Introduction
The frequency of cesarean section operations has been steadily increasing all over the world, including in the Russian Federation during recent years [1—3]. Uterine ruptures most often occur at the end of the third trimester of pregnancy and during childbirth. In Russia in 2005-2017 there was an increase in cases of uterine rupture from 0.14 to 0.16 per 1000 births, the proportion of uterine rupture outside the hospital increased from 25.4 to 43.5% [4, 5]. The leading cause [6] of this pathology is the presence of uterine scar after a previous cesarean section or, in rare cases, a spontaneous rupture of the uterus without anatomical changes (in the absence of a scar). Uterine ruptures can be incomplete and complete [1, 2, 7]. Uterine ruptures are most common in the lower segment of the uterus along the anterior surface due to overstretching and thinning of muscles in the lower segment, while ruptures in the body and in the fundus occur in the area of the old scar [8, 9]. When the uterus tears large vessels are damaged and internal bleeding begins, a picture of hemorrhagic shock develops and hematomas are formed [5, 10] Healing of the uterine wall after surgery can occur with complete restoration of muscle elements (complete scar) but sometimes healing takes place with forming of connective tissue in place of intervention. Such a scar is considered to be defective. Inadequate scars of the uterus are caused by improper healing techniques. Most often, a defective scar is formed after a corporal cesarean section. Cicatricial changes in areas of the lower segment of the uterus during childbirth do not stretch, which leads to rupture of the uterus [9, 10]. Ultrasound is used to characterize the uterine scar. Echographic signs of uterine scar failure during pregnancy include thinning of the lower segment in the scar area (less than 0.3 cm) with a significant number of acoustic dense inclusions [9, 11].
Cesarean section could be performed by incision of the anterior abdominal wall and carried out through the anterior part of the vaginal fornix. Depending on whether the abdominal cavity is opened or not and the fact of localization of the incision of the uterus, there are intraperitoneal cesarean section by a corporal incision-classic cesarean section and a cesarean section in the lower segment of the uterus by a transverse incision. Cesarean section in the lower segment of the uterus with a transverse incision is the optimal one. The previously widely used corporal section has had its own indications; it is performed in case of pronounced adhesive process in the lower segment of the uterus, in the presence of a defective scar after the previous corporal cesarean section [7, 12, 13]
Uterine rupture during labor is not only the most serious maternal complication but also potentially threatens the life of the fetus and can cause the fetal death as a result of the cessation of oxygen supply due to placental abruption or to hypoxic-ischemic brain disorders [4, 14, 15]. Hypoxic-ischemic damage of the central nervous system develops as a result of oxygen starvation of the newborn and occurs in 10% of cases.
The causes of hypoxic damage of the central nervous system in newborns are different. These are gestosis of late pregnancy, premature placental abruption, threatened abortion, entanglement of the fetal umbilical cord, diabetes mellitus of the mother, bleeding during the 2nd or 3rd trimesters of pregnancy, prolonged rupture of membranes period, premature birth before than 37 weeks of gestation and, of course, rupture of the previous uterine scar [5, 16].
Asphyxia during childbirth or intrauterine fetal hypoxia are the main causes of hypoxic-ischemic encephalopathy (cerebral hypoxemia and ischemia) in newborns.
Clinical manifestations of hypoxic-ischemic encephalopathy (HIE) in newborns are manifested by a variety of neurological symptoms. Depending on the severity and duration of ischemia, neurological disorders can range from minimal and transient to severe and irreversible [4, 14, 17, 18]. An important role is played by a decrease in blood oxygen saturation, due to which the fetus develops acidosis, intracellular edema and swelling of brain tissue, increased intracranial pressure and decreased cerebral blood flow in the pathogenesis of hypoxic-ischemic encephalopathy. The main attention is paid to the general condition of the child (estimated by the Apgar score), the level of consciousness, posture, muscle tone, pupils, and the rest of the reflexes while diagnosing HIE in newborns. The electro- encephalographic (EEG) plays an important role in diagnosing of the condition [4, 15, 17].
Properly organized medical care in the delivery room can reduce the number of adverse effects of perinatal hypoxia for the life and health of children.
Case report
This article describes a rare clinical case of rupture of the uterus along the scar during childbirth and successful resuscitation of a newborn removed from the abdominal cavity with hypoxic-ischemic damage to the central nervous system.
A pregnant woman of 29 years old was admitted emergently to the maternity ward of the hospital of Neftekamsk on ambulance car on 10/30/2018 at 01:20 a.m. with a gestational age of 34—35 weeks with a corporal scar on the uterus.
Her complaints on admission: strong pain in the lower abdomen, vomiting, oedema of the legs. The deterioration of the condition started 5 hours ago, when pains in the abdomen appeared, the fetal movements ceased. Anamnesis: this is the second pregnancy and the second delivery, the former pregnancy finished by cesarean section. The pregnant woman was registered at the antenatal clinic of 7—8 weeks of gestation. Ultrasound screenings were performed at 12, 24 and 32 weeks of pregnancy. There is a thinning in the area of the uterine scar up to 0.2 cm on ultrasound screening of 32 weeks of gestation.
The general condition at admission is severe, due to pain, the patient is agitated, her hands on her lower abdomen, on examination there was vomiting. The skin is moist and its color is normal. The musculoskeletal system has no pathology. The auscultation of lungs is normal. The breathing rate is 18 per minute. Heart tones are clear, the blood pressure is 100 /60 mm. Hg, pulse rate is 102 per minute.
The abdomen is increased in volume due to the pregnant uterus, the abdominal circumference is 91 cm, the height of the fundus of the uterus is 27 cm, palpation of the abdomen is sharply painful, the uterus is in an increased tonus. The fetal heartbeats are not auscultated. Previous birth has been performed by corporal caesarean section 3 years ago.
With the suspicion of a ruptured uterus, it was decided to carry out an emergency delivery. During vaginal examination in the operating room the vagina of a nulliparous woman, the cervix is immature, the head of the fetus is not palpable. Lower midline laparotomy and corporal caesarean section were performed under general anesthesia, and complete rupture of the uterus along the scar was revealed.
There was intact amniotic sac between boarders of the dehiscent scar and liveborn male fetus weighing 2640 g, height-48 cm was extracted. The operation ended with suturing the rupture of the uttering scar and suturing wound of the anterior abdominal wall. The operation began 30 minutes after the pregnant woman admittance to the maternity ward, the duration of the operation was 45 minutes.
The condition of the newborn when removed from the uterine cavity was extremely severe (the Apgar score — 1/2). There were pronounced cyanosis of the skin, areflexia, repeated convulsions due to asphyxia, rare, shallow breathing. Heart tones were muffled, there was bradycardia — up to 80 per min. Immediately after delivery resuscitation measures began in the delivery room (according to the clinical recommendations edited by Prof. E. Baybarina in 2020: « Reanimation and stabilization of the newborns in the delivery room». The newborn was transferred to the artificial lung ventilation device AVEA AS ventilator Pressure XL-50, FiO-80% Sequence of main resuscitation measures: prevention of hypothermia and maintenance of normal body temperature of the newborn. The child was placed on a heated resuscitation table, the upper airways were sanitized with a catheter, catheterization of the umbilical vein was accomplished, the newborn was taken up to mechanical ventilation.
A survey radiography of the chest was performed. The neurosonography showed the signs of cerebral edema and severe hypoxic cerebral ischemia. The newborn was examined by a neonatal neurologist.
Taking into account the severity of the condition of the newborn, caused by asphyxia and RDS syndrome, the gestation age of 34, taking into account the X-ray picture of the lungs Kurosorf was administered intratracheally at a dose of 182 mg / kg. There were no complications. 25 ml of physiological sodium chloride solution were introduced into the umbilical vein to reduce metabolic acidosis and replenishment of the deficit of blood volume. The heart rate was 108 beats per min after starting the resuscitation. The newborn was transferred to the intensive care unit after stabilization of the condition where the syndromic therapy was continued. Craniocerebral hypothermia was performed to prevent and reduce cerebral edema. In order to prevent seizures, anticonvulsants were prescribed — sodium oxybutyrate and phenobarbital.
Complete blood count: hemoglobin — 130 g/l, erythrocytes — 3.65•1012, NT-40, platelets 98•109, leukocytes — 12.8•109.
Blood chemistry; total protein — 37.6 g/l, bilirubin — 22.8-7.9-14.9 mmol/l, glucose — 5.6 mmol/l, potassium — 4.16 mmol/l, sodium — 130.9 mmol/l.
3 days later the newborn was removed from the ventilator, spontaneous breathing was restored, the convulsions did not occur, the state gradually stabilized, weak sucking reflexes appeared, there was no vomiting. The child was consulted by a neonatal neurologist and for further follow-up treatment was transferred to the stage 2 of nursing in the pediatric department. In 3 weeks, the baby was discharged home under the supervision of a pediatrician and a neurologist.
The child was examined after 6 and 12 months. The mother had no complaints. An ultrasound scan of the brain was performed, no pathology was revealed. Physical and psychomotor development are suitable for the age appropriate.
Conclusion
The presence of a scar on the uterus after a cesarean section is a risk factor for rupture of the uterus during a second pregnancy. In the above clinical observation - timely diagnosis of uterine rupture in a pregnant woman, emergency surgical intervention, immediate provision of resuscitation measures in the delivery room and adequate treatment of a newborn with hypoxic-ischemic lesion of the central nervous system in the intensive care unit in the first minutes and hours after removal from the uterine cavity and with its complete rupture in the scar after a corporal cesarean section contributed to the prevention of various complications as in the mother, so it is in a newborn. Pregnant women with a thin scar on the uterus after cesarean section due to the danger of its rupture should be observed in a hospital of the 3rd level before delivery.
Participation of the authors:
Concept and design of the study — L.F. Latypova, R.N. Rayanova, N.V. Rayanov
Data collection and processing — O.I. Khintsinskaya, I.F. Khasanova, R.N. Rayanova
Text writing — R.N. Rayanova, O.I. Khintsinskaya, I.F. Khasanova
Editing — L.F. Latypova, N.V. Rayanov, R.N. Rayanova
Authors declare lack of the conflicts of interests.