscopic salpingectomy performed 6 months prior to conception. The analysis of case description indicates that rupture of the uterus occurred spontaneously before the onset of myometrial contractions and resulted in constriction of the uterine muscle and induced labor. It is of note that the patient did not present with any specific symptoms of uterine rupture, such as sudden abdominal pain, internal hemorrhage or hypovolemic shock. Our findings are consistent with those reported in the literature, where all of Stanirowski/Trojanowski/Słomka/ Cendrowski/Sawicki
Downloaded by: NYU Medical Center Library 128.122.253.228 - 5/30/2015 7:43:16 PM
taneous rupture of the uterus following surgical removal of a fallopian tube associated with intraperitoneal amniotic fluid leakage. To the best of our knowledge the presented literature review and case report have not been published so far.
Table 1. Summary of the studies included in the review Case Reference No. (first author, year)
Patient age, years
Indication for salpingectomy
Mode of salpingectomy
Salpingectomy technique
Interval between Gestational Signs and salpingectomy age, weeks/ symptoms of UR and conception, trimester months
Maternofetal outcomes
Pregnancy management
1
Olobo-Lalobo, 22 1984 [5]
ovarian cyst
LPT
partial US
ca. 200
38/3rd
no symptoms
uterine scar dehiscence
CS and CRU
2
Kasprowicz, 1996 [6]
24
EP
LPT
US
10
38/3rd
abdominal pain, uterine scar vaginal bleeding, rupture, hemorrhagic shock fetal death
CS and CRU
3
Inovay, 1999 [7]
31
hydrosalpinx
LPSC
BS with monopolar electrocautery without CR
6
14/2nd
vaginal spotting, abdominal pain
uterine scar dehiscence, fetal death
LPT and CRU
4
Ayoubi, 2003 [8]
28
EP/tubal stump pregnancy
LPT/LPSC
partial US/CR
24
22/2nd
abdominal pain
UR, pregnancy termination
LPT and CRU
5
Chatterjee, 2009 [9]
29
IP
LPSC
US with electrocautery
Gynecol Obstet Invest DOI: 10.1159/000398795
Spontaneous Rupture of the Pregnant Uterus following Salpingectomy: A Literature Review Paweł Jan Stanirowski Seweryn Trojanowski Anna Słomka Krzysztof Cendrowski Włodzimierz Sawicki Department of Obstetrics, Gynecology and Oncology, Second Faculty of Medicine, Medical University of Warsaw, Mazovian Bródno Hospital, Warsaw, Poland
Abstract Background: Spontaneous rupture of the uterus is a lifethreatening obstetric complication in rare cases associated with previously performed salpingectomy. Aim: This paper presents an analysis of uterine rupture cases during pregnancy in patients after surgical removal of the fallopian tubes. Methods: The English and Polish language literature was reviewed for studies published between January 1, 1980 and September 30, 2014 to identify articles that described rupture of the uterus in women with a previous history of salpingectomy. Results: Thirteen case reports and case series studies in 18 women were identified. 33% of cases of uterine rupture following salpingectomy occurred during intrauterine pregnancy, whereas the rest was associated with interstitial ectopic pregnancy. Laparoscopic salpingectomy more often resulted in rupture of the uterus during non-ectopic pregnancy as compared to laparotomy (4 vs. 2 cases, respectively). When interstitial pregnancies were excluded, uterine rupture was a cause of fetal death in 67% of reported gestations. There were no cases of maternal mortality. Con-
© 2015 S. Karger AG, Basel 0378–7346/15/0000–0000$39.50/0 E-Mail [email protected] www.karger.com/goi
servative treatment was the preferred management option, and total hysterectomy was performed in only 2 patients. Conclusion: Particular attention should be paid to patients with a previous history of salpingectomy due to the risk of uterine rupture throughout the entire pregnancy. © 2015 S. Karger AG, Basel
Introduction
Spontaneous rupture of the uterus is a rare, life-threatening obstetric complication associated with increased morbidity and mortality rates in both mother and fetus. The overall incidence of uterine rupture is approximately 0.04–0.09% in the general population, and women with a previous history of uterine surgery, including cesarean section or myomectomy, are considered the highest-risk group [1–4]. Few reports suggests there is an association between uterine rupture during pregnancy with previously performed salpingectomy. This paper presents a review of the available literature on uterine rupture in patients subject to salpingectomy and discusses current methods of tubal surgery, as well as pregnancy outcomes and mortality rate among mothers and fetuses. The analysis was based on a rare case of sponPaweł Jan Stanirowski Mazovian Bródno Hospital Kondratowicza 8 PL–03-242 Warsaw (Poland) E-Mail stanirowski @ gmail.com
Downloaded by: NYU Medical Center Library 128.122.253.228 - 5/30/2015 7:43:16 PM
Key Words Uterine rupture · Salpingectomy · Interstitial pregnancy · Laparoscopy
Case Presentation A 29-year-old Caucasian woman (gravida 2, para 1) at 38 gestational weeks of uncomplicated pregnancy was admitted to our department in August 2014 with regular uterine contractions. She had no history of previous surgery, except for laparoscopic salpingectomy for a ruptured tubal pregnancy in June 2013. According to the postoperative protocol the patient underwent total surgical resection of the left fallopian tube using bipolar electrosurgical coagulation. The woman was in a good general health at physical examination on admission. The only abnormalities detected on abdominal examination were non-specific and included muscular guarding associated with a mild, dull pain in the lower and middle abdomen. Cardiotocography demonstrated normal uterine activity, regular contractions and a fetal heart rate of about 140 bpm. Antepartum ultrasound scan showed breech presentation, normal fetal biometry and placenta located at the fundus of the uterus with no evidence of preterm abruption. The amount of amniotic fluid was significantly decreased, although no clinical signs of external leakage were observed. Due to the breech presentation of the fetus in a primiparous woman, a cesarean section was performed via the Pfannenstiel skin incision. Intraoperatively, a large (about 1,000 ml) collection of colorless fluid was found within the peritoneal cavity and a 50-ml sample was obtained for cytological analysis. A horizontal incision was performed in the lower uterine segment, and a single living male fetus was extracted from the uterus. The newborn weighted 3,750 g and was in good health on initial assessment. Although the placenta appeared normal on macroscopic inspection, tissue samples together with the umbilical cord were taken for histological examination. Then both ovaries, the parietal peritoneum and the liver were visually inspected and no abnormal findings were observed. Finally, a 1-cm-long tear was found in the uterine wall at the scar site from the previous tubal surgery. The rupture was closed with two layers of absorbable sutures. The early postpartum period was uneventful and the patient was discharged from hospital on the 4th day after surgery. Histological examination of the placenta revealed no evidence of intrauterine infection or focal lesions, whereas cytological analysis of peritoneal fluid showed the presence of protein, red blood cells and lysed squamous epithelial cells, indicating amniotic origin and unequivocally confirming spontaneous rupture of the uterus.
Methods A review of the English and Polish language literature was undertaken for studies published between January 1, 1980 and September 30, 2014 to identify articles that described rupture of the
2
Gynecol Obstet Invest DOI: 10.1159/000398795
uterus in women with a history of previous salpingectomy. Studies were identified via PubMed and EMBASE databases using the key words ‘uterine rupture’ and ‘salpingectomy’ by three authors (P.S., K.C., W.S.) independently. The reference lists of retrieved articles were reviewed to locate additional studies. Publications eligible for the study included full-text randomized controlled trials, cohort studies, letters to the editor, case reports and case series studies. Abstracts, conference supplements and reviews were excluded from the analysis. 164 potentially useful publications were retained, and during further selection 13 case reports and case series studies on uterine rupture in 18 pregnant women with a previous history of surgical removal of the fallopian tubes were identified. A summary of the selected publications is provided in table 1 [5–17]. The following data were collected: patient age, signs and symptoms associated with uterine rupture, indication for as well as mode and technique of salpingectomy, time interval between salpingectomy and conception, gestational age, pregnancy management and maternofetal final outcomes.
Results and Discussion
Spontaneous rupture of the uterus defined as a partial or full-thickness separation of the uterine wall before the onset of myometrial contractions is a rare obstetric complication that occurs primarily in the third trimester of pregnancy when the intrauterine volume and pressure are increased to the highest possible levels. The risk of rupture is greatest in patients with a previous history of uterine surgery, including cesarean section or myomectomy, and extremely low in those with intact and unscarred uterus [1–4]. Possible causes of uterine rupture in the latter group include e.g. abnormal placentation or interstitial pregnancy defined as ectopic gestation, in which an embryo implants outside of the uterine cavity within the cornual portion of the fallopian tube [11–19]. Labor induction with prostaglandins or oxytocin, fetal malpresentation, labor dystocia, delivery after ≥42 gestational weeks, fetal birth weight ≥4,000 g or advanced maternal age constitute other factors responsible for increased risk of uterine rupture [1–3]. The only identified risk factors in our patient were breech presentation of the fetus and laparoscopic salpingectomy performed 6 months prior to conception. The analysis of case description indicates that rupture of the uterus occurred spontaneously before the onset of myometrial contractions and resulted in constriction of the uterine muscle and induced labor. It is of note that the patient did not present with any specific symptoms of uterine rupture, such as sudden abdominal pain, internal hemorrhage or hypovolemic shock. Our findings are consistent with those reported in the literature, where all of Stanirowski/Trojanowski/Słomka/ Cendrowski/Sawicki
Downloaded by: NYU Medical Center Library 128.122.253.228 - 5/30/2015 7:43:16 PM
taneous rupture of the uterus following surgical removal of a fallopian tube associated with intraperitoneal amniotic fluid leakage. To the best of our knowledge the presented literature review and case report have not been published so far.
Table 1. Summary of the studies included in the review Case Reference No. (first author, year)
Patient age, years
Indication for salpingectomy
Mode of salpingectomy
Salpingectomy technique
Interval between Gestational Signs and salpingectomy age, weeks/ symptoms of UR and conception, trimester months
Maternofetal outcomes
Pregnancy management
1
Olobo-Lalobo, 22 1984 [5]
ovarian cyst
LPT
partial US
ca. 200
38/3rd
no symptoms
uterine scar dehiscence
CS and CRU
2
Kasprowicz, 1996 [6]
24
EP
LPT
US
10
38/3rd
abdominal pain, uterine scar vaginal bleeding, rupture, hemorrhagic shock fetal death
CS and CRU
3
Inovay, 1999 [7]
31
hydrosalpinx
LPSC
BS with monopolar electrocautery without CR
6
14/2nd
vaginal spotting, abdominal pain
uterine scar dehiscence, fetal death
LPT and CRU
4
Ayoubi, 2003 [8]
28
EP/tubal stump pregnancy
LPT/LPSC
partial US/CR
24
22/2nd
abdominal pain
UR, pregnancy termination
LPT and CRU
5
Chatterjee, 2009 [9]
29
IP
LPSC
US with electrocautery
