UTERINE RUPTURE Sandeep Das 4 th year MBBS Gauhati Medical College and Hospital Guwahati, Assam.
UTERINE RUPTURESandeep Das4th year MBBSGauhati Medical College and HospitalGuwahati, Assam.
DEFINITION• Uterine rupture
It is defined as “dissolution in the continuity of uterine wall any time after 28 weeks of gestation, with or without expulsion of the fetus.”
• Uterine scar dehiscenceIt is defined as “separation of walls of the uterus along the line of the previous scar.”
INCIDENCE• 0.07/1000 births in developed
countries• 0.62/1000 births in India
TRADITIONAL CLASSIFICATION1. Complete rupture
All the layers of the uterus, including the peritoneum, are torn.
Uterine contents escape into the uterine cavity.
Usually results in fetal death.
2. Incomplete Rupture Visceral peritoneum is intact. Usually the fetus lies in the uterine
cavity
TRADITIONAL CLASSIFICATION
ANATOMICAL CLASSIFICATION• Lower segment rupture• Rupture of corpus/fundus (upper segment) of uterus
ETIOLOGICAL CLASSIFICATION1. Spontaneous rupture2. Scar rupture3. Iatrogenic (Traumatic) rupture
ETIOLOGICAL CLASSIFICATION (CAUSES)
During pregnancy During labor
Spontaneous Rupture
1. Past history of dilatation and curettage operation/manual removal of placenta
2. Grand multiparity3. Couvelaire uterus4. Congenital malformations
of the uterus5. Congenital fetal
abnormalities6. Morbidly adherent
placenta7. Collagen disorders
1. Obstructed labor2. Multiparity3. Oxytocics and
prostaglandins
ETIOLOGICAL CLASSIFICATION (CAUSES)
During pregnancy
During labor
Scar rupture 1. Classical caesarean (hysterotomy) scar
1. Classical caesarean (hysterotomy) scar
Iatrogenic rupture
1. Injudicious and unmonitored use of oxytocics on pregnant uterus
2. Injudicious use of prostaglandins on a pregnant uterus
3. Difficult and forced external cephalic version, especially if performed under general anaesthesia
4. Abdominal blunt trauma
1. Internal podalic version and breech extraction especially in cases of obstructed labor
2. Destructive surgeries on fetus
3. Manual removal of placenta
4. Difficult or rotational forceps delivery in obstructed labor
5. Injudicious and unmonitored oxytocin infusion for acceleration of labor
PATHOGENESIS
Pathological retraction ring (Bandl’s ring) occurs, strong uterine contractions without
cervical dilatation
Causative factors
“Tearing” sensation
Incomplete rupture
Complete rupture
Rupture of• Endometrium• Myometrium
Rupture of• Endometrium• Myometrium• Perimetrium
Uterine contraction stops
Swelling of the abdomen :• Retracted uterus• Extrauterine fetus
Localised tenderness and
persisting aching pain over the area
of the uterine segment
Bleeding into the peritoneal cavity
Haemorrhage from torn uterine arteries
Bleeding into the vagina
Decreased blood volume
Disturbance of vitals (BP, heart rate,
respiratory rate)
Death of mother and fetus
DIAGNOSTIC TRIAD FOR UTERINE RUPTURE1. Painful third trimester bleeding
with unstable vitals2. Loss of fetal heart sounds3. Hot, dry vagina on vaginal
examination
DIFFERENTIAL DIAGNOSIS1. Abruptio placentae2. Amniotic fluid embolism3. Other causes of acute abdomen
PREVENTION1. Early diagnosis and management of
cephalo-pelvic disproportion (CPD), malpresentations and other factors leading to obstructed labor.
2. Proper selection of cases for vaginal birth after caesarean deliveries (VBAC)
3. Careful selection of cases and careful watch during oxytocin infusion either for induction or augmentation of labor and to avoid their non-judicious use, especially in multiparas
4. Avoid all uterine manipulations if the liquor has drained away.
PREVENTION(CONTD.)5. Instrumental delivery should be performed
only after all the pre-requisites are fulfilled and on no account should forceps be applied prior to complete cervical dilatation.
6. In cases of obstructed labor or threatened rupture, immediate caesarean delivery should be performed and all intrauterine manipulations avoided.
7. Hospital delivery for high-risk cases.8. Forced and difficult external cephalic
version especially under general anaesthesia should be avoided.
PREVENTION(CONTD.)9. Undue delay in the progress of labor in a
multipara with previous uneventful delivery should be taken seriously and couse should be looked into.
10. Manual removal of a morbidly adherent placenta should be performed gently and carefully by an experienced obstetrician.
TREATMENT• Resuscitation with adequate
hydration, hemaccel and blood transfusion.
• Laparotomy as a definitive treatment. The treatment modalities are-• Hysterectomy• Repair.