Silent Danger: Risk Factors and Outcomes of Fortuitously Discovered Uterine Rupture – A 41-Case Cohort Study

Narjes karmous; Siwar Ghrab; Abdelwahab Masmoudi; Badreddine Bouguerra; Aymen Mabrouk; Anis ben Dhaou; Abdennour Karmous

doi:10.12688/f1000research.164778.1

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Research Article

Silent Danger: Risk Factors and Outcomes of Fortuitously Discovered Uterine Rupture – A 41-Case Cohort Study

[version 1; peer review: 2 approved with reservations]

Narjes karmous ^1,2, Siwar Ghrab², Abdelwahab Masmoudi², [...] Badreddine Bouguerra^1,2, Aymen Mabrouk³, Anis ben Dhaou³, Abdennour Karmous⁴

Narjes karmous ^1,2, Siwar Ghrab², [...] Abdelwahab Masmoudi², Badreddine Bouguerra^1,2, Aymen Mabrouk³, Anis ben Dhaou³, Abdennour Karmous⁴

PUBLISHED 13 Jun 2025

Author details Author details

¹ University of Tunis El Manar Faculty of Medicine of Tunis, Tunis, Tunisia
² Department B of Obstetrics and Gynecology, Charles Nicolle Hospital, Tinis, Tunisia
³ General surgery department B, Charles Nicolle Hospital, Tunis, Tunisia
⁴ Psychiatry Department, Razi Hospital, Manouba, Tunisia

Narjes karmous
Roles: Conceptualization, Methodology, Writing – Original Draft Preparation

Siwar Ghrab
Roles: Data Curation, Visualization

Abdelwahab Masmoudi
Roles: Writing – Review & Editing

Badreddine Bouguerra
Roles: Supervision, Validation

Aymen Mabrouk
Roles: Writing – Review & Editing

Anis ben Dhaou
Roles: Writing – Review & Editing

Abdennour Karmous
Roles: Formal Analysis, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

Abstract

Background

Uterine rupture (UR) remains a major cause of maternal morbidity, especially in low-resource settings. While typically detected during labor, some cases are clinically silent, discovered incidentally during imaging/surgery, highlighting a knowledge gap in risk assessment. In Tunisia, 1.5% of pregnancies involve UR, mostly scar-related. The study aim was to identify factors associated with the development of complete UR in cases that were incidentally found during pregnancy or delivery.

Methods

This was retrospective, longitudinal cohort study conducted over an eleven-year period, from January 2014 to December 2024, at the Gynaecology and Obstetrics department B, Charles Nicolle Hospital, Tunis, Tunisia. Asymptomatic UR cases (complete/incomplete) were analysed to compare clinical profiles, identify risk factors, and assess maternal and neonatal outcomes.

Results

A total of 41 cases of asymptomatic UR were included, which accounted for an average of 50% of the UR cases. In a cohort comparing complete UR cases (N=27) and incomplete UR cases (N=14), significant differences in duration of pregnancy and labor were found. The mean gestational age was longer in the incomplete UR group (p=0.03), and the duration of labor was also significantly longer (p=0.006). No significant differences were observed in sociodemographic characteristics, quality of prenatal care, or complications such as gestational diabetes or preeclampsia. Nonsignificant factors included pregnancy interval, scars number and labor stagnation. The analysis showed two significant predictors of complete UR outcomes. Prolonged labor (>220 minutes) was strongly associated with increased odds of complete UR (OR=45.231, 95% CI=2.591-789.486, p=0.009) and lower maternal weight (<68 kg) correlated with reduced odds of incomplete UR (OR=0.033, 95% CI=0.001–0.837, p=0.039), suggesting a protective effect per kilogram decrease.

Conclusion

Findings redefine UR as part of a broader clinical spectrum, not just an acute complication, enabling tailored surveillance and improved prevention in high-risk pregnancies.

Keywords

"Uterine rupture", "Silent uterine rupture", "Incidental diagnosis", "Scarred uterus", "Post-cesarean delivery complications", "Third-trimester obstetric emergencies".

Corresponding author: Narjes karmous

Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2025 karmous N et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: karmous N, Ghrab S, Masmoudi A et al. Silent Danger: Risk Factors and Outcomes of Fortuitously Discovered Uterine Rupture – A 41-Case Cohort Study [version 1; peer review: 2 approved with reservations]. F1000Research 2025, 14:585 (https://doi.org/10.12688/f1000research.164778.1) First published: 13 Jun 2025, 14:585 (https://doi.org/10.12688/f1000research.164778.1) Latest published: 28 Aug 2025, 14:585 (https://doi.org/10.12688/f1000research.164778.3)

Introduction

Uterine rupture (UR) is still a significant cause of injury in the obstetrician’s field, it is particularly prevalent in low-income settings and contributes to the majority of maternal morbidity.¹ While typically detected during labor via classic symptoms, emerging evidence suggests that a subset of UR cases are likely to remain clinically silent.² These asymptomatic discoveries, which were made during imaging or surgery, represent a significant knowledge deficiency in the assessment of obstetric risks.^3–5

In Tunisia, 1.5% of pregnancies have UR, the majority of which are caused by scarred uteri. Today, the diagnostic paradigm is primarily concerned with incidental presentations, which may or may not include silent cases that predispose to future obstetric issues.² Notably, the clinical importance of having complete or incomplete rupture in women that are symptomatic remains poorly understood, despite the potential difference in management and outcome.

This study analyzed a cohort of asymptomatic UR which includes both complete and incomplete UR, to address critical knowledge gaps regarding asymptomatic rupture. The analysis compared clinical and demographic characteristics of different UR types and identified specific risk factors for asymptomatic events. Particular attention was paid to the impact of evaluating the completeness of the UR on subsequent reproductive outcomes and to provide important data for parturient counseling and treatment.

Hence, the study aim was to identify factors associated with the development of complete UR in cases that were incidentally found during pregnancy or delivery.

Methods

Study design and setting

Retrospective, longitudinal and descriptive cohort study was conducted over an eleven-year period, from January 1, 2014, to December 31, 2024, at Gynaecology and Obstetrics department B, Charles Nicolle Hospital, Tunis, Tunisia.

Study population

This retrospective case series analyzed asymptomatic parturients with incidentally discovered and intraoperatively confirmed complete UR.

The cohort was defined according to the following criteria:

▪ At least one previous uterine surgery (e.g., cesarean section, myomectomy);
▪ Incidental diagnosis of UR in a non-urgent clinical setting (e.g., routine antenatal imaging, elective cesarean section for other reasons, or non-urgent surgery);
▪ And complete clinical records, including surgical records, were available.

Symptomatic cases or UR discovered during labor or in an emergency setting were excluded to isolate the unique clinical features of asymptomatic, incidentally discovered ruptures.

Variables

Data were retrospectively extracted from electronic medical records and focused on four domains:

▪ Maternal characteristics: Age, sociodemographic status, medical and surgical history, obstetric history …
▪ Characteristics of the pregnancy in question: Prenatal follow-up, delivery history …
▪ UR characteristics: Gestational age at diagnosis, clinical settings, anatomical type, surgical treatment …
▪ Maternal and neonatal outcomes: Maternal blood transfusion, intensive care unit (ICU) admission, neonatal status (Apgar score, birth weight, neonatal ICU admission …) …

Statistical analysis

Data were entered and analysed with SPSS software (version 26.0, IBM Corp). Microsoft Office Excel was used to create the tables and graphs (https://www.office.com/?omkt=fr-FR ).

For the primary analysis, we focused on the asymptomatic (randomized) group and compared cases of complete and incomplete UR. Bivariate comparisons were performed using the chi-square test or Fisher’s exact test for categorical variables and Student’s t test or Mann-Whitney U test for continuous variables.

Multivariate logistic regression models were then constructed to identify independent predictors of complete UR in incidentally diagnosed cases. Variables with a p value ≤ 0.20 in the univariate analysis were included in the model. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were reported. A p value ≤ 0.05 was considered statistically significant.^6,7

Ethical considerations

The study protocol was approved on 13 February 2025 by the institutional ethics committee of Charles Nicolle Hospital, Tunis, Tunisia before conducting the study with approval number FWA 00032748- IORG0011243.

As this was a retrospective study using anonymized data, informed consent was waived.

Results

During the study period, a total of 41 cases of asymptomatic UR were included.

From 2014 to 2024 (Table 1 and Figure 1), the maternity unit experienced a significant decrease in annual births, falling from 3939 to just 1964. UR cases peaked at 16 in 2017 but decreased afterward, with only one case reported in 2024. Cesarean deliveries reached their highest point in 2018 at 2033 but declined steadily to 1166 by 2024. In contrast, the number of vaginal deliveries remained relatively stable from 2019 onward, varying between 798 and 1043 each year. Asymptomatic UR accounted for an average of 50% of the UR cases over the eleven-year study period. It exhibited a fluctuating pattern, with the highest occurrence in 2017 (14 cases (88%).

Table 1. Annual distribution of asymptomatic uterine ruptures (UR), total of UR, and total births (2014–2024).

Year	Asymptomatic UR (N = 41)	Total UR (N = 69)	Cesarean deliveries (N = 15266)	Vaginal deliveries (N = 14600)	Total births (N = 29866)	Prevalence of Asymptomatic UR	Incidence of UR	Incidence of asymptomatic UR
2014	8	15	1547	2392	3939	53%	0,38%	0,20%
2015	8	13	1628	2582	4210	62%	0,31%	0,19%
2016	4	7	1289	2003	3292	57%	0,21%	0,12%
2017	14	16	1158	1390	2548	88%	0,63%	0,55%
2018	1	2	2033	654	2687	50%	0,07%	0,04%
2019	1	3	1340	892	2232	33%	0,13%	0,04%
2020	1	2	1215	870	2085	50%	0,10%	0,05%
2021	3	6	1223	1006	2229	50%	0,27%	0,13%
2022	0	3	1411	1043	2454	0%	0,12%	0%
2023	0	0	1256	970	2226	0%	0%	0%
2024	1	2	1166	798	1964	50%	0,10%	0,05%

Figure 1. Trends in asymptomatic Uterine Rupture (UR) prevalence (2014-2024): proportion of asymptomatic cases among total UR at Charles Nicolle Hospital.

The average age was 33.29 ± 4.9 years (24-44 years). Among the 41 parturients, 51% were classified as having an average socioeconomic status, followed by 32% with a high status, and 17% with a low status. In terms of educational attainment, 49% had completed secondary education, 32% held a university-level degree, and 19% had attained only primary education.

Table 2 presents descriptive statistics for various variables related to the study population including weight, height, gravidity, parity, term, interpregnancy interval, and duration of labor.

Table 2. Descriptive statistics of parturients demographics and labor parameters.

Variable	Median	Minimum	25^th percentile (Q1)	75^th percentile (Q3)	Maximum
Weight (kg)	72	61	69	75	80
Height (m)	1.61	1.53	1.57	1.66	1.73
Gravidity	3	1	2	4	5
Parity	3	2	2	3.5	6
Term (weeks)	39	22	37	39	41
Interpregnancy Interval (months)	24	6	12	48	72
Duration of Labor (min)	170	60	63.75	300	600

Thirty-six (88%) of the parturients arrived in active labor. Clinically, seven parturients (17%) developed hypertension during pregnancy, and four parturients (10%) were diagnosed with gestational diabetes Labor stagnation occurred in 7 individuals (17%).

Regarding the time of UR diagnosis, 40 parturients (98%) were diagnosed after delivery, whilst 1 parturient (2%) was diagnosed during labor.

Table 3 presents UR type (complete or incomplete), maternal and neonatal outcomes.

Table 3. Uterine Rupture (UR) type, maternal and neonatal outcomes.

Variable	Statistics
Complete UR N (%)	27 (66%)
Incomplete UR N (%)	14 (34%)
Transfusion N (%)	7 (17%)
Urological Injury N (%)	1 (2%)
Duration of Hospitalization (days) median [IQR]	3 [2-7]
APGAR Score at 5 Minutes median [IQR]	10 [6-10]
Birth Weight (PFN) median [IQR]	3460 [1150-4050]
Neonatal Hospitalization N (%)	1 (2%)
Neonatal Death N (%)	0

In a cohort comparing complete UR cases (N = 27) and incomplete UR cases (N = 14) ( Table 4), significant differences in duration of pregnancy and labor were found. The mean gestational age was longer in the incomplete UR group (38.86 weeks vs. 36.85 weeks, p = 0.03), and the duration of labor was also significantly longer (305.45 minutes vs. 142.94 minutes, p = 0.006). Trends showed that the parity and the proportion of parturients with multiple scars was higher in the complete UR group (3.22 vs. 2.50, p = 0.071 and 82% vs. 18%, p = 0.092 respectively). No significant differences were observed in demographic characteristics (age, weight, BMI), socioeconomic status or education level, quality of prenatal care, or complications such as gestational diabetes or preeclampsia. Preeclampsia occurred only in the incomplete UR group (14% vs. 0%, p = 0.111). Nonsignificant factors included pregnancy interval, number of scars and labor stagnation.

Table 4. Univariate analysis comparing complete Uterine Ruptures (UR) cases and incomplete UR cases.

Characteristics	Complete UR (N = 27)	Incomplete UR (N = 14)	P
Age (Mean ± SD)	33 ± 5	34 ± 6	0,634
Weight (kg)	72 ± 3	70 ± 5	0,115
Height (m)	1.62 ± 0.06	1.60 ± 0.04	0,246
Body mass index	27.51 ± 1.59	27.17 ± 1.20	0,422
Gravidity	3.30 ± 1.17	3.07 ± 1.21	0,523
Parity	3.22 ± 1.37	2.50 ± 0.94	0,071
Gestational age (weeks)	36.85 ± 3.98	38.86 ± 1.70	0,03
Scar number	1.52 ± 0.75	1.36 ± 0.74	0,333
One scar	13 (54%)	11 (46%)	0,092
More than one scar	14 (82%)	3 (18%)	0,092
Socioeconomic status			0,922
- Poor	4 (15%)	3 (21%)
- Average	14 (52%)	7 (50%)
- Good	9 (33%)	4 (29%)
Education Level			0,744
- Primary	5 (19%)	3 (21%)
- Secondary	13 (48%)	7 (50%)
- University	9 (33%)	4 (29%)
Prenatal Follow-up			0,901
- Poor	2 (7%)	1 (7%)
- Average	11 (41%)	6 (43%)
- Good	14 (52%)	7 (50%)
Gestational Diabetes	2 (50%)	2 (50%)	1
Pre-eclampsia	0 (0%)	2 (14%)	0,111
Stagnation of Dilation	5 (19%)	2 (14%)	0,385
Moment of Discovery			1
- During Labor	1 (4%)	0 (0%)
- After Delivery	26 (96%)	14 (100%)
Interval (months)	30.92 ± 17.26	28.71 ± 20.87	0,592
Duration of Labor (min)	142.94 ± 111.78	305.45 ± 150.76	0,006

The analysis identified two significant predictors of complete UR outcomes ( Table 5): Prolonged labor (>220 minutes) was strongly associated with increased odds of complete UR (OR = 45.231, 95% CI = 2.591-789.486, p = 0.009), indicating a 45-fold higher risk compared to shorter labor durations and lower maternal weight (<68 kg) correlated with reduced odds of incomplete UR (OR = 0.033, 95% CI = 0.001–0.837, p = 0.039), suggesting a protective effect per kilogram decrease.

Table 5. Multivariate analysis for identification of predictors of complete Uterine Rupture (UR) outcomes.

	p	OR	Confidence interval
			Low	High
Parity	0,132	0,318	0,072	1,413
Number of scar	0,113	10,343	0,574	186,467
Prolonged labor (>220 minutes)	0,009	45,231	2,591	789,486
Weight <68 kg	0,039	0,033	0,001	0,837

Discussion

Between 2014 and 2024, the number of deliveries per year at the institution decreased by 53% (from 3939 to 1964), and the number of cesarean sections decreased by 43% (from a peak of 2033 in 2018 to 1166 in 2024). These trends likely reflect changes in medical practices and demographic factors over the decade. The high proportion of asymptomatic UR (median 50% of cases) highlights the limitations of symptom-based diagnosis, especially in years with increasing prevalence (up to 88%).

At the same time, the number of UR cases decreased from 16 in 2017 to 1 in 2024. This is consistent with the literature linking prior cesarean sections to the risk of UR.^8,9 This suggests that the decline in surgical births and improvements in surgical techniques may have led to the reduction in UR. Of note, there was also a decrease in asymptomatic cases of UR after 2018 (from 14 in 2017 to 1-3 per year), which may be due to advances in prenatal imaging, as described by Giampaolino et al.¹⁰ However, 98% of UR cases in this cohort were diagnosed after delivery, which contradicts studies advocating prenatal MRI/ultrasound for early detection, indicating a major gap in prenatal surveillance.^11,12

This cohort showed no demographic (age, body mass index, socioeconomic status) or obstetric (quality of antenatal care, gestational diabetes) associations with UR outcomes. However, two new predictors emerged:

Prolonged labor: Labor longer than 220 minutes increased the odds of complete UR by 45 times (OR=45.231, p=0.009), which is consistent with Savukyne et al.,⁹ who identified prolonged labor as a major risk factor.

Lower maternal weight: Weight less than 68 kg decreased the odds of incomplete UR (OR=0.033/kg, p=0.039), a finding that contradicts the literature that frequently links obesity to obstetric risk. This warrants further investigation of biomechanical or metabolic protective mechanisms.

Gestational age (38.86 weeks vs. 36.85 weeks, p=0.03) and delivery time (306 minutes vs. 143 minutes, p=0.006) were also longer in incomplete UR cases, suggesting that sustained uterine pressure may have led to partial UR.

Despite advances in imaging technology, 98% of UR cases were diagnosed after birth. This highlights the underutilization of prenatal MRI and ultrasound, an important tool for detecting scar dehiscence or placenta accreta.^13,14 Although the treatment of UR has not been described in detail, the dramatic decline in cases may be due to improved surgical interventions¹⁴ or conservative strategies for asymptomatic cases.¹⁰

Study strengths and limitations

This study’s analysis of UR trends over a decade (2014–2024) offers significant contributions to the literature, particularly through its identification of novel risk factors- prolonged labor (>220 minutes) and lower maternal weight- and its demonstration of a 94% decline in UR cases coinciding with reduced cesarean delivery rates, reflecting broader improvements in obstetric practices. The cohort of 41 UR cases, larger than most prior studies,⁸ enabled robust comparisons between complete and incomplete UR types, revealing key differences in gestational age and labor duration.

However, the retrospective, single-center design introduces limitations, including potential selection bias and underpowered subgroup analyses (e.g., preeclampsia rates), while the near-exclusive reliance on post-delivery diagnosis (98% of cases) contrasts sharply with literature advocating prenatal MRI/ultrasound for early detection of scar dehiscence or placental anomalies.^11,12

Recommendations

The findings advance UR risk stratification by expanding beyond traditional predictors (prior uterine surgery) and highlight the need for prospective, multicenter studies to validate novel associations while integrating advanced imaging and standardized management protocols to bridge diagnostic and care disparities observed across institutions.

Conclusions

Our findings redefine UR as part of the clinical picture rather than simply an acute complication of obstetrics. This paradigm shift enables customized surveillance of the scarred uterus and improves detection and prevention capabilities in high-risk obstetrics.

Ethical considerations

We confirm that we have read the Journal’s position on issues involved in ethical publication and affirm that this report is consistent with those guidelines.

The study protocol was approved on 13 February 2025 by the institutional ethics committee of Charles Nicolle Hospital, Tunis, Tunisia before conducting the study (approval number: FWA 00032748- IORG0011243).

Consent to participate

As this was a retrospective study using anonymized data, informed consent was waived.

Data availability statement

All data sets can be assessed and all study findings reported in the article are shared via Harvard Dataverse: “Silent Danger: Risk Factors and Outcomes of Fortuitously Discovered Uterine Rupture – A 41-Case Cohort Study”, https://doi.org/10.7910/DVN/D9OO16.¹⁵

This project contains the following:

• Dataset silent UR- English
• Study findings silent UR

Extended data

Harvard Dataverse: “Silent Danger: Risk Factors and Outcomes of Fortuitously Discovered Uterine Rupture – A 41-Case Cohort Study”, https://doi.org/10.7910/DVN/D9OO16.¹⁵

This project contains the following:

Questionnaire (in English)

Reporting guidelines

This work has been reported in line with the STROBE guidelines.¹⁶

Harvard Dataverse: “Silent Danger: Risk Factors and Outcomes of Fortuitously Discovered Uterine Rupture – A 41-Case Cohort Study”, https://doi.org/10.7910/DVN/D9OO16.¹⁵

This project contains the following:

STROBE Checklist

Data are available under the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication).

References

1. Ahmed DM, Mengistu TS, Endalamaw AG: Incidence and factors associated with outcomes of uterine rupture among women delivered at Felegehiwot referral hospital, Bahir Dar, Ethiopia: cross sectional study. BMC Pregnancy Childbirth. 2018 Nov 16; 18: 447. PubMed Abstract | Publisher Full Text | Free Full Text
2. Zine S, Abed A, Sfar E, et al.: Uterine rupture during labor. Report of 106 cases at the Maternity Center of Tunis (Tunisia). Rev. Fr. Gynecol. Obstet. 1995 Mar; 90(3): 166, 169–173. PubMed Abstract
3. Yang H, Zhao Y, Tu J, et al.: Clinical analysis of incomplete rupture of the uterus secondary to previous cesarean section. Open Med (Wars). 2024 Apr 1; 19(1): 20240927. PubMed Abstract | Publisher Full Text | Free Full Text
4. Guiliano M, Closset E, Therby D, et al.: Signs, symptoms and complications of complete and partial uterine ruptures during pregnancy and delivery. Eur. J. Obstet. Gynecol. Reprod. Biol. 2014 Aug; 179: 130–134. PubMed Abstract | Publisher Full Text
5. Ahmadi F, Siahbazi S, Akhbari F: Incomplete Cesarean Scar Rupture. J. Reprod. Infertil. 2013; 14(1): 43–45. PubMed Abstract
6. Rybak A, Levy C, Ouldali N, et al.: Dynamics of Antibiotic Resistance of Streptococcus pneumoniae in France: A Pediatric Prospective Nasopharyngeal Carriage Study from 2001 to 2022. Antibiotics. 2023 Jun; 12(6): 1020. PubMed Abstract | Publisher Full Text | Free Full Text
7. Hasan MM, Kamruzzaman M, Anik KS, et al.: Dengue Encephalopathy, its Presentations and Outcome, A Study on 200 Dengue Encephalopathy Patients in Tertiary Level Hospitals in Bangladesh. Sch. J. App. Med. Sci. 2024 Nov 11; 12(11): 1550–1557. Publisher Full Text
8. Xiao J, Zhang C, Zhang Y, et al.: Ultrasonic manifestations and clinical analysis of 25 uterine rupture cases. J. Obstet. Gynaecol. Res. 2021 Apr; 47(4): 1397–1408. PubMed Abstract | Publisher Full Text
9. Savukyne E, Bykovaite-Stankeviciene R, Machtejeviene E, et al.: Symptomatic Uterine Rupture: A Fifteen Year Review. Medicina (Kaunas). 2020 Oct 29; 56(11): 574. PubMed Abstract | Publisher Full Text | Free Full Text
10. Giampaolino P, De Rosa N, Morra I, et al.: Management of Cesarean Scar Pregnancy: A Single-Institution Retrospective Review. Biomed. Res. Int. 2018; 2018(1): 6486407.
11. Zermano S, Seminara G, Parisi N, et al.: Prenatal Detection and Conservative Management of Uterine Scar Dehiscence in Patient with Previous Uterine Rupture and Multiple Surgeries-A Case Report. Healthcare (Basel). 2024 May 10; 12(10): 988. PubMed Abstract | Publisher Full Text | Free Full Text
12. Hoffman MK, Grant GH: Induction of labor in women with a prior cesarean delivery. Semin. Perinatol. 2015 Oct 1; 39(6): 471–474. Publisher Full Text
13. Li XF, Wu J, Zhou Y, et al.: Clinical analysis of 12 cases of spontaneous uterine rupture caused by placenta percreta. Zhonghua Fu Chan Ke Za Zhi. 2020 Oct 25; 55(10): 691–696. PubMed Abstract | Publisher Full Text
14. Setubal A, Alves J, Osório F, et al.: Treatment for Uterine Isthmocele, A Pouchlike Defect at the Site of a Cesarean Section Scar. J. Minim. Invasive Gynecol. 2018 Jan; 25(1): 38–46. PubMed Abstract | Publisher Full Text
15. Karmous N, Ghrab S, Masmoudi A, et al.: Silent danger: risk factors and outcomes of fortuitously discovered uterine rupture – a 41-case cohort study. [Dataset]. Harvard Dataverse. 2025.
16. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J. Clin. Epidemiol. 2008 Apr; 61(4): 344–349. Publisher Full Text

Comments on this article Comments (0)

Version 3

VERSION 3 PUBLISHED 13 Jun 2025

Author details Author details

Narjes karmous
Roles: Conceptualization, Methodology, Writing – Original Draft Preparation

Siwar Ghrab
Roles: Data Curation, Visualization

Abdelwahab Masmoudi
Roles: Writing – Review & Editing

Badreddine Bouguerra
Roles: Supervision, Validation

Aymen Mabrouk
Roles: Writing – Review & Editing

Anis ben Dhaou
Roles: Writing – Review & Editing

Abdennour Karmous
Roles: Formal Analysis, Writing – Review & Editing

Competing interests

No competing interests were disclosed.

Grant information

The author(s) declared that no grants were involved in supporting this work.

Article Versions (3)

version 3

Revised

Published: 28 Aug 2025, 14:585

https://doi.org/10.12688/f1000research.164778.3

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Published: 08 Aug 2025, 14:585

https://doi.org/10.12688/f1000research.164778.2

version 1

Published: 13 Jun 2025, 14:585

https://doi.org/10.12688/f1000research.164778.1

© 2025 karmous N et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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karmous N, Ghrab S, Masmoudi A et al. Silent Danger: Risk Factors and Outcomes of Fortuitously Discovered Uterine Rupture – A 41-Case Cohort Study [version 1; peer review: 2 approved with reservations]. F1000Research 2025, 14:585 (https://doi.org/10.12688/f1000research.164778.1)

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Open Peer Review

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Reviewer Report 30 Jun 2025

Mathew Olumide Adebisi, Afe Babalola University, Ado-Ekiti, Ekiti, Nigeria; Obstetrics and Gynaecology, Federal Teaching Hospital Ido-Ekiti (Ringgold ID: 605037), Ido Ekiti, Ekiti, Nigeria

Approved with Reservations

https://doi.org/10.5256/f1000research.181350.r392395

GENERAL COMMENTS
The manuscript delved into an important obstetric mishap that is a major contributor to maternal morbidity and mortality especially in developing nations.
However, manuscript needs major revisions especially in the areas of literature review on the existing knowledge and knowledge gap, methodology, result presentation, discussion and conclusion.

SPECIFIC COMMENTS ON SECTIONS

Title: Nothing remarkable and it is well written.

Abstract: “The aim is to identify factors associated with complete uterine rupture (UR)”. In your methodology, asymptomatic UR cases (complete/incomplete) were analyzed. This should be harmonized to make the methodology reproducible and thoroughly understood by the readers.
Result (in the abstract section): ……. protective effect per kilogram decrease?
This statement should be clearly mentioned. For example, …. protective effect per kilogram maternal body weight.

Main text:
Introduction: This is grossly inadequate. Are there no studies on the topic of silent uterine rupture either scarred or unscarred from developing countries? Are there no studies on how asymptomatic UR cases are being recognized either by imaging or at surgery?
Suggested citations:

Ebeigbe PN et.al. (2005) - Ref. 1
Kadowa I. (2010)- Ref. 2
Fofie C and Baffoe P (2011) - Ref. 3

There are still many more that can be cited to add to the literature review.

Methodology: Is this study only on complete uterine rupture? Your stated in the methodology that “asymptomatic uterine rupture cases (complete/incomplete) were analyzed to compare clinical profiles, identify risk factors and assess maternal and neonatal outcomes. Also, result section revealed comparison of complete UR versus incomplete UR.
You also stated that symptomatic cases and those in labour or other emergency settings were excluded from the study. However, some of the tables (2 and 4) in the result section show duration of labour as variable. I suggest that the different sections of the manuscript should be harmonized.

Statistical analysis: Is this study a randomized study?

Results:
Parturient refers to a woman in labour and those in labour were said to be excluded.
Other terms or phrases could be used to describe the 41 cases. For example; Among the 41 women with asymptomatic uterine rupture…..
Tables 2 and 4- Harmonized the Methodology and the variables.

Discussion:
Quoting your statement from this section- “This cohort showed no demographic (Age, body mass index, socioeconomic status) or obstetric (quality of antenatal care, gestational diabetes) association with uterine rupture outcomes. However, it was reported that two “new predictors” emerged; namely (1) prolonged labour, leading to uterine rupture is a reflection of the type of obstetric care received (2) lower maternal weight.
“Gestational age and delivery time were also noted to be longer in the incomplete uterine rupture cases”. These are also obstetric /labour factors.

I therefore suggest that the exclusion criteria (and by extension, the methodology) and result presentation should be revised.
Conclusion: The study reported that two new predictors emerged which is a strong point in this study. However, authors concluded on factor which the study did not reveal. The conclusion should be revised.

References: some references have been suggested. If the literature review (introduction section) is revised as recommended, definitely 2 or more citations will be added to the reference.

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

No
If applicable, is the statistical analysis and its interpretation appropriate?

Partly
Are all the source data underlying the results available to ensure full reproducibility?

Partly
Are the conclusions drawn adequately supported by the results?

No

References

1. Ebeigbe P, Enabudoso E, Ande A: Ruptured uterus in a Nigerian community: a study of sociodemographic and obstetric risk factors. Acta Obstetricia et Gynecologica Scandinavica. 2005; 84 (12): 1172-1174 Publisher Full Text
2. I, Kadowa: Ruptured uterus in rural Uganda: prevalence, predisposing factors and outcomes dust. https://pubmed.ncbi.nlm.nih.gov/20200773/. 2010.
3. Fofie C, Baffoe P: A two-year review of uterine rupture in a regional hospital. Ghana Medical Journal. 2011; 44 (3). Publisher Full Text
4. Karmous, Narjes: Silent Danger: Risk Factors and Outcomes of Fortuitously Discovered Uterine Rupture - ; A 41-Case Cohort Study. https://dataverse.harvard.edu/dataset.xhtml?persistentId. 2025. Publisher Full Text

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Obstetrics and Gynaecology

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

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Author Response 23 Aug 2025

Narjes karmous, Department B of Obstetrics and Gynecology, Charles Nicolle Hospital, Tinis, Tunisia

23 Aug 2025

Author Response

Dear Mathew Olumide Adebisi,
We sincerely appreciate your constructive feedback. Your insightful comments have helped us refine and enhance the quality of our manuscript.

Reviewer comment:
Abstract: Harmonize the ... Continue reading Dear Mathew Olumide Adebisi,
We sincerely appreciate your constructive feedback. Your insightful comments have helped us refine and enhance the quality of our manuscript.

Reviewer comment:
Abstract: Harmonize the aim and methodology regarding complete/incomplete UR.
Author response:
The Abstract has been revised to clearly state that both complete and incomplete forms of asymptomatic uterine rupture were included and analyzed in the study, ensuring coherence with the Methods and Results sections.

Reviewer comment:
Result (Abstract): Clarify “protective effect per kilogram decrease”.
Author response:
We revised the phrasing in the Abstract to “a protective effect per kilogram of maternal body weight” for clarity and statistical accuracy.

Reviewer comment:
Introduction is grossly inadequate. Literature on silent uterine rupture in developing countries should be reviewed. Suggested citations: Ref. 1–3.
Author response:
The Introduction has been substantially expanded and now includes data from studies conducted in Nigeria, Uganda, and Ghana, as suggested (references [7]–[9]). These studies help contextualize our findings within a broader regional framework of silent uterine rupture and its risk factors.

Reviewer comment:
Methodology unclear: Complete vs incomplete UR? Harmonize with Results.
Author response:
This issue has been addressed. We now explicitly state in the Methods that both complete and incomplete asymptomatic uterine ruptures were included in the study and compared across multiple variables. Terminology and consistency have been corrected throughout.

Reviewer comment:
Tables 2 and 4 mention labor variables, yet laboring women were excluded.
Author response:
We clarified that “asymptomatic” in our study refers to the absence of clinical signs of rupture (pain, bleeding, fetal distress), but not necessarily the absence of labor. Some patients had labor activity before cesarean delivery, which justifies the inclusion of labor variables. This is now clearly stated in the 'Study Population' and 'Discussion' sections.

Reviewer comment:
Is this a randomized study?
Author response:
No. We confirm this is a retrospective observational cohort study. This has been clearly stated in the revised Methodology section.

Reviewer comment:
Replace “parturient” with more appropriate term for asymptomatic cases.
Author response:
We have replaced the term “parturient” with “women with asymptomatic uterine rupture” or more specific language throughout the manuscript for precision and accuracy.

Reviewer comment:
Discussion contradicts exclusion criteria: Prolonged labor and gestational age as predictors?
Author response:
This has been clarified. Although these women had no rupture symptoms, many experienced labor prior to cesarean. This distinction has been made clear in the revised Discussion and Methods sections.

Reviewer comment:
Conclusion not supported by results. Revise accordingly.
Author response:
We have revised the Conclusion to focus strictly on statistically supported findings: prolonged labor and maternal weight <68 kg as independent predictors of complete rupture. Speculative elements were removed.

Reviewer comment:
References: more literature needed if Introduction is revised.
Author response:
We have included all the suggested references and added several recent publications to strengthen the Introduction and Discussion.

Reviewer comment:
Are sufficient details of methods and analysis provided to allow replication by others? → No
Author response:
The Methods section has been substantially revised to improve clarity and reproducibility. It now includes more precise definitions of study population, variables, criteria, and analysis thresholds.

Reviewer comment:
Are the conclusions drawn adequately supported by the results? → No
Author response:
The conclusions have been adjusted to align fully with the results. We now only report findings that were statistically demonstrated and explicitly acknowledge study limitations.

Sincerely,
Narjes Karmous
Dear Mathew Olumide Adebisi,
We sincerely appreciate your constructive feedback. Your insightful comments have helped us refine and enhance the quality of our manuscript.

Reviewer comment:
Abstract: Harmonize the aim and methodology regarding complete/incomplete UR.
Author response:
The Abstract has been revised to clearly state that both complete and incomplete forms of asymptomatic uterine rupture were included and analyzed in the study, ensuring coherence with the Methods and Results sections.

Reviewer comment:
Result (Abstract): Clarify “protective effect per kilogram decrease”.
Author response:
We revised the phrasing in the Abstract to “a protective effect per kilogram of maternal body weight” for clarity and statistical accuracy.

Reviewer comment:
Introduction is grossly inadequate. Literature on silent uterine rupture in developing countries should be reviewed. Suggested citations: Ref. 1–3.
Author response:
The Introduction has been substantially expanded and now includes data from studies conducted in Nigeria, Uganda, and Ghana, as suggested (references [7]–[9]). These studies help contextualize our findings within a broader regional framework of silent uterine rupture and its risk factors.

Reviewer comment:
Methodology unclear: Complete vs incomplete UR? Harmonize with Results.
Author response:
This issue has been addressed. We now explicitly state in the Methods that both complete and incomplete asymptomatic uterine ruptures were included in the study and compared across multiple variables. Terminology and consistency have been corrected throughout.

Reviewer comment:
Tables 2 and 4 mention labor variables, yet laboring women were excluded.
Author response:
We clarified that “asymptomatic” in our study refers to the absence of clinical signs of rupture (pain, bleeding, fetal distress), but not necessarily the absence of labor. Some patients had labor activity before cesarean delivery, which justifies the inclusion of labor variables. This is now clearly stated in the 'Study Population' and 'Discussion' sections.

Reviewer comment:
Is this a randomized study?
Author response:
No. We confirm this is a retrospective observational cohort study. This has been clearly stated in the revised Methodology section.

Reviewer comment:
Replace “parturient” with more appropriate term for asymptomatic cases.
Author response:
We have replaced the term “parturient” with “women with asymptomatic uterine rupture” or more specific language throughout the manuscript for precision and accuracy.

Reviewer comment:
Discussion contradicts exclusion criteria: Prolonged labor and gestational age as predictors?
Author response:
This has been clarified. Although these women had no rupture symptoms, many experienced labor prior to cesarean. This distinction has been made clear in the revised Discussion and Methods sections.

Reviewer comment:
Conclusion not supported by results. Revise accordingly.
Author response:
We have revised the Conclusion to focus strictly on statistically supported findings: prolonged labor and maternal weight <68 kg as independent predictors of complete rupture. Speculative elements were removed.

Reviewer comment:
References: more literature needed if Introduction is revised.
Author response:
We have included all the suggested references and added several recent publications to strengthen the Introduction and Discussion.

Reviewer comment:
Are sufficient details of methods and analysis provided to allow replication by others? → No
Author response:
The Methods section has been substantially revised to improve clarity and reproducibility. It now includes more precise definitions of study population, variables, criteria, and analysis thresholds.

Reviewer comment:
Are the conclusions drawn adequately supported by the results? → No
Author response:
The conclusions have been adjusted to align fully with the results. We now only report findings that were statistically demonstrated and explicitly acknowledge study limitations.

Sincerely,
Narjes Karmous
Competing Interests: No competing interests were disclosed. Close
Report a concern
Respond or Comment

COMMENTS ON THIS REPORT

Author Response 23 Aug 2025

Narjes karmous, Department B of Obstetrics and Gynecology, Charles Nicolle Hospital, Tinis, Tunisia

23 Aug 2025

Author Response

Dear Mathew Olumide Adebisi,
We sincerely appreciate your constructive feedback. Your insightful comments have helped us refine and enhance the quality of our manuscript.

Reviewer comment:
Abstract: Harmonize the ... Continue reading Dear Mathew Olumide Adebisi,
We sincerely appreciate your constructive feedback. Your insightful comments have helped us refine and enhance the quality of our manuscript.

Reviewer comment:
Abstract: Harmonize the aim and methodology regarding complete/incomplete UR.
Author response:
The Abstract has been revised to clearly state that both complete and incomplete forms of asymptomatic uterine rupture were included and analyzed in the study, ensuring coherence with the Methods and Results sections.

Reviewer comment:
Result (Abstract): Clarify “protective effect per kilogram decrease”.
Author response:
We revised the phrasing in the Abstract to “a protective effect per kilogram of maternal body weight” for clarity and statistical accuracy.

Reviewer comment:
Introduction is grossly inadequate. Literature on silent uterine rupture in developing countries should be reviewed. Suggested citations: Ref. 1–3.
Author response:
The Introduction has been substantially expanded and now includes data from studies conducted in Nigeria, Uganda, and Ghana, as suggested (references [7]–[9]). These studies help contextualize our findings within a broader regional framework of silent uterine rupture and its risk factors.

Reviewer comment:
Methodology unclear: Complete vs incomplete UR? Harmonize with Results.
Author response:
This issue has been addressed. We now explicitly state in the Methods that both complete and incomplete asymptomatic uterine ruptures were included in the study and compared across multiple variables. Terminology and consistency have been corrected throughout.

Reviewer comment:
Tables 2 and 4 mention labor variables, yet laboring women were excluded.
Author response:
We clarified that “asymptomatic” in our study refers to the absence of clinical signs of rupture (pain, bleeding, fetal distress), but not necessarily the absence of labor. Some patients had labor activity before cesarean delivery, which justifies the inclusion of labor variables. This is now clearly stated in the 'Study Population' and 'Discussion' sections.

Reviewer comment:
Is this a randomized study?
Author response:
No. We confirm this is a retrospective observational cohort study. This has been clearly stated in the revised Methodology section.

Reviewer comment:
Replace “parturient” with more appropriate term for asymptomatic cases.
Author response:
We have replaced the term “parturient” with “women with asymptomatic uterine rupture” or more specific language throughout the manuscript for precision and accuracy.

Reviewer comment:
Discussion contradicts exclusion criteria: Prolonged labor and gestational age as predictors?
Author response:
This has been clarified. Although these women had no rupture symptoms, many experienced labor prior to cesarean. This distinction has been made clear in the revised Discussion and Methods sections.

Reviewer comment:
Conclusion not supported by results. Revise accordingly.
Author response:
We have revised the Conclusion to focus strictly on statistically supported findings: prolonged labor and maternal weight <68 kg as independent predictors of complete rupture. Speculative elements were removed.

Reviewer comment:
References: more literature needed if Introduction is revised.
Author response:
We have included all the suggested references and added several recent publications to strengthen the Introduction and Discussion.

Reviewer comment:
Are sufficient details of methods and analysis provided to allow replication by others? → No
Author response:
The Methods section has been substantially revised to improve clarity and reproducibility. It now includes more precise definitions of study population, variables, criteria, and analysis thresholds.

Reviewer comment:
Are the conclusions drawn adequately supported by the results? → No
Author response:
The conclusions have been adjusted to align fully with the results. We now only report findings that were statistically demonstrated and explicitly acknowledge study limitations.

Sincerely,
Narjes Karmous
Dear Mathew Olumide Adebisi,
We sincerely appreciate your constructive feedback. Your insightful comments have helped us refine and enhance the quality of our manuscript.

Reviewer comment:
Abstract: Harmonize the aim and methodology regarding complete/incomplete UR.
Author response:
The Abstract has been revised to clearly state that both complete and incomplete forms of asymptomatic uterine rupture were included and analyzed in the study, ensuring coherence with the Methods and Results sections.

Reviewer comment:
Result (Abstract): Clarify “protective effect per kilogram decrease”.
Author response:
We revised the phrasing in the Abstract to “a protective effect per kilogram of maternal body weight” for clarity and statistical accuracy.

Reviewer comment:
Introduction is grossly inadequate. Literature on silent uterine rupture in developing countries should be reviewed. Suggested citations: Ref. 1–3.
Author response:
The Introduction has been substantially expanded and now includes data from studies conducted in Nigeria, Uganda, and Ghana, as suggested (references [7]–[9]). These studies help contextualize our findings within a broader regional framework of silent uterine rupture and its risk factors.

Reviewer comment:
Methodology unclear: Complete vs incomplete UR? Harmonize with Results.
Author response:
This issue has been addressed. We now explicitly state in the Methods that both complete and incomplete asymptomatic uterine ruptures were included in the study and compared across multiple variables. Terminology and consistency have been corrected throughout.

Reviewer comment:
Tables 2 and 4 mention labor variables, yet laboring women were excluded.
Author response:
We clarified that “asymptomatic” in our study refers to the absence of clinical signs of rupture (pain, bleeding, fetal distress), but not necessarily the absence of labor. Some patients had labor activity before cesarean delivery, which justifies the inclusion of labor variables. This is now clearly stated in the 'Study Population' and 'Discussion' sections.

Reviewer comment:
Is this a randomized study?
Author response:
No. We confirm this is a retrospective observational cohort study. This has been clearly stated in the revised Methodology section.

Reviewer comment:
Replace “parturient” with more appropriate term for asymptomatic cases.
Author response:
We have replaced the term “parturient” with “women with asymptomatic uterine rupture” or more specific language throughout the manuscript for precision and accuracy.

Reviewer comment:
Discussion contradicts exclusion criteria: Prolonged labor and gestational age as predictors?
Author response:
This has been clarified. Although these women had no rupture symptoms, many experienced labor prior to cesarean. This distinction has been made clear in the revised Discussion and Methods sections.

Reviewer comment:
Conclusion not supported by results. Revise accordingly.
Author response:
We have revised the Conclusion to focus strictly on statistically supported findings: prolonged labor and maternal weight <68 kg as independent predictors of complete rupture. Speculative elements were removed.

Reviewer comment:
References: more literature needed if Introduction is revised.
Author response:
We have included all the suggested references and added several recent publications to strengthen the Introduction and Discussion.

Reviewer comment:
Are sufficient details of methods and analysis provided to allow replication by others? → No
Author response:
The Methods section has been substantially revised to improve clarity and reproducibility. It now includes more precise definitions of study population, variables, criteria, and analysis thresholds.

Reviewer comment:
Are the conclusions drawn adequately supported by the results? → No
Author response:
The conclusions have been adjusted to align fully with the results. We now only report findings that were statistically demonstrated and explicitly acknowledge study limitations.

Sincerely,
Narjes Karmous
Competing Interests: No competing interests were disclosed. Close
Report a concern

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Reviewer Report 25 Jun 2025

Phuc Nhon Nguyen, Tu Du Hospital, Ho Chi Minh City, Vietnam

Approved with Reservations

https://doi.org/10.5256/f1000research.181350.r392398

Thank you for paper. I have some comments:
In introduction, the study should mention some etiologies of uterine rupture, even in rare cases of placenta accreta spectrum on unscarred uterus. PMCID: PMC9568723
The inclusion criteria: “At least one previous uterine surgery” is necessary?
A study flowchart with inclusion/exclusion cases should be added.
Maternal weight < 68kg is a protective factor? Could the authors please explain the relationship between maternal weight and uterine rupture? The neonatal weight may be more significant?
Blood loss and blood transfusion should be presented additionally as median [IQR].
Definition of important variable should be added. For example: complete/incomplete UR.
BMI should be represented instead of separate weight and height.
The small sample size made the CI of multivariate logistic regression too large. This is confused.
Please discuss why the period 2014-2017 related to increasing number of UR cases?
In discussion, some other etiologies of intraabdominal hemorrhage in pregnancy should be also noted as well as role of imaging modalities such as ultrasound. doi: 10.1186/s12245-023-00498-w.
Pulmonary embolism complication should be prevented in cesarean with severe blood loss.refer to 1
Please discuss the role of cardiotocography in monitoring labor and detecting UR. refer to 2
Change of fetal head's position during labor should be exanimated.
Practical points should be summarized.

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

I cannot comment. A qualified statistician is required.
Are all the source data underlying the results available to ensure full reproducibility?

Partly
Are the conclusions drawn adequately supported by the results?

Partly

References

1. Vuong A, Pham T, Bui V, Nguyen X, et al.: Successfully conservative management of the uterus in acute pulmonary embolism during cesarean section for placenta previa: a case report from Tu Du Hospital, Vietnam and literature review. International Journal of Emergency Medicine. 2024; 17 (1). Publisher Full Text
2. Overtoom E, Huynh T, Rosman A, Zwart J, et al.: Predicting the risks and recognizing the signs: a two-year prospective population-based study on pregnant women with uterine rupture in The Netherlands. The Journal of Maternal-Fetal & Neonatal Medicine. 2024; 37 (1). Publisher Full Text

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Pregnancy pathology

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Report a concern

Author Response 23 Aug 2025

Narjes karmous, Department B of Obstetrics and Gynecology, Charles Nicolle Hospital, Tinis, Tunisia

23 Aug 2025

Author Response

Dear Phuc Nhon Nguyen,
We sincerely appreciate your constructive feedback. Your insightful comments have helped us refine and enhance the quality of our manuscript.

Reviewer comment: In introduction, the ... Continue reading Dear Phuc Nhon Nguyen,
We sincerely appreciate your constructive feedback. Your insightful comments have helped us refine and enhance the quality of our manuscript.

Reviewer comment: In introduction, the study should mention some etiologies of uterine rupture, even in rare cases of placenta accreta spectrum on unscarred uterus. PMCID: PMC9568723
Author response: We appreciate this suggestion. A sentence addressing rare etiologies of uterine rupture, including placenta accreta spectrum in unscarred uteri, has been added to the Introduction, with citation [6].

Reviewer comment: The inclusion criteria: “At least one previous uterine surgery” is necessary?
Author response: Thank you for your insightful comment. We acknowledge that our earlier wording may have created some confusion. To clarify: a history of uterine surgery was not required for inclusion in this study. Our aim was to analyze all cases of fortuitously discovered uterine rupture, regardless of uterine surgical history.
As such, the presence or absence of a uterine scar was not used as an inclusion criterion. What defined eligibility was the asymptomatic nature of the rupture and its intraoperative or immediate postpartum discovery, combined with complete medical documentation. Both scarred and unscarred uteri were represented in our cohort.
We have updated the Materials and Methods section accordingly to ensure clarity and consistency with this inclusion approach.

Reviewer comment: A study flowchart with inclusion/exclusion cases should be added.
Author response: A flowchart has been included as Figure 1 to illustrate the inclusion and exclusion process clearly.

Reviewer comment : Maternal weight < 68kg is a protective factor? Could the authors please explain the relationship between maternal weight and uterine rupture? The neonatal weight may be more significant?
Author response : This point has been expanded in the Discussion, with added references [21–26] explaining the physiopathological links between obesity, uterine healing, and rupture. The role of neonatal weight is also discussed.

Reviewer comment : Blood loss and blood transfusion should be presented additionally as median [IQR].
Author response: We have revised Table 3 to present blood loss and transfusion data as median [IQR], in line with reviewer recommendations.

Reviewer comment: Definition of important variable should be added. For example: complete/incomplete UR.
Author response: Definitions of 'complete' and 'incomplete' uterine rupture have been added to the Methods section under the 'Definitions' subsection.

Reviewer comment: BMI should be represented instead of separate weight and height.
Author response: We replaced separate weight and height with BMI throughout the manuscript and added BMI statistics in Table 2.

Reviewer comment: The small sample size made the CI of multivariate logistic regression too large. This is confused.
Author response: We agree. This limitation is acknowledged explicitly in the Methods and Discussion sections.

Reviewer comment: Please discuss why the period 2014–2017 related to increasing number of UR cases?
Author response: We provided an explanation in the Discussion, linking the peak in 2017 to institutional practices and changes in intraoperative exploration and documentation.

Reviewer comment: In discussion, some other etiologies of intraabdominal hemorrhage in pregnancy should be also noted as well as role of imaging modalities such as ultrasound.
Author response: These aspects have been discussed in the revised Discussion, with references [17,18,19].

Reviewer comment: Pulmonary embolism complication should be prevented in cesarean with severe blood loss.
Author response: We agree. The importance of thromboprophylaxis has been added to the Discussion, citing reference [29].

Reviewer comment: Please discuss the role of cardiotocography in monitoring labor and detecting UR.
Author response: The role of CTG as an early indicator of uterine rupture has been included in the Discussion with appropriate reference [27].

Reviewer comment: Change of fetal head's position during labor should be examined.
Author response: This was mentioned in the Discussion as a potential indirect sign of uterine dehiscence, citing reference [28].

Reviewer comment: Practical points should be summarized.
Author response: We added a bullet-style summary of clinical implications and recommendations at the end of the Discussion section.

Sincerely,
Narjes Karmous
Dear Phuc Nhon Nguyen,
We sincerely appreciate your constructive feedback. Your insightful comments have helped us refine and enhance the quality of our manuscript.

Reviewer comment: In introduction, the study should mention some etiologies of uterine rupture, even in rare cases of placenta accreta spectrum on unscarred uterus. PMCID: PMC9568723
Author response: We appreciate this suggestion. A sentence addressing rare etiologies of uterine rupture, including placenta accreta spectrum in unscarred uteri, has been added to the Introduction, with citation [6].

Reviewer comment: The inclusion criteria: “At least one previous uterine surgery” is necessary?
Author response: Thank you for your insightful comment. We acknowledge that our earlier wording may have created some confusion. To clarify: a history of uterine surgery was not required for inclusion in this study. Our aim was to analyze all cases of fortuitously discovered uterine rupture, regardless of uterine surgical history.
As such, the presence or absence of a uterine scar was not used as an inclusion criterion. What defined eligibility was the asymptomatic nature of the rupture and its intraoperative or immediate postpartum discovery, combined with complete medical documentation. Both scarred and unscarred uteri were represented in our cohort.
We have updated the Materials and Methods section accordingly to ensure clarity and consistency with this inclusion approach.

Reviewer comment: A study flowchart with inclusion/exclusion cases should be added.
Author response: A flowchart has been included as Figure 1 to illustrate the inclusion and exclusion process clearly.

Reviewer comment : Maternal weight < 68kg is a protective factor? Could the authors please explain the relationship between maternal weight and uterine rupture? The neonatal weight may be more significant?
Author response : This point has been expanded in the Discussion, with added references [21–26] explaining the physiopathological links between obesity, uterine healing, and rupture. The role of neonatal weight is also discussed.

Reviewer comment : Blood loss and blood transfusion should be presented additionally as median [IQR].
Author response: We have revised Table 3 to present blood loss and transfusion data as median [IQR], in line with reviewer recommendations.

Reviewer comment: Definition of important variable should be added. For example: complete/incomplete UR.
Author response: Definitions of 'complete' and 'incomplete' uterine rupture have been added to the Methods section under the 'Definitions' subsection.

Reviewer comment: BMI should be represented instead of separate weight and height.
Author response: We replaced separate weight and height with BMI throughout the manuscript and added BMI statistics in Table 2.

Reviewer comment: The small sample size made the CI of multivariate logistic regression too large. This is confused.
Author response: We agree. This limitation is acknowledged explicitly in the Methods and Discussion sections.

Reviewer comment: Please discuss why the period 2014–2017 related to increasing number of UR cases?
Author response: We provided an explanation in the Discussion, linking the peak in 2017 to institutional practices and changes in intraoperative exploration and documentation.

Reviewer comment: In discussion, some other etiologies of intraabdominal hemorrhage in pregnancy should be also noted as well as role of imaging modalities such as ultrasound.
Author response: These aspects have been discussed in the revised Discussion, with references [17,18,19].

Reviewer comment: Pulmonary embolism complication should be prevented in cesarean with severe blood loss.
Author response: We agree. The importance of thromboprophylaxis has been added to the Discussion, citing reference [29].

Reviewer comment: Please discuss the role of cardiotocography in monitoring labor and detecting UR.
Author response: The role of CTG as an early indicator of uterine rupture has been included in the Discussion with appropriate reference [27].

Reviewer comment: Change of fetal head's position during labor should be examined.
Author response: This was mentioned in the Discussion as a potential indirect sign of uterine dehiscence, citing reference [28].

Reviewer comment: Practical points should be summarized.
Author response: We added a bullet-style summary of clinical implications and recommendations at the end of the Discussion section.

Sincerely,
Narjes Karmous
Competing Interests: No competing interests were disclosed. Close
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Respond or Comment

COMMENTS ON THIS REPORT

Author Response 23 Aug 2025

Narjes karmous, Department B of Obstetrics and Gynecology, Charles Nicolle Hospital, Tinis, Tunisia

23 Aug 2025

Author Response

Dear Phuc Nhon Nguyen,
We sincerely appreciate your constructive feedback. Your insightful comments have helped us refine and enhance the quality of our manuscript.

Reviewer comment: In introduction, the ... Continue reading Dear Phuc Nhon Nguyen,
We sincerely appreciate your constructive feedback. Your insightful comments have helped us refine and enhance the quality of our manuscript.

Reviewer comment: In introduction, the study should mention some etiologies of uterine rupture, even in rare cases of placenta accreta spectrum on unscarred uterus. PMCID: PMC9568723
Author response: We appreciate this suggestion. A sentence addressing rare etiologies of uterine rupture, including placenta accreta spectrum in unscarred uteri, has been added to the Introduction, with citation [6].

Reviewer comment: The inclusion criteria: “At least one previous uterine surgery” is necessary?
Author response: Thank you for your insightful comment. We acknowledge that our earlier wording may have created some confusion. To clarify: a history of uterine surgery was not required for inclusion in this study. Our aim was to analyze all cases of fortuitously discovered uterine rupture, regardless of uterine surgical history.
As such, the presence or absence of a uterine scar was not used as an inclusion criterion. What defined eligibility was the asymptomatic nature of the rupture and its intraoperative or immediate postpartum discovery, combined with complete medical documentation. Both scarred and unscarred uteri were represented in our cohort.
We have updated the Materials and Methods section accordingly to ensure clarity and consistency with this inclusion approach.

Reviewer comment: A study flowchart with inclusion/exclusion cases should be added.
Author response: A flowchart has been included as Figure 1 to illustrate the inclusion and exclusion process clearly.

Reviewer comment : Maternal weight < 68kg is a protective factor? Could the authors please explain the relationship between maternal weight and uterine rupture? The neonatal weight may be more significant?
Author response : This point has been expanded in the Discussion, with added references [21–26] explaining the physiopathological links between obesity, uterine healing, and rupture. The role of neonatal weight is also discussed.

Reviewer comment : Blood loss and blood transfusion should be presented additionally as median [IQR].
Author response: We have revised Table 3 to present blood loss and transfusion data as median [IQR], in line with reviewer recommendations.

Reviewer comment: Definition of important variable should be added. For example: complete/incomplete UR.
Author response: Definitions of 'complete' and 'incomplete' uterine rupture have been added to the Methods section under the 'Definitions' subsection.

Reviewer comment: BMI should be represented instead of separate weight and height.
Author response: We replaced separate weight and height with BMI throughout the manuscript and added BMI statistics in Table 2.

Reviewer comment: The small sample size made the CI of multivariate logistic regression too large. This is confused.
Author response: We agree. This limitation is acknowledged explicitly in the Methods and Discussion sections.

Reviewer comment: Please discuss why the period 2014–2017 related to increasing number of UR cases?
Author response: We provided an explanation in the Discussion, linking the peak in 2017 to institutional practices and changes in intraoperative exploration and documentation.

Reviewer comment: In discussion, some other etiologies of intraabdominal hemorrhage in pregnancy should be also noted as well as role of imaging modalities such as ultrasound.
Author response: These aspects have been discussed in the revised Discussion, with references [17,18,19].

Reviewer comment: Pulmonary embolism complication should be prevented in cesarean with severe blood loss.
Author response: We agree. The importance of thromboprophylaxis has been added to the Discussion, citing reference [29].

Reviewer comment: Please discuss the role of cardiotocography in monitoring labor and detecting UR.
Author response: The role of CTG as an early indicator of uterine rupture has been included in the Discussion with appropriate reference [27].

Reviewer comment: Change of fetal head's position during labor should be examined.
Author response: This was mentioned in the Discussion as a potential indirect sign of uterine dehiscence, citing reference [28].

Reviewer comment: Practical points should be summarized.
Author response: We added a bullet-style summary of clinical implications and recommendations at the end of the Discussion section.

Sincerely,
Narjes Karmous
Dear Phuc Nhon Nguyen,
We sincerely appreciate your constructive feedback. Your insightful comments have helped us refine and enhance the quality of our manuscript.

Reviewer comment: In introduction, the study should mention some etiologies of uterine rupture, even in rare cases of placenta accreta spectrum on unscarred uterus. PMCID: PMC9568723
Author response: We appreciate this suggestion. A sentence addressing rare etiologies of uterine rupture, including placenta accreta spectrum in unscarred uteri, has been added to the Introduction, with citation [6].

Reviewer comment: The inclusion criteria: “At least one previous uterine surgery” is necessary?
Author response: Thank you for your insightful comment. We acknowledge that our earlier wording may have created some confusion. To clarify: a history of uterine surgery was not required for inclusion in this study. Our aim was to analyze all cases of fortuitously discovered uterine rupture, regardless of uterine surgical history.
As such, the presence or absence of a uterine scar was not used as an inclusion criterion. What defined eligibility was the asymptomatic nature of the rupture and its intraoperative or immediate postpartum discovery, combined with complete medical documentation. Both scarred and unscarred uteri were represented in our cohort.
We have updated the Materials and Methods section accordingly to ensure clarity and consistency with this inclusion approach.

Reviewer comment: A study flowchart with inclusion/exclusion cases should be added.
Author response: A flowchart has been included as Figure 1 to illustrate the inclusion and exclusion process clearly.

Reviewer comment : Maternal weight < 68kg is a protective factor? Could the authors please explain the relationship between maternal weight and uterine rupture? The neonatal weight may be more significant?
Author response : This point has been expanded in the Discussion, with added references [21–26] explaining the physiopathological links between obesity, uterine healing, and rupture. The role of neonatal weight is also discussed.

Reviewer comment : Blood loss and blood transfusion should be presented additionally as median [IQR].
Author response: We have revised Table 3 to present blood loss and transfusion data as median [IQR], in line with reviewer recommendations.

Reviewer comment: Definition of important variable should be added. For example: complete/incomplete UR.
Author response: Definitions of 'complete' and 'incomplete' uterine rupture have been added to the Methods section under the 'Definitions' subsection.

Reviewer comment: BMI should be represented instead of separate weight and height.
Author response: We replaced separate weight and height with BMI throughout the manuscript and added BMI statistics in Table 2.

Reviewer comment: The small sample size made the CI of multivariate logistic regression too large. This is confused.
Author response: We agree. This limitation is acknowledged explicitly in the Methods and Discussion sections.

Reviewer comment: Please discuss why the period 2014–2017 related to increasing number of UR cases?
Author response: We provided an explanation in the Discussion, linking the peak in 2017 to institutional practices and changes in intraoperative exploration and documentation.

Reviewer comment: In discussion, some other etiologies of intraabdominal hemorrhage in pregnancy should be also noted as well as role of imaging modalities such as ultrasound.
Author response: These aspects have been discussed in the revised Discussion, with references [17,18,19].

Reviewer comment: Pulmonary embolism complication should be prevented in cesarean with severe blood loss.
Author response: We agree. The importance of thromboprophylaxis has been added to the Discussion, citing reference [29].

Reviewer comment: Please discuss the role of cardiotocography in monitoring labor and detecting UR.
Author response: The role of CTG as an early indicator of uterine rupture has been included in the Discussion with appropriate reference [27].

Reviewer comment: Change of fetal head's position during labor should be examined.
Author response: This was mentioned in the Discussion as a potential indirect sign of uterine dehiscence, citing reference [28].

Reviewer comment: Practical points should be summarized.
Author response: We added a bullet-style summary of clinical implications and recommendations at the end of the Discussion section.

Sincerely,
Narjes Karmous
Competing Interests: No competing interests were disclosed. Close
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Version 3 (revision) 28 Aug 25
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Phuc Nhon Nguyen, Tu Du Hospital, Ho Chi Minh City, Vietnam
Mathew Olumide Adebisi, Afe Babalola University, Ado-Ekiti, Nigeria; Federal Teaching Hospital Ido-Ekiti (Ringgold ID: 605037), Ido Ekiti, Nigeria

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28 Aug 2025 | for Version 2

Phuc Nhon Nguyen, Tu Du Hospital, Ho Chi Minh City, Vietnam

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Approved

Thank you for your revision.
The paper is more improved in scientific points.

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Pregnancy pathology

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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28 Aug 2025 | for Version 2

Mathew Olumide Adebisi, Afe Babalola University, Ado-Ekiti, Ekiti, Nigeria; Obstetrics and Gynaecology, Federal Teaching Hospital Ido-Ekiti (Ringgold ID: 605037), Ido Ekiti, Ekiti, Nigeria

9 Views Cite this report Responses(0)

Approved

No further comments to make.

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Obstetrics and Gynaecology

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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25 Views

30 Jun 2025 | for Version 1

Mathew Olumide Adebisi, Afe Babalola University, Ado-Ekiti, Ekiti, Nigeria; Obstetrics and Gynaecology, Federal Teaching Hospital Ido-Ekiti (Ringgold ID: 605037), Ido Ekiti, Ekiti, Nigeria

25 Views Cite this report Responses(1)

Approved With Reservations

Ebeigbe PN et.al. (2005) - Ref. 1
Kadowa I. (2010)- Ref. 2
Fofie C and Baffoe P (2011) - Ref. 3

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

No
If applicable, is the statistical analysis and its interpretation appropriate?

Partly
Are all the source data underlying the results available to ensure full reproducibility?

Partly
Are the conclusions drawn adequately supported by the results?

No

References

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Obstetrics and Gynaecology

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Author Response

23 Aug 2025

Narjes karmous, Department B of Obstetrics and Gynecology, Charles Nicolle Hospital, Tinis, Tunisia

Dear Mathew Olumide Adebisi,
We sincerely appreciate your constructive feedback. Your insightful comments have helped us refine and enhance the quality of our manuscript.

Reviewer comment:
Abstract: Harmonize the aim and methodology regarding complete/incomplete UR.
Author response:
The Abstract has been revised to clearly state that both complete and incomplete forms of asymptomatic uterine rupture were included and analyzed in the study, ensuring coherence with the Methods and Results sections.

Reviewer comment:
Result (Abstract): Clarify “protective effect per kilogram decrease”.
Author response:
We revised the phrasing in the Abstract to “a protective effect per kilogram of maternal body weight” for clarity and statistical accuracy.

Reviewer comment:
Introduction is grossly inadequate. Literature on silent uterine rupture in developing countries should be reviewed. Suggested citations: Ref. 1–3.
Author response:
The Introduction has been substantially expanded and now includes data from studies conducted in Nigeria, Uganda, and Ghana, as suggested (references [7]–[9]). These studies help contextualize our findings within a broader regional framework of silent uterine rupture and its risk factors.

Reviewer comment:
Methodology unclear: Complete vs incomplete UR? Harmonize with Results.
Author response:
This issue has been addressed. We now explicitly state in the Methods that both complete and incomplete asymptomatic uterine ruptures were included in the study and compared across multiple variables. Terminology and consistency have been corrected throughout.

Reviewer comment:
Tables 2 and 4 mention labor variables, yet laboring women were excluded.
Author response:
We clarified that “asymptomatic” in our study refers to the absence of clinical signs of rupture (pain, bleeding, fetal distress), but not necessarily the absence of labor. Some patients had labor activity before cesarean delivery, which justifies the inclusion of labor variables. This is now clearly stated in the 'Study Population' and 'Discussion' sections.

Reviewer comment:
Is this a randomized study?
Author response:
No. We confirm this is a retrospective observational cohort study. This has been clearly stated in the revised Methodology section.

Reviewer comment:
Replace “parturient” with more appropriate term for asymptomatic cases.
Author response:
We have replaced the term “parturient” with “women with asymptomatic uterine rupture” or more specific language throughout the manuscript for precision and accuracy.

Reviewer comment:
Discussion contradicts exclusion criteria: Prolonged labor and gestational age as predictors?
Author response:
This has been clarified. Although these women had no rupture symptoms, many experienced labor prior to cesarean. This distinction has been made clear in the revised Discussion and Methods sections.

Reviewer comment:
Conclusion not supported by results. Revise accordingly.
Author response:
We have revised the Conclusion to focus strictly on statistically supported findings: prolonged labor and maternal weight <68 kg as independent predictors of complete rupture. Speculative elements were removed.

Reviewer comment:
References: more literature needed if Introduction is revised.
Author response:
We have included all the suggested references and added several recent publications to strengthen the Introduction and Discussion.

Reviewer comment:
Are sufficient details of methods and analysis provided to allow replication by others? → No
Author response:
The Methods section has been substantially revised to improve clarity and reproducibility. It now includes more precise definitions of study population, variables, criteria, and analysis thresholds.

Reviewer comment:
Are the conclusions drawn adequately supported by the results? → No
Author response:
The conclusions have been adjusted to align fully with the results. We now only report findings that were statistically demonstrated and explicitly acknowledge study limitations.

Sincerely,
Narjes Karmous

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No competing interests were disclosed.

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Reviewer Report

24 Views

25 Jun 2025 | for Version 1

Phuc Nhon Nguyen, Tu Du Hospital, Ho Chi Minh City, Vietnam

24 Views Cite this report Responses(1)

Approved With Reservations

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

I cannot comment. A qualified statistician is required.
Are all the source data underlying the results available to ensure full reproducibility?

Partly
Are the conclusions drawn adequately supported by the results?

Partly

References

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Pregnancy pathology

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Author Response

23 Aug 2025

Narjes karmous, Department B of Obstetrics and Gynecology, Charles Nicolle Hospital, Tinis, Tunisia

Dear Phuc Nhon Nguyen,
We sincerely appreciate your constructive feedback. Your insightful comments have helped us refine and enhance the quality of our manuscript.

Reviewer comment: In introduction, the study should mention some etiologies of uterine rupture, even in rare cases of placenta accreta spectrum on unscarred uterus. PMCID: PMC9568723
Author response: We appreciate this suggestion. A sentence addressing rare etiologies of uterine rupture, including placenta accreta spectrum in unscarred uteri, has been added to the Introduction, with citation [6].

Reviewer comment: The inclusion criteria: “At least one previous uterine surgery” is necessary?
Author response: Thank you for your insightful comment. We acknowledge that our earlier wording may have created some confusion. To clarify: a history of uterine surgery was not required for inclusion in this study. Our aim was to analyze all cases of fortuitously discovered uterine rupture, regardless of uterine surgical history.
As such, the presence or absence of a uterine scar was not used as an inclusion criterion. What defined eligibility was the asymptomatic nature of the rupture and its intraoperative or immediate postpartum discovery, combined with complete medical documentation. Both scarred and unscarred uteri were represented in our cohort.
We have updated the Materials and Methods section accordingly to ensure clarity and consistency with this inclusion approach.

Reviewer comment: A study flowchart with inclusion/exclusion cases should be added.
Author response: A flowchart has been included as Figure 1 to illustrate the inclusion and exclusion process clearly.

Reviewer comment : Maternal weight < 68kg is a protective factor? Could the authors please explain the relationship between maternal weight and uterine rupture? The neonatal weight may be more significant?
Author response : This point has been expanded in the Discussion, with added references [21–26] explaining the physiopathological links between obesity, uterine healing, and rupture. The role of neonatal weight is also discussed.

Reviewer comment : Blood loss and blood transfusion should be presented additionally as median [IQR].
Author response: We have revised Table 3 to present blood loss and transfusion data as median [IQR], in line with reviewer recommendations.

Reviewer comment: Definition of important variable should be added. For example: complete/incomplete UR.
Author response: Definitions of 'complete' and 'incomplete' uterine rupture have been added to the Methods section under the 'Definitions' subsection.

Reviewer comment: BMI should be represented instead of separate weight and height.
Author response: We replaced separate weight and height with BMI throughout the manuscript and added BMI statistics in Table 2.

Reviewer comment: The small sample size made the CI of multivariate logistic regression too large. This is confused.
Author response: We agree. This limitation is acknowledged explicitly in the Methods and Discussion sections.

Reviewer comment: Please discuss why the period 2014–2017 related to increasing number of UR cases?
Author response: We provided an explanation in the Discussion, linking the peak in 2017 to institutional practices and changes in intraoperative exploration and documentation.

Reviewer comment: In discussion, some other etiologies of intraabdominal hemorrhage in pregnancy should be also noted as well as role of imaging modalities such as ultrasound.
Author response: These aspects have been discussed in the revised Discussion, with references [17,18,19].

Reviewer comment: Pulmonary embolism complication should be prevented in cesarean with severe blood loss.
Author response: We agree. The importance of thromboprophylaxis has been added to the Discussion, citing reference [29].

Reviewer comment: Please discuss the role of cardiotocography in monitoring labor and detecting UR.
Author response: The role of CTG as an early indicator of uterine rupture has been included in the Discussion with appropriate reference [27].

Reviewer comment: Change of fetal head's position during labor should be examined.
Author response: This was mentioned in the Discussion as a potential indirect sign of uterine dehiscence, citing reference [28].

Reviewer comment: Practical points should be summarized.
Author response: We added a bullet-style summary of clinical implications and recommendations at the end of the Discussion section.

Sincerely,
Narjes Karmous

View more View less

Competing Interests

No competing interests were disclosed.

Alongside their report, reviewers assign a status to the article:

Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions

[1] 1. Ahmed DM, Mengistu TS, Endalamaw AG: Incidence and factors associated with outcomes of uterine rupture among women delivered at Felegehiwot referral hospital, Bahir Dar, Ethiopia: cross sectional study. BMC Pregnancy Childbirth. 2018 Nov 16; 18: 447. PubMed Abstract | Publisher Full Text | Free Full Text

[2] 2. Zine S, Abed A, Sfar E, et al.: Uterine rupture during labor. Report of 106 cases at the Maternity Center of Tunis (Tunisia). Rev. Fr. Gynecol. Obstet. 1995 Mar; 90(3): 166, 169–173. PubMed Abstract

[3] 3. Yang H, Zhao Y, Tu J, et al.: Clinical analysis of incomplete rupture of the uterus secondary to previous cesarean section. Open Med (Wars). 2024 Apr 1; 19(1): 20240927. PubMed Abstract | Publisher Full Text | Free Full Text

[4] 4. Guiliano M, Closset E, Therby D, et al.: Signs, symptoms and complications of complete and partial uterine ruptures during pregnancy and delivery. Eur. J. Obstet. Gynecol. Reprod. Biol. 2014 Aug; 179: 130–134. PubMed Abstract | Publisher Full Text

[5] 5. Ahmadi F, Siahbazi S, Akhbari F: Incomplete Cesarean Scar Rupture. J. Reprod. Infertil. 2013; 14(1): 43–45. PubMed Abstract

[6] 6. Rybak A, Levy C, Ouldali N, et al.: Dynamics of Antibiotic Resistance of Streptococcus pneumoniae in France: A Pediatric Prospective Nasopharyngeal Carriage Study from 2001 to 2022. Antibiotics. 2023 Jun; 12(6): 1020. PubMed Abstract | Publisher Full Text | Free Full Text

[7] 7. Hasan MM, Kamruzzaman M, Anik KS, et al.: Dengue Encephalopathy, its Presentations and Outcome, A Study on 200 Dengue Encephalopathy Patients in Tertiary Level Hospitals in Bangladesh. Sch. J. App. Med. Sci. 2024 Nov 11; 12(11): 1550–1557. Publisher Full Text

[8] 8. Xiao J, Zhang C, Zhang Y, et al.: Ultrasonic manifestations and clinical analysis of 25 uterine rupture cases. J. Obstet. Gynaecol. Res. 2021 Apr; 47(4): 1397–1408. PubMed Abstract | Publisher Full Text

[9] 9. Savukyne E, Bykovaite-Stankeviciene R, Machtejeviene E, et al.: Symptomatic Uterine Rupture: A Fifteen Year Review. Medicina (Kaunas). 2020 Oct 29; 56(11): 574. PubMed Abstract | Publisher Full Text | Free Full Text

[10] 10. Giampaolino P, De Rosa N, Morra I, et al.: Management of Cesarean Scar Pregnancy: A Single-Institution Retrospective Review. Biomed. Res. Int. 2018; 2018(1): 6486407.

[11] 11. Zermano S, Seminara G, Parisi N, et al.: Prenatal Detection and Conservative Management of Uterine Scar Dehiscence in Patient with Previous Uterine Rupture and Multiple Surgeries-A Case Report. Healthcare (Basel). 2024 May 10; 12(10): 988. PubMed Abstract | Publisher Full Text | Free Full Text

[12] 12. Hoffman MK, Grant GH: Induction of labor in women with a prior cesarean delivery. Semin. Perinatol. 2015 Oct 1; 39(6): 471–474. Publisher Full Text

[13] 13. Li XF, Wu J, Zhou Y, et al.: Clinical analysis of 12 cases of spontaneous uterine rupture caused by placenta percreta. Zhonghua Fu Chan Ke Za Zhi. 2020 Oct 25; 55(10): 691–696. PubMed Abstract | Publisher Full Text

[14] 14. Setubal A, Alves J, Osório F, et al.: Treatment for Uterine Isthmocele, A Pouchlike Defect at the Site of a Cesarean Section Scar. J. Minim. Invasive Gynecol. 2018 Jan; 25(1): 38–46. PubMed Abstract | Publisher Full Text

[15] 15. Karmous N, Ghrab S, Masmoudi A, et al.: Silent danger: risk factors and outcomes of fortuitously discovered uterine rupture – a 41-case cohort study. [Dataset]. Harvard Dataverse. 2025.

[16] 16. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J. Clin. Epidemiol. 2008 Apr; 61(4): 344–349. Publisher Full Text

Silent Danger: Risk Factors and Outcomes of Fortuitously Discovered Uterine Rupture – A 41-Case Cohort Study

Abstract

Background

Methods

Results

Conclusion

Keywords

Introduction

Methods

Study design and setting

Study population

Variables

Statistical analysis

Ethical considerations

Results

Table 1. Annual distribution of asymptomatic uterine ruptures (UR), total of UR, and total births (2014–2024).

Figure 1. Trends in asymptomatic Uterine Rupture (UR) prevalence (2014-2024): proportion of asymptomatic cases among total UR at Charles Nicolle Hospital.

Table 2. Descriptive statistics of parturients demographics and labor parameters.

Table 3. Uterine Rupture (UR) type, maternal and neonatal outcomes.

Table 4. Univariate analysis comparing complete Uterine Ruptures (UR) cases and incomplete UR cases.

Table 5. Multivariate analysis for identification of predictors of complete Uterine Rupture (UR) outcomes.

Discussion

Study strengths and limitations

Recommendations

Conclusions

Ethical considerations

Consent to participate

Data availability statement

Extended data

Reporting guidelines

References

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