LAUSR

A 39-year-old woman, gravida 4, para 2 was admitted at 34weeks of gestation in threatened preterm labour. She had a voluntary abortion in 2005 with dilatation and curettage, a normal delivery at term in 2011 and a caesarean section for preterm labour with a breech foetus at 32weeks in 2012. The type of the uterine incision was unknown. Transabdominal ultrasound did not show any abnormality; the placenta was anterograde-fundal and the lower segment thickness was 2.5 cm. Tocolysis and steroid therapy, for lung maturation, were implemented. Nevertheless, 6 days later, after a preterm premature rupture of membranes (pPROM), the labour started. The patient opted for a vaginal birth after caesarean section (VBAC) and, after 2 h, gave birth to a healthy male. An epidural analgesia was not requested. Neither external intervention nor pharmacological augmentation was performed. The continuous cardiotocography was reassuring throughout the labour. After delivery, uterotonics were administered (synthetic Oxytocin, 5 UI i.v.) as postpartum haemorrhage prophylaxis. The third stage, however, was prolonged. Since the patient felt well, she requested to be submitted to as few as possible interventions; her vital signs were stable, and as the bleeding was minimal it was decided to wait. During this time, a controlled cord traction and moderate fundal pressure were administered intermittently. However, after an hour, the placenta was still retained. Before attempting a manual placental removal, an ultrasound was performed and revealed an empty uterus and placental extrusion thought a dehiscence of the uterine scar (see Figure 1(A)). A pelvic MR confirmed the diagnosis and showed that the placenta was completely detached, excluding a morbid adherence to the uterine wall (see Figure 1(B)). The placenta was removed through a laparotomic access. The uterus was contracted around the rupture. No clinically significant hemoperitoneum was found. The uterine scar dehiscence was sutured in double layers. The woman subsequently developed an infection and sepsis, was treated with antibiotics and this was completely solved at her discharge, 5 days after her delivery. Discussion