10
Članek prispel / Received
25. 11. 2019
Članek sprejet / Accepted
1. 3. 2021
Abstract
Purpose: Hysterotomy extension at the 
time of cesarean section is frequent and 
associated with severe blood loss, risk of 
transfusion, and unplanned hysterecto-
my. Cesarean section during the second 
stage of labor is the most important risk 
factor.
Case report: We describe a case of a 
35-year-old gravida 4 para 1 at 26+1 
weeks gestation who underwent a repeat 
cesarean section. An unintentional hy-
sterotomy extension led to severe blood 
loss. The patient was discharged on day 
4 after the operation in stable condition.
Izvleček
Namen: Ob carskem rezu se pogosto 
dogaja nenamerno zatrganje kotov ma-
ternice, ki je povezano z resnejšo izgubo 
krvi, večjim tveganjem za potrebo po 
transfuziji in nenačrtovano histerekto-
mijo. Najpomembnejši dejavnik tvega-
nja je carski rez v drugi porodni dobi. 
Poro~ilo o primeru: Opisujemo 
primer 35-letne nosečnice v drugem tri-
mesečju, pri kateri smo opravili drugi 
carski rez. Prišlo je do nenamernega za-
trganja kotov maternice, kar je vodilo 
v resno izgubo krvi. Odpuščena je bila 
četrti pooperativni dan v klinično sta-
bilnem stanju.
Ključne besede: 
carski rez v drugem trimesečju, 
nenamerno zatrganje kotov 
maternice, tehnika carskega reza
Key words: 
second trimester cesarean section, 
unintentional hysterotomy tear, 
cesarean section technique
Predstavitev primera: Je carski rez v drugem 
trimestru nosečnosti nerazpoznavni dejavnik 
tveganja za nenamerno podaljšanje histerotomije v 
spodnji del maternice?
Case report: Is mid-trimester cesarean section an 
unrecognized risk factor for accidental extension to 
the lower uterine segment?
Avtor / Author Leyla Al Mahdawi1, Lucija Kuder2, Faris Mujezinović2, 3
Ustanova / Institute 1Univerzitetni klinični center Maribor, Klinika za ginekologijo in perinatologijo, Oddelek za 
ginekološko onkologijo in onkologijo dojk, Maribor, Slovenija; 2Univerzitetni klinični center 
Maribor, Klinika za ginekologijo in perinatologijo, Oddelek za perinatologijo, Maribor, 
Slovenija; 3Univerza v Mariboru, Medicinska fakulteta, Katedra za ginekologijo in porodništvo, 
Maribor, Slovenija; 
1University Medical Centre Maribor, University Department of Gynecology and 
Perinatology, Department of Gynecological Oncology and Breast Oncology, Maribor, 
Slovenia; 2University Medical Centre Maribor, University Department of Gynecology 
and Perinatology, Department of Perinatology, Maribor, Slovenia; 3University of Maribor, 
Faculty of Medicine, Department of Gynecology and Obstetrics, Maribor, Slovenia
Poročilo o primeru / Case report
ACTA MEDICO-BIOTECHNICA
2021; 14 (1): 25–37
11
Poročilo o primeru / Case report
ACTA MEDICO-BIOTECHNICA
2021; 14 (1): 25–37
INTRODUCTION
Caesarean section (CS) is one of the most frequent 
operative procedures in obstetrics and gynecology, 
and is considered to be a safe procedure (1). 
In some cases, however, incidental injury to the uterus 
can significantly increase the operative time and be 
life-threatening. In our case, this type of complication 
is described as an unintended hysterotomy extension 
(UHE). 
CASE REPORT
A 35-year-old gravida 4 para 1 was admitted to 
the delivery room with a diagnosis of preterm 
premature rupture of membranes (PPROM) at 26+1 
weeks gestation. A CS was required in the previous 
pregnancy at approximately the same gestational 
age. Both pregnancies were characterized by cervical 
insufficiency with a cervical cerclage. In the current 
pregnancy, gestational hypertension and gestational 
diabetes were managed with anti-hypertensives and 
diet. At 24+3 weeks gestation the patient had one 
episode of vaginal bleeding. Antenatal corticosteroids 
were recommended for fetal lung maturation, but the 
patient declined further in-patient care. The bleeding 
subsided shortly thereafter. 
At the time of PPROM, antibiotics were initiated, a 
vaginal smear was obtained, and laboratory testing was 
performed. The laboratory testing results were normal 
(leukocytosis [as expected in pregnancy]; hemoglobin, 
107 g/L; and hematocrit, 0.33), except C-reactive 
protein, which was minimally elevated at 9 mg/mL. 
Escherichia coli and Saccharomyces cerevisiae were 
isolated from the vaginal swab. The vital signs were 
normal (blood pressure, 139/79 mmHg; and pulse, 
90 beats/min).
Shortly after PPROM, contractions ensued and 
the cervix began to dilate. Accordingly, atosiban 
for tocolysis and magnesium sulphate for neonatal 
neuroprotection were administered. The cerclage was 
removed. 
Cervical dilation continued and a CS was 
recommended. Immediately after extraction of the 
fetal head, the surgeon noticed a major laceration of 
the uterus extending from the right hysterotomy angle 
towards the lower uterine segment. The laceration 
was quickly repaired; however, the hemorrhage was 
profound. The patient was administered methergine 
(0.2 mg IM), carboprost (250 mcg IM [2 doses]), 2 units 
of O+ blood along with 2 liters of crystalloids. The 
estimated blood loss was 2800 mL. At the end of the 
2-h procedure, the blood pressure was 98/56 mmHg 
and the heart rate was approximately 120 beats/min. 
The hemoglobin concentration was 94 g/L and the 
hematocrit 0.30. Further laboratory testing did not 
reveal a coagulopathy or platelet disorder. During the 
hospital stay, the hemoglobin level decreased to 62 
g/L and the hematocrit decreased to 0.22.
Naslov za dopisovanje /  
Correspondence
Leyla Al Mahdawi, dr. med., 
Univerzitetni klinični center Maribor, 
Oddelek za ginekološko onkologijo in 
onkologijo dojk, Ljubljanska 5, 2000 
Maribor, Slovenija
Telefon +386 23212408 
Fax +386 23212085
E-pošta: almahdawi@gmail.com
Zaklju~ek: Nenamerno zatrganje ko-
tov maternice je povezano z višjo ma-
ternalno obolevnostjo in umrljivostjo. 
Topa kirurška tehnika vstopa in obra-
tna medenična ekstrakcija sta poveza-
ni z manjšim tveganjem za zatrganje 
kotov maternice.
 Conclusion: Hysterotomy extension 
is associated with higher maternal mor-
bidity and mortality. Blunt expansion 
of the hysterotomy and a reverse breech 
extraction are associated with a lower 
uterine tear rate.
12
Poročilo o primeru / Case report
ACTA MEDICO-BIOTECHNICA
2021; 14 (1): 25–37
DISCUSSION
A UHE occurred as a complication associated with 
an emergency CS resulting in an increased operative 
time, blood loss, and injured uterus. Considering 
the frequency of CSs, it is interesting that UHE was 
not reported in detail in the literature until 2006 (2). 
Even more surprising was that this complication has 
an incidence of 8% (3). Therefore, it is important to 
be aware of UHE as a potential complication when 
making the decision for an emergency cesarean section, 
especially during the last stage of labor. 
The probability of a UHE increases 10-fold during the 
second stage of labor. In this stage, the lower uterine 
segment is very thin, and thus highly susceptible to a 
tear during the transabdominal disengagement of the 
fetal head, which is fixed deep in the pelvis. Of note, a 
UHE can occur in other stages of delivery (2). Our case 
confirms that a UHE can occur, even during the first 
stage of labor. 
Our procedure lasted for 2 h, which is significantly 
more time than reported in the literature. The reason 
for the increased operative time was the brisk bleeding 
that required immediate attention and doubled the 
length of the operation. Thus, the additional time was 
not devoted to managing the laceration, but rather on 
achieving adequate hemostasis. 
In an uneventful CS, the hemoglobin values are 
< 10% in 34.4% of the patients; however, the 
decreased hemoglobin level is more pronounced after 
hemorrhage, often requiring a blood transfusion (3, 4).
Bilgard et al. (3) reported that the UHE risk is as high 
as 5-fold, with a 17-fold increased risk of hematoma 
formation, injury to the bladder, and need for 
hysterectomy. A delayed decrease in the hemoglobin 
concentration after hemorrhage with a normal 
postoperative recovery confirms the weak correlation 
between blood loss and hemoglobin markers, and 
should therefore always be interpreted with caution (5).
A blunt surgical technique and reverse breech extraction 
are options that will lower the risk of UHE (6-10).
CONCLUSIONS
A UHE is a potential complication of CS, not only in 
the second stage of labor, but also in the first stage of 
labor and the second trimester, and is associated with 
increased patient morbidity.
Figure 1. A sketch of unintentional uterine repair
13
Poročilo o primeru / Case report
ACTA MEDICO-BIOTECHNICA
2021; 14 (1): 25–37
REFERENCES
1. Dahlke JD, Mendez-Figueroa H, Rouse DJ, Ber-
ghella V, Baxter JK, Chauhan SP. Evidence-based 
surgery for cesarean delivery: an updated system-
atic review. Am J Obstet Gynecol. 2013; 209 (4): 
294-306.
2. De la Torre L, González-Quintero VH, Mayor-Lynn 
K, et al. Significance of accidental extensions in 
the lower uterine segment during cesarean deliv-
ery. Am J Obstet Gynecol 2006; 194 (05): e4–e6.
3. 3. Bligard KH, Durst JK, Stout MJ, Martin S, Cahill 
AG, Macones GA et al. Risk Factors and Maternal 
Morbidity Associated with Unintentional Hysteroto-
my Extension at the Time of Cesarean Delivery. Am 
J Perinatol. 2019; 36 (10): 1054–59.
4. Giugale LE, Sakamoto S, Yabes J, Dunn SL, Krans 
EE. Unintended hysterotomy extension during cae-
sarean delivery: risk factors and maternal morbid-
ity. J Obstet Gynaecol. 2018; 38 (8): 1048–53.
5. Anger H, Durocher J, Dabash R, Winikoff B. How 
well do postpartum blood loss and common defi-
nitions of postpartum hemorrhage correlate with 
postpartum anemia and fall in hemoglobin? PLoS 
One. 2019; 14 (8): e0221216
6. Rodriguez AI, Porter KB, O'Brien WF. Blunt ver-
sus sharp expansion of the uterine incision in low-
segment transverse cesarean section. Am J Obstet 
Gynecol. 1994; 171 (4): 1022-5. 
7. 7. AsIcIoglu O, Gungorduk K, AsIcIoglu BB, YIldIrIm 
G, Gungorduk OC, Ark C. Unintended extension 
of the lower segment uterine incision at cesarean 
delivery: a randomized comparison of sharp versus 
blunt techniques. Am J Perinatol. 2014; 31 (10): 
837-44.
8. 8. Saad AF, Rahman M, Costantine MM, Saade 
GR. Blunt versus sharp uterine incision expansion 
during low transverse cesarean delivery: a meta-
analysis. Am J Obstet Gynecol. 2014; 211 (6): 
684.e1-11. 
9. 9. Waterfall H, Grivell RM, Dodd JM. Techniques 
for assisting difficult delivery at caesarean sec-
tion. Cochrane Database Syst Rev. 2016; (1): 
CD004944.
10. 10. Lenz F, Kimmich N, Zimmermann R, Kreft M. 
Maternal and neonatal outcome of reverse breech 
extraction of an impacted fetal head during caesar-
ean section in advanced stage of labour: a retro-
spective cohort study. BMC Pregnancy Childbirth. 
2019; 19 (1): 98.