Rupture of the uterus

RUPTURE OF THE UTERUS

FAHAD ZAKWAN

INTRODUCTION Uterine rupture is a grave obstetric complication.

Associated with high

Maternal mortality

Perinatal mortality

It may occur

Labour

Delivery

Pregnancy – lesser extent

Every second of time is vital for survival

Incidence of uterus rupture

•0.05% for all pregnancies

•0.8% after previous lower segment caesarean section(LSCS)

• >5% after classical caesarean section

• Scar dehiscence has an incidence of 0.6% in pregnancies with previous C/S and has a more favourable outcome for both mother and fetus than does uterine rupture.

Definition•Separation of the muscular wall of the uterus

•Usually occurs during labor

•Occasionally happen during the later weeks of pregnancy

Uterine rupture

Total disruption of the wall of the pregnant uterus with or without extrusion of its contents

Uterine scar dehiscence

Herniation of intact amniotic membrane into an existing uterine scar

Uterine scar rupture

Separation of the scar along its entire length often with involvement of the amniotic membranes

•Uterine dehiscence involves myometrial separation at a site of uterine scar from previous surgery, and the uterine serosa remains intact.

•Uterine rupture, on the other hand, involves the entire thickness of the uterine wall, resulting in communication between the uterus and peritoneal cavities.

•Uterine rupture: separation of an old uterine incision with rupture of the fetal membranes so that the uterine cavity and the peritoneal cavity communicate directly.

•Dehiscence of a scar does not involve rupture of the fetal membranes.

•Rupture is more acute while dehiscence is more gradual.

CAUSESDuring pregnancy

•weak scar after previous operations on the uterus

•History of cesarean section (VBAC - vaginal birth after c-section)

•myomectomy

• excision of a uterine septum

•previous perforation of uterus(D&C, hysteroscopy, forceps delivery

During labor:•uterine hyper-stimulation(oxytocin with pitocin induction

or augmentation of labor)

•obstructed labor(macrosomia, feopelvic dispropotion)

• intrauterine manipulation(internal version, manual removal of an adherent placenta)

• forcible dilatation(cervical tear)

• a weak scar(C-section or other operations)

TYPES•Incomplete rupture•complete rupture

depending on whether the peritoneal coat is torn through or

not

Traditional classificationComplete

▪The visceral peritoneum overlying the uterus is disrupted

Incomplete

▪Overlying peritoneum is intact

Not clinical relevant

Etiological classification

Spontaneous rupture

Scar rupture

Traumatic rupture

Spontaneous rupture

• Feto-pelvic disproportion• Congenital uterine anomalies• Soft tissue obstruction

Scar rupture

• Previous uterine surgery• Previous uterine perforation

PREDISPOSING FACTORS

Traumatic/ iatrogenic ruptureSurgical intervention

Internal versionForceps deliveryManual removal of placentaDestructive operations

Medical interventionUterine stimulation

Symptoms and signs•Abdominal pain and tenderness

• Shock

•Vaginal bleeding

•Undetectable fetal heart beat

•Palpable fetal body parts

•Cessation of contractions

• Signs of intraperitoneal bleeding

• The most common sign is the sudden appearance of fetal distress during labor

•The signs and symptoms of uterine rupture in patients with a previous scarred uterus differ from patients without a uterine scar.•The most common sign in woman with uterine scar is lower abdominal

•In women without a scar, shock is the common sign, followed by uterine abdominal pain, and easily palpable fetal

•Ultrasonography is probably the safest and most useful imaging technique during pregnancy.

•sonographic findings associated with includes:• Extra peritoneal hematoma• intrauterine blood• free peritoneal blood• empty uterus• gestational sac above the uterus• large uterus mass with gas bubbles

DIAGNOSIS

TREATMENT

•Principles for the treatment of uterine rupture includes:•Intensive resuscitation•Emergency laparotomy•Broad spectrum antibiotics•Adequate post operative care

Intensive resuscitation Correct hypovolaemia from…. Haemorrhage

Sepsis

Dehydration Intravenous broad spectrum antibiotics Cephalosporin + Metronidazole combination

Monitor to ensure adequate fluid and blood replacement

Blood volume expansion may worsen the bleeding from damaged vessel and

so the laparotomy should not be delay, once patient condition has improved

Surgical options Hysterectomy Treatment of choice except any other compelling reasons

to preserve the uterus

Total

Sub-total Rupture repair Occasionally one may be forced to repair

Repair with sterilization Not an attractive option

May be useful especially in unskilled hands

Outcome• Death from uterine rupture is not uncommon.

• Mortality appears to be higher in women who have an unscarred uterus and when the rupture occurs outside the hospital.

• Overall mortality: 15.9%

• Perinatal morbidity rate associated with uterine rupture ranges from 8-56%

Preventive measures

Antenatal careHigh risk casesOxytocicsPrevious caesarean sectionAugmentation of labour

NOTE!!!

•During trial of scar watch out for…….• Fetal heart abnormalities•Maternal tachycardia•Vague abdominal pain in between contractions• Suprapubic tenderness•Vaginal bleeding•Bladder tenesmus

DIAGNOSTIC CRITERIA FOR UTRINE RUPTURE

Painful late trimester bleeding

Loss of FHT

Inability to identify UCs

Thank you for your attention