RUPTURE OF THE UTERUS

GENERAL CONSIDERATIONS
Rupture of the pregnant uterus is a potential obstetric
catastrophe and a major cause of maternal death. The incidence of
uterine rupture is reported between 1:1148 and 1: 2250 deliveries1.

DEFINITION
Anatomical, etiological or clinical definitions of uterine rupture
are employed and add to the confusion surrounding nomenclature 7.
The anatomical definition suggests that a true or complete
rupture extends through the uterine serosa, and other forms are occult
or incomplete 7.
An etiological school classifies uterine rupture as spontaneous,
traumatic or scar 7.
The most commonly held definition of uterine rupture is clinical
and although somewhat subjective, acknowledges the high rate of
asymptomatic dehiscence during a successful vaginal birth after a
previous cesarean. This definition was described by Plauche: as those
cases of complete separation of the wall of pregnant uterus with or
without expulsion of the fetus that endanger the life f the mother and/
or fetus 7.

CLASSIFICATION OF UTERINE RUPTURE

Complete rupture includes the entire thickness of the uterine wall
and, in most cases, the overlying serosal peritoneum (broad ligament)
1, 2, 3
. Occult or incomplete rupture is a term usually reserved for
dehiscence of a uterine incision from previous surgery, in which the
1, 3
visceral peritoneum remains intact . Such defects are usually
asymptomatic unless converted to complete rupture during the course
of pregnancy or labor1. The complete variety appears to be more
dangerous of the two varieties6, 7.

INCIDENCE
Rupture of a previous caesarean section scar is the most
2, 3, 4, 7
common-est cause of uterine rupture in the developed world .A
previous lower segment scar carries a 0.25-0.5% risk of rupture,
compared with a vertical (classical) scar where the risk of rupture is 3-
4%. Previous scar rupture carries a much higher risk of recurrent
rupture2.
The rate of true uterine rupture with one prior low-transverse
scar has been reported by ACOG to be between 0.2 and 1.5 percent
(one of 67 to 500 women). Other studies involving more than 130,000
women undergoing a trial of labor for VBAC report rates that average
0.6 percent (approximately one of every 170 women) 6.

In women with two or more prior cesareans, the rate of rupture

rises as high as 3.9 percent (one of 26 women). Such rates are
threefold to fivefold higher than rates in women having only one prior
cesarean delivery. A history of a successful prior vaginal delivery was
found to reduce the risk of rupture from 1.1 to 0.2 percent (one of 511
women). Among less common incisions, classic and T-shaped uterine
incisions are reported to rupture in 4 to 9 percent of cases, while low-
vertical incisions carry a rupture risk of 1 to 7 percent. In comparison,
rupture of an unscarred uterus occurs in one of 8,000 to 17,000
deliveries 6.

RISK FACTORS CAUSING UTERINE RUPTURE

 Risk factors for uterine rupture include history of prior
hysterotomy (cesarean section, myomectomy, metroplasty, corneal
resection), trauma (motor vehicle accident, rotational forceps,
extension of cervical lacerations), uterine over distention
(hydramnions, multiple gestation, macrosomia), uterine anomalies,
placenta percreta, and choriocarcinoma1,2, 4, 7.
Rupture usually occurs during the course of labour. One notable
exception is scars from a classis cesarean section (or hysterotomy),
one-third of which rupture during the third semester before the onset
labour. Other causes of rupture without labor are placenta percreta,
invasive mole, choriocarcinoma, and cornual pregnancy1.
Complete rupture may classified as traumatic or spontaneous.
Traumatic rupture occurs most commonly as a result of motor vehicle
accident, improper administration of an oxytocic agent1, 4, or an inept
attempt at operative vaginal delivery. Breech extraction through an
incompletely dilated cervix is the type of operative vaginal delivery
most likely to produce uterine rupture. Other maneuvers that impose
risk of rupture are internal podalic version and extraction, difficult
forceps delivery4, destructive operation, and maneuvers to relieve
shoulder dystocia. Tumultuos labor, excessive fundal pressure or
violent bearing-down efforts, and neglected obstructive labor may also
be responsible for rupture of the uterus. Causes of obstructive labor
include contracted pelvis, fetal macrosomia, brow or face presentation,
hydrocephalus, or tumors involving the birth canal. Direct abdominal
trauma is a rare cause of rupture, but it is occasionally encountered in
automobile accident, particularly if the victim was wearing a lap-type
seat belt1.
Spontaneous rupture is somewhat of a misnomer because most
such patients either have uterine scar or give a history consistent with
a previous trauma that may have resulted in permanent uterine
damage. Previous uterine surgery includes both classic and low
cervical section, intramural or submucous myomectomy, resection of
the uterine cornu, metroplasty, and trachelectomy. Other operative
procedures that may have damaged the uterus are vigorous curettage,
induced abortion, and manual removal of the placenta. In contrast,
some patients give no history of surgery but may be suspected of
having a weakened uterus because of multiparity 1, 4
. Oxytocin
stimulation of labor has been commonly associated with uterine
rupture especially in women of high parity 4. Other uterotonic agents
are also implicated. Uterine rupture has resulted from labor induction
with prostaglandin E2 gel or E1 vaginal tablets4. Such patients are
particularly at risk if they have an old lateral cervical laceration that
could extend to involve uterine artery 1. Compared with women who
had repeated C-sections without labor, women who were induced
without prostaglandin were nearly 5 times more likely to have a uterine
rupture, and women with prostaglandin induction were 15 times more
likely to have uterine rupture 5. For these reasons, all uterotonic agents
should be given with great caution to induce or stimulate labor in
women of high parity4. Similarly, in women of high parity, a trial of
labor with suspected cephalopelvic disproportion, high cephalic
presentation, or abnormal presentation such as a brow must be
undertaken with caution4.

CLINICAL FINDINGS
There are no reliable signs of impending uterine rupture although
the sudden appearance of gross hematuria is suggestive 1. Rupture of
uterus during labour is more dangerous than that occurring in
pregnancy because shock is greater and infection is almost inevitable 8,
9
.
If rupture occurs before delivery, signs and symptoms usually
include abdominal pain, vaginal bleeding, fetal heart rate abnormality
and easy palpitation of fetal parts through the abdominal wall as the
fetus is partially or completely extruded from the uterus2.
If rupture is not diagnosed until after delivery, it may be
suspected by signs of collapse or hypovolemic shock associated with
some vaginal bleeding and lower abdominal pain. Shoulder tip pain
from haemoperitoneum may be present2.
Prior to the onset of labor, a beginning rupture may produce local
pain and tenderness associated with increased uterine irritability and,
in some cases, a small amount of vaginal bleeding. Premature labor
may follow. As the extent of the uterus increases, there will be more
pain, more bleeding and perhaps sign of hypovolemic shock.
Exsanguination prior surgery is unlikely because of the reduced
vascularity of scar tissue, but the placenta may be completely
separated and the fetus extruded partially or completely into the
abdominal cavity1.
Rupture of a low cervical scar usually occurs during labor. Clearly
identifiable signs and symptoms are often lacking. However 78% of
patients will have evidence of fetal distress prior to the onset of pain or
bleeding. Thus it is quite possible that labor will progress to the vaginal
birth of an unaffected infant. Even so, the rupture may lacerate a
uterine artery, producing exsanguinations, or the fetus may be
extruded into the abdominal cavity. If the defect is palpated in the
lower uterine segment following vaginal delivery, laparotomy may be
necessary to access the damage1. Laparotomy is mandatory if
continuing hemorrhage is present1, 2.
The classic findings of spontaneous rupture during labor are
suprapubic pain and tenderness, cessation of uterine contraction,
disappearance of fetal heart tones, recession of the presenting part,
and vaginal hemorrhage- followed by the signs and symptoms of
hypovolemic shock and hemoperitoneum. Ultrasound examination
might confirm an abnormal fetal position or extension of the fetal
extremities. Hemoperitoneum can sometimes be seen on ultrasound 1.
Uterine rupture due to obstetric trauma is usually not diagnosed
until after the infants birth. The clinical picture depends on the site
and extent of rupture. Unfortunately, valuable time is often lost
because the rupture was not diagnosed at the time of the initial
examination. Whenever a newly delivered patient exhibits persistent
bleeding or shock, the uterus must be carefully reexamined for signs of
a rupture that may have been difficult to palpate because of the soft,
irregular tissue surface. Whenever an operative delivery is performed-
especially if the past history includes events or problems that increase
the likelihood of uterine rupture- the initial examination of the uterus
and birth canal must be diligent1.
Hysterectomy is the preferred treatment for the most cases of
complete uterine rupture1, 2. Either total hysterectomy or subtotal
operation can be employed, depending on the site of rupture and
patients condition. The most difficult cases are lateral rupture
involving the lower uterine segment and a uterine artery with
hemorrhage and hematome formation obscuring the operative field.
These patients may be better saved by ligation of the ipsilateral
hypogastric artery for hemostasis, thus avoiding the risk of ureteral
drainage by blind suturing at the base of the broad ligament. If there is
a question of ureteral occlusion by the suture, it is best to perform
cystotomy to observe the bilateral appearance of an intravenously
injected dye such as indigo carmine. If doubts still exist, a retrograde
ureteral catheter should be passed upward through the cystostomy
wound1.
If child bearing is important and the risk both short and long term
are acceptable to the patient, rupture repair can be attempted. Many
ruptures can be repaired. Successful pregnancies have been reported
following uterine repair; however, in this series repeat rupture occurred
in approximately 20% of pregnancies1.
In long neglected and badly infected cases, survival may be
improved by limiting the surgical procedure to repair of the rupture and
by the antibiotic therapy1.
Occult rupture by the lower uterine segment encountered at
repeat section maw be treated by freshening the wound edges and
secondary repair, but the newly repaired incision will probably be
weak1.

DIAGNOSIS
Prior to circulatory collapse from hemorrhage, the symptoms and
physical findings may appear bizarre unless the possibility of uterine
rupture is kept in mind 3.
For example, hemoperitoneum from a ruptured uterus may result
in irritation of the diaphragm with pain referred to the chest-leading
one to the other diagnosis of pulmonary or amnionic fluid embolism
instead of uterine rupture3.
Few woman experience cessation of contractions following
uterine rupture, and the use of intrauterine pressure catheters (IUPC)
3, 6
has not been shown to assist reliably in the diagnosis . Further more,
uterine contraction pattern are unreliable for detecting rupture and
often appear normal. Even ruptures monitored with an IUPC often fail
to show a loss of uterine tone or contractile pattern after uterine
rupture 6.
Fetal distress has been found to be the most reliable presenting
clinical symptom. Prolonged, late, or variable decelerations and
bradycardia seen on fetal heart rate monitoring are the most common
6
and often the only manifestations of uterine rupture . The most
common electronic fetal monitoring finding tends to be sudden, severe
heart rate decelerations that may evolve into late decelerations,
bradycardia, and undetectable fetal heart action. Ridgeway and co-
workers (2004) found that bradycardia was the only finding that
differentiated uterine rupture from a successful trial of labor 3. One
author concluded that if a prolonged deceleration to 90 beats per
minute or less lasting for more than one minute occurs during a trial
labor, you should perform an immediate cesarean operation. Do not
waste time performing an ultrasound examination or counting
instruments. In many such cases, you will find no uterine rupture, but
in other cases, you will have saved a babys life. In one study the best
outcomes were noted when surgical delivery was accomplished within
17 minutes from the onset of fetal distress on electronic fetal heart
rate monitors6.
In a minority of women, the appearance of uterine rupture is
identical to that of placental abruption. In most, however, there is
remarkably little appreciable pain or tenderness. Also, because most
women in labor are treated for discomfort with either narcotics or
lumbar epidural analgesia, pain and tenderness may not be readily
apparent. The condition usually becomes evident because of signs of
fetal distress and occasionally because of maternal hypovolemia from
concealed hemorrhage3.
In some cases in which the fetal presenting parts has entered the
pelvis with labor, loss of station may be detected by pelvic
examination. If the fetus is partly or totally extruded from the site of
uterine rupture, abdominal palpitation or vaginal examination may be
helpful to identify the presenting part, which will have moved away
from pelvic inlet. A firm, contracted uterus may be felt along side the
fetus3.

MANAGEMENT
Treatment is surgical-either hysterectomy or repair.
Hysterectomy is preferred if the patient does not desire further child
bearing, is of high parity or in poor condition. Notwithstanding the 4-
10% recurrence rate of uterine rupture, surgical repair is a reasonable
option in younger, stable patient with an uncomplicated rupture. It has
been suggested that repeat cesarean section be performed at 36
weeks or upon documentation of fetal lung maturity in patients
pregnant after a previous uterine rupture 7.

PREVENTION
Most of the causes of uterine rupture can be avoided by good
obstetric assessment and technique. Probably the most common error
in judgment leading to rupture is underestimation of fetal weight,
resulting in traumatic delivery. The most common technical error is the
poorly supervised administration of oxytocin during labor. A frequent
deficiency in operative technique is poor closure of cesarean section
incision1.

COMPLICATION
The complications of ruptured uterus are hemorrhage, shock,
postoperative infection, ureteral damage, thrombophlebitis, amniotic
fliud embolus, disseminated intravascular coagulation, pituitary failure,
and death. If the patient survives, infertility or sterility may result1.
Patients who have massive haemorrhage may develop renal liver
or pituitary failure and will generally require transfer to renal or
intensive care units. Improvements in intensive care have led to longer
survival but some patients have succumb to adult respiratory distress
syndrome2.
Long-term sequelae include renal failure and Sheehans
syndrome (avascular necrosis of the pituitary gland characterized by
failure of lactation followed by amenorrhoea, hypothyroidism and
adrenocortical insufficiency) 2.
PROGNOSIS
The maternal mortality rate is 4,2%. The perinatal mortality rate
is approximately 46%1.
Outcome seems to be worst when a fetus is extruded from the
uterus into the peritoneal cavity, probably as a result of more
extensive disruption of the maternal-plasental circulation, which can
lead to fetal asphyxia and potential long term neurologic impairment 6.
Fetal condition depends on how much plasenta is intact, although likely
to decreases over minutes. If the fetus is alive at the time of rupture,
the only chance of continued survival is afforded by immediate
delivery, most often by laparotomy. Otherwise, hypoxia from both
plasental separation and maternal hypovolemia is inavitabe. If rupture
is followed by total plasental separation, then very few infants will be
salvaged3.
The maternal prognosis is much better and rupture will is seldom
fatal. If untreated however, most women die from hemorrhage or, less
often, later from infection3.

REFERENCES
1. C.S. Claydon, MD, & Martin L. Pernoll, MD : Third-Trimester Vaginal
Bleeding : Current Obstetric & Gynecologic Diagnosis & Treatment
9th edition 2003 : 365:67.
2. William Thompson, M. Ann Harper : Postpartum hemorrhage and
abnormalities of the third stage of labour : Turnbulls Obstetrics 3 rd
edition 2002 : 629:30.
3. F. Gary Cunningham, Kenneth J. Leveno et al. : Prior Cesarean
Delivery ; Chap 26 : Williams Obstetrics 22nd edition 2005 : 615:16.
4 F. Gary Cunningham, Kenneth J. Leveno et al. : Obstetrical
Hemorrhage ; Chap 35 : Williams Obstetrics 22 nd edition 2005 :
837:39.
5. AHQR, Research Activities. Risk of uterine rupture during labor is
higher for women with prior cesarean delivery. http://www.ahrq.gov/
[11/03/06]
6. Kevin S. Toppenberg, M.D., William A Block, JR., M.D. American
Family Physician Vol.66/No.5 (September 1, 2002), Uterine Rupture :
What family Physicians Need to Know. www.aafp.org.htm. [11/03/06]
7. Edward H. Park/ Benjamin P. Sachs. Postpartum hemorrhage and
other problems of the third stage ; Chap 69 :High Risk Management
Options 2nd edition 2001 : 1241:42