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      Spontaneous intrapartum Posterior Cul-de-sac rupture: A case report and literature review

      case-report

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          Abstract

          Introduction

          Posterior Cul-de-sac rupture is a rare delivery complication and a diagnostic challenge to every obstetrician. The associated predisposing factors include genital anomalies (such as vaginal atresia), the use of misoprostol to induce delivery, previous pelvic infection, and caesarean scar. Herein, we report the case of a posterior Cul-de-sac rupture without any disposing risk factor.

          Case presentation

          A 27-year-old G5P4 pregnant woman at the 33rd week of gestation presented with spontaneous onset of labor, the administration of calcium channel blockers failed to stop her active labor, which progressed with a spontaneous rupture of membranes. The fetal heart rate decelerated suddenly to 40 beats per minute. Therefore, an emergency lower transverse cesarean section was performed. During the operation, a transverse 6 cm tear in the posterior vaginal wall was found. The ruptured vagina was sutured and the patient was discharged two days later in a good condition.

          Clinical discussion

          Posterior Cul-de-sac rupture might happen without any predisposing risk factors. Also, the vague and unspecific symptoms –mainly, sudden abdominal pain-can delay the diagnosis of such an entity.

          Conclusion

          we recommend keeping a high level of suspicion for a concealed vaginal wall rupture even in the absence of any predisposing factors, when sudden severe pain during labour cannot be otherwise explained.

          Highlights

          • Posterior Cul-de-sac rupture is a rare –but serious-delivery complication.

          • Posterior Cul-de-sac rupture could happen spontaneously without any predisposing risk factor.

          • In most cases, the rupture manifests as sudden abdominal pain.

          • The early detection and management of such cases can reduce morbidity and mortality.

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          Most cited references6

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          The SCARE 2020 Guideline: Updating Consensus Surgical CAse REport (SCARE) Guidelines

          The SCARE Guidelines were first published in 2016 and were last updated in 2018. They provide a structure for reporting surgical case reports and are used and endorsed by authors, journal editors and reviewers, in order to increase robustness and transparency in reporting surgical cases. They must be kept up to date in order to drive forwards reporting quality. As such, we have updated these guidelines via a DELPHI consensus exercise.
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            Myometrial wound healing post-Cesarean delivery in the MRL/MpJ mouse model of uterine scarring.

            There is little known about healing of the uterus after Cesarean delivery (CD). Uterine wound repair was studied by using two strains of mice with different wound healing characteristics: MRL/MpJ(+/+) (MRL: "high-healer" phenotype) and C57Bl/6 ("low-healer" phenotype). First, we examined the morphology and histology of the uterine wall repair. We identified wound granulation tissue 3 days post-CD in both strains, albeit less in the MRL strain. Macroscopically, no scar could be identified either in MRL or C57Bl/6 mice on day 60 post-CD. However, histologically, we found significant differences in wound integration, inflammation, and collagen birefringence between the two strains of mice. Using a histological index, we provided evidence for significant differences in mitotic activity in the initial phases of uterine healing among strains. Functional behavior of the uterine scar also was analyzed by using biomechanical parameters such as slope (measure of stiffness), yield point (measure of elasticity), and break point (measure of strength). There were significant differences in stiffness of the scarred myometrium between the two phenotypes. MRL mice displayed a significantly lower yield point compared with C57Bl/6. The break point was reached faster on days 15 and 60 in both C57Bl/6 and MRL strains compared with day 3 post-CD. Our findings indicate that differences in regenerative ability translate in histological, mitotic, and functional differences in biomechanical properties of the scarred myometrium after CD.
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              Rupture of the posterior cul-de-sac during spontaneous labor.

              Women with genital anomalies are at increased risk of labor dysfunction. Rupture of the posterior cul-de-sac causing an intraabdominal delivery is a rare complication of labor that may be related to a congenitally atretic vagina. A nulliparous woman at 28 weeks of gestation with a known short vagina presented with preterm labor; her cervix could not be palpated or visualized. At cesarean delivery, the cervix was intraabdominal and the fetal head was delivered in the abdomen. A large rent in the posterior cul-de-sac required repair to restore correct anatomical positioning. The uterus was intact. Rupture of the posterior cul-de-sac is a rare event that can cause significant maternal and fetal morbidity.
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                Author and article information

                Contributors
                Journal
                Ann Med Surg (Lond)
                Ann Med Surg (Lond)
                Annals of Medicine and Surgery
                Elsevier
                2049-0801
                13 September 2022
                October 2022
                13 September 2022
                : 82
                : 104572
                Affiliations
                [a ]University Hospital of Obstetrics and Gynecology, Damascus, Syria
                [b ]Faculty of Medicine, Damascus University, Damascus, Syria
                Author notes
                []Corresponding author. Department: Faculty of Medicine, Damascus University, Abbassiyyin, Damascus, Syria. fouadnahhat@ 123456hotmail.com
                Article
                S2049-0801(22)01332-2 104572
                10.1016/j.amsu.2022.104572
                9577446
                36268396
                10199904-58ad-4c96-8d10-35525a68d8ce
                © 2022 The Authors

                This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

                History
                : 20 July 2022
                : 1 September 2022
                : 4 September 2022
                Categories
                Case Report

                case report,cul-de-sac,douglas pouch,rupture
                case report, cul-de-sac, douglas pouch, rupture

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