Introduction
Spontaneous rupture of the non-laboring uterus is a quite rare stuation (1). In the literature, There are cases that uterine rupture has been reported in patients without a history of uterine surgery (2-4).
Uterin rupture may occur in the first period of plasental invasion due to myometrial invasion. We think that fetal anomaly may also be the cause of uterine rupture. And we think that as cesarean number increases, it may lead to uterine rupture earlier.
Case Report
Thirty-three years old, para four patient referred to our hospital at 13th weeks of gestation. She had a history of cesarean section four times. She was using low molecular weight heparin (LMWH) 4000 U as subcutaneous, per day for thrombophilia treatment. She had a for Factor V Leiden heterozygous genetic anomaly. It has been learned that she admitted to the emergency service in June 2018 with a complaint of lower abdominal pain. She described her vital findings was stable, and the pain was generalized when she went to emergency service.
The patient consulted to radiology for an ultrasound. It has been showed in the ultrasonography, free fluid in the Morrison area, a single fetus at 13th weeks of gestation with occipital encephalocele (Figures 1 and 2). The placenta was at the left lateral side and cervical ostium was covered completely by the plasenta.
Magnetic resonance imaging (MRI) performed to investigate the cause of intraabdominal bleeding. MRI showed mild high-density ascites suggesting intraperitoneal hemorrhage and placenta previa (Figure 3). We hospitalized the patient. The general condition of the patient deteriorated after one hour. Her blood pressure decreased to 80/52 mmHg, and her heart rate was 104/min. With these reasons, we decided to perform an emergency laparotomy. With general anesthesia, phanensteel incision was performed. There was about 2 liters of hematoma intraoperatively. We observed active bleeding at the previous incision side, and the placenta was partially visible outside the uterus. Fetus and fetal materials were taken out. Bleeding control could not be achieved. There were some invasion areas with bleeding in the posterior cervical region. We tried to stop bleeding by suturing. We ligated uterine arteries and ovary proprium ligaments due to the bleeding did not stop. However none of them worked. Because of this, we performed the cesarean hysterectomy. The recorded blood loss was about 2.5 liters. We transferred 5U erythrocyte suspension. We placed a drain on the abdomen. The patient stabilized at the 6th postoperative hour and discharged without any problem. Hemoglobin values of the patient reported before surgery, during surgery and after transfusion as 7.2-5.6-9.3 g/dL. We examined the fetus and confirmed that it had occipital encephalocele, type 3 Arnold Chiari (Figure 4). İn the pathological evaluation of fetus occipital encephalocele was (Figure 5).
Discussion
The most common cause of uterine rupture is previous cesarean surgeries. Uterine rupture due to placenta acreta and percreta is mostly detected in the first and second trimesters (5). The main pathology in placenta acreta cases is the deficiency of the Nitabuch layer in the uterine muscle tissue. Although our patient was not in labor, uterine rupture developed in the first trimester due to many risk factors (previous scar, placenta previa, fetal anomaly).
The most common cause of uterine rupture is dilatation curettage due to missed abortion (6). A case of uterine rupture diagnosed with ultrasound in early pregnancy has been reported. They also reported that the uterus was repaired without pregnancy termination and pregnancy continued until 32 weeks (7). In our case, we preferred to terminate pregnancy due to incomplete rupture and fetal anomaly.
The patient with uterine rupture who described by Medel et al. (8) was at the 18th week of gestation after fertility treatment. The authors reported that this patient died due to coagulopathy and hypovolemic shock. We think that our patient has improved because we provide early intervention and blood replacement.
In the literature, a small number of cases of uterine rupture reported in the early stages of pregnancy are present (9,10). Our patient had been cesarean four times before.
Contrary to the literature, these studies have shown that even at the first stage of placental invasion, placenta percreata and uterine rupture can be observed. We believe that fetal anomaly may be associated with placenta previa/percreata and uterine rupture as in our patient.
In conclusion, Considering our case, uterine rupture should be kept in mind in the differential diagnosis in case of acute abdomen in early weeks of pregnancy.
Ethics
Informed Consent: Informed consent was obtained from the patient orally.
Peer-review: Externally and internally peer-reviewed.
Authorship Contributions
Surgical and Medical Practices: E.Ş., N.S., Concept: E.Ş., E.E., Design: E.Ş., E.E., Data Collection or Processing: E.Ş., N.S., Analysis or Interpretation: E.Ş., N.S., Literature Search: E.Ş., E.E., Writing: E.Ş., E.E.,
Conflict of Interest: No conflict of interest was declared by the authors.
Financial Disclosure: The authors declared that this study received no financial support.
