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Seth G.S. Medical College and K.E.M. Hospital, Mumbai , India

Case of the Month

< Case No. 46 : February 2024 >

A rare presentation of uterine dehiscence in a grand multipara

Contributed by: Avani Natu

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Clinical Profile:

A 45 year old G8P5L5A2 woman presented with amenorrhea for a period of three months with lower abdominal distension. She complained of lower abdominal pain and bleeding per vaginum for three days .

Ultrasonography done elsewhere was suggestive of an ectopic pregnancy; hence, exploratory laparotomy was performed. It showed a mass in the lower uterine segment protruding into the broad ligament. As it was not a tertiary care hospital and the surgeons didn't know what it could be, they closed the abdomen, suggested MRI and referred her to our hospital.

Radiological findings:

MRI of the pelvis with contrast shows a well-defined. pedunculated, T2 heterogeneously hypointense lesion with isointense areas within, arising from the endometrium. The lesion extends laterally to the left and is covered by serosa (Fig 1A). Lateral to this polypoidal lesion, an isointense soft tissue mass is seen corresponding to a fetus (Fig 1B, Fig 1C). Subtle T1 hypointense lesions as well as areas of diffusion restriction with drop in ADC values are seen within the lesion suggestive of hemorrhage. The lesion shows no appreciable post contrast enhancement (Fig 1D). Features are suggestive of incomplete (contained) uterine dehiscence involving the antero- left lateral wall with non-viable retained products of conception within the dehiscent area.

Fig. 1: Figure 1 A, B, C, D:

MRI pelvis with contrast shows a well-defined pedunculated T2 heterogenously hypointense lesion with isointense areas within seen arising from the endometrium extending laterally to the left covered by serosa. Lateral to this polypoidal lesion an isointense soft tissue mass is seen corresponding to fetus. Subtle T1 hypointense lesions as well as areas of diffusion restriction with drop in ADC values are seen within the lesion suggestive of hemorrhage. The lesion shows no appreciable post contrast enhancement.

On ultrasonography, there is a large, well defined, heterogeneously hypoechoic solid cystic mass arising from the endometrium crossing a breached myometrium and projecting exophytically into the left adnexa (Fig 2A). It shows few fetal parts. Fetal cardiac activity is absent. The placenta is seen separately extending from the endometrium to the lesion (Fig 2B). Features are suggestive of incomplete uterine dehiscence with demised fetus within a contained sac on the left side.

FIG 2 Figure 2 A, B: Ultrasonography shows a large well defined heterogeneously hypoechoic solid cystic mass lesion arising from the endometrium crossing a breached myometrium and going exophytically into the left adnexa. It shows few fetal parts. Fetal cardiac activity is absent. The placenta is seen separately going from the endometrium to the lesion.

On non contrast CT of the abdomen and pelvis there is a heterogenous, solid, exophytic lesion arising from the uterus going into the left adnexa with multiple calcific foci (Fig 3A, Fig 3B). There is no free fluid in the abdomen.

Fig. 3 : Figure 3 A, B:

On non contrast CT of the abdomen and pelvis there is a heterogenous solid exophytic lesion arising from the uterus going into the left adnexa with multiple calcific foci.

Radiological diagnosis:

Complete uterine dehiscence with non viable fetus.

Intra-operative images show the location of the fetus and the resected specimen shows the fetus and placenta.

Fig. 4 Figure 4 A, B:

Intra-operative images show the location of the fetus and the resected specimen showing the fetus and placenta.

Treatment:

Exploratory laparotomy was performed with evacuation of products of conception with uterine rent repair.

Timeline:

Discussion

Uterine dehiscence is defined as incomplete division of the uterine wall that does not encompass all uterine layers. Uterine dehiscence can cause the thinning of the uterus, often allowing the fetus to be seen through the myometrium. It is often an occult finding in an asymptomatic patient.(1)

Uterine rupture is defined as complete disruption of all uterine layers. Complete rupture usually involves direct communication between the uterine cavity and the peritoneum, and is associated with high rates of perinatal mortality and morbidity. (2,3)

While the incidence of unscarred uterine rupture or dehiscence is low, the rupture of an unscarred uterus causes significantly more maternal and neonatal morbidity than the rupture of a scarred uterus. (4)

Most ruptures involving unscarred uteri can be traced to one of the following etiologies:

(a)Blunt abdominal trauma and procedures like internal podalic and external cephalic versions.

(b) Genetic disorders associated with uterine wall weakness like Ehlers-Danlos and Loeys-Dietz syndrome.(5,6)

(c)Prolonged uterine exposure to oxytocin and other uterotonic medications increases uterine wall stress and can lead to rupture, especially in the setting of obstructed labor.(1)

(d) Overstretching of the uterine wall in conditions such as gestational diabetes with macrosomia, polyhydramnios, multiple gestation pregnancy, and uterine anomalies such as fibroids.(7,8) Serial stretching of the uterine wall in multiparous women, may increase the risk of rupture.(2)

References:

1. Guiliano M, Closset E, Therby D, LeGoueff F, Deruelle P, Subtil D. Signs, symptoms and complications of complete and partial uterine ruptures during pregnancy and delivery. Eur J Obstet Gynecol Reprod Biol. 2014 Aug;179:130-4. [PubMed]

2. Abbas A MA. Maternal and perinatal outcomes of uterine rupture in a tertiary care hospital: a cross-sectional study. J Matern Fetal Neonatal Med. 2019;32(20):3352–3356. doi: 10.1080/14767058.2018.1463369.

3. Motomura K, Ganchimeg T, Nagata C, Ota E, Vogel J P, Betran A P. Incidence and outcomes of uterine rupture among women with prior caesarean section: WHO Multicountry Survey on Maternal and Newborn Health. Sci Rep. 2017;7:44093. doi: 10.1038/srep44093.

4. Gibbins KJ, Weber T, Holmgren CM, Porter TF, Varner MW, Manuck TA. Maternal and fetal morbidity associated with uterine rupture of the unscarred uterus. Am J Obstet Gynecol. 2015 Sep;213(3):382.e1-6.

5. Sahin H G, Kolusari A, Yildizhan R, Kurdoglu M, Adali E, Kamaci M. Uterine rupture: a twelve-year clinical analysis. J Matern Fetal Neonatal Med. 2008;21(07):503–506. doi: 10.1080/14767050802042225.

6. Al-Zirqi I, Stray-Pedersen B, Forsén L, Daltveit A K, Vangen S. Uterine rupture: trends over 40 years. BJOG. 2016;123(05):780–787. doi: 10.1111/1471-0528.13394.

7. Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal–Fetal Medicine Units Network . Landon M B, Grobman W A. What we have learned about trial of labor after cesarean delivery from the maternal-fetal medicine units cesarean registry. Semin Perinatol. 2016;40(05):281–286. doi: 10.1053/j.semperi.2016.03.003.

8. Guyot A, Carbonnel M, Frey C, Pharisien I, Uzan M, Carbillon L.[Uterine rupture: risk factors, maternal and perinatal complications] J Gynecol Obstet Biol Reprod (Paris) 20103903238–245. 10.1016/j.jgyn.2010.03.003French.

Acknowledgement :

We are grateful to the Department of Obstetrics and Gynecology at our institution for sharing the operative images.

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