This is a 30-year-old gravida 3 para 2 patient from western Ethiopia whose gestational age from reliable last normal menstrual period (LNMP) was 39 weeks plus 4 days presented to Wollega University Referral Hospital (WURH) for elective cesarean delivery. Here, previous two deliveries were by cesarean section. The interval between the first and the second pregnancy and between the second and the third pregnancy (current pregnancy) was 17 and 4 months, respectively. During the current pregnancy, she had five antenatal care (ANC) contacts during which time she was supplemented with iron and folic acid. She was also given two doses of tetanus toxoid. She had a history of hyperemesis gravidarum in all pregnancies.
Her past obstetric history showed unremarkable maternal complications. Her postoperative conditions during previous deliveries were smooth. Postpartum ultrasound examination showed no isthmocele. But she had early neonatal death in her second delivery. This made her get pregnant only after 4 months of delivery. She has no history of trauma to her abdomen. Her past medical and surgical history is unremarkable.
On examination, she was healthy-looking. Her vital signs were blood pressure (BP) = 110/70 mmHg, pulse rate (PR) = 80 beats per minute, respiratory rate (RR) = 18 breaths per minute, and temperature of 37.5 C. She had pink conjunctivae. Lymph glandular system, chest, and cardiovascular system were normal. On abdominal examination, there was a transverse suprapubic healed scar, 38 weeks-sized uterus, longitudinal lie, cephalic presentation, no uterine contraction, on the area of tenderness, and fetal heartbeat (FHB) = 142 beats per minute. Pelvic examination showed an unfavorable Bishop score. On the integumentary system, she had no palmar pallor. On neurologic examination, she was oriented to time, person, and place. She had normal reflexes and no neurologic deficits.
Ultrasound examination was done by radiologist four times during the current pregnancy (in first trimester, second trimester, early third trimester, and at admission). However, the uterine defect was not detected during these examinations. Uterine wall thickness was also not measured. The last ultrasound examination showed aggregate gestational age of 39 weeks plus 3 days, cephalic presentation, reassuring biophysical profile, fundal placenta, and adequate amniotic fluid.
On laboratory investigation, urinalysis, complete blood count, and serum blood glucose level were normal. Serology for syphilis, hepatitis, and human immunodeficiency virus was non-reactive (Table 1). With the final diagnosis of full-term pregnancy and previous two cesarean scars, the patient was prepared for a cesarean section. Intraoperatively, there was a transverse lower uterine segment defect including more than two-thirds of its length through which fetal parts were visible and moving. The defect was only covered by a fetal membrane (Figure 2). After rupturing the fetal membrane, a female alive neonate weighing 3200 g and placenta was delivered. The edge of the defect was trimmed and sutured in two layers with chromic catgut. The abdomen was closed in layers. The patient was transferred to the recovery room with stable vital signs. The patient was counseled for family planning, and she preferred Implanon. On the sixth postoperative day, the patient and new born were discharged in good condition.