Uterine rupture is a rare, but serious childbirth complication that can occur during vaginal birth. It causes a mother’s uterus to tear so her baby slips into her abdomen. This can cause severe bleeding in the mother and can suffocate the baby.
The wall of your uterus is made of soft tissue that expands to accommodate your growing baby during pregnancy. Usually, your uterus expands sufficiently, your baby is born, and your uterus shrinks back after your baby’s birth. In some cases, your uterus may rupture because of the pressure of your growing baby.
Uterine rupture is most common among pregnant women who previously delivered a baby via a cesarean section. When you undergo a cesarean section, your doctor cuts open your uterus to deliver your baby. A uterine rupture is most likely to occur along the scar line of previous cesarean deliveries.
There are two main types:
▪︎ Incomplete – where the peritoneum overlying the uterus is intact. In this case, the uterine contents remain within the uterus.
▪︎ Complete – the peritoneum is also torn, and the uterine contents can escape into the peritoneal cavity.
° A road traffic collision.
° Incorrect use of oxytocic agent.
° A poorly conducted attempt at operative vaginal delivery (typically breech extraction with an incompletely dilated cervix).
° (Operative hysteroscopy in the non-pregnant woman).
° Most patients have either had a caesarean section or a history of trauma that could have caused permanent damage.
° Patients may have no history of surgery but a weakened uterus due to multiparity, particularly if they have an old lateral cervical laceration.
A variety of symptoms are associated with uterine ruptures. Some possible symptoms include:
• excessive vaginal bleeding
• sudden pain between contractions
• contractions that become slower or less intense
• abnormal abdominal pain or soreness
• recession of the baby’s head into the birth canal
• bulging under the pubic bone
• sudden pain at the site of a previous uterine scar
• loss of uterine muscle tone
• rapid heart rate, low blood pressure, and shock in the mother
• abnormal heart rate in the baby
• failure of labor to progress naturally
The majority of uterine ruptures happen at the site of a scar from a previous c-section. And ruptures tend to occur during labor because a scar is most likely to give way under the stress of contractions.
During labor, pressure builds as the baby moves through the mother’s birth canal. This pressure can cause the mother’s uterus to tear. Often, it tears along the site of a previous cesarean delivery scar. When a uterine rupture occurs, the uterus’s contents — including the baby — may spill into the mother’s abdomen.
Risk Factors –
The risk factors for uterine rupture are generally those that make the uterus inherently weaker –
▪︎ Previous caesarean section – this is the greatest risk factor for uterine rupture.
• A high vertical (or “classical”) scar carries the highest risk of uterine rupture. This type of cut, which runs up and down, is made in the upper part of the uterus, sometimes for C-sections in preemie babies. Fibroid surgery tends to have vertical cuts, too.
• A low transverse scar is a side-to-side cut across the lower, thinner part of the uterus. It’s the most common type of C-section scar, and has the least chance of rupturing during a delivery.
• A low vertical scar is an up-and-down cut that’s made in the lower part of the uterus. With a low vertical cut, the risk of uterine rupture is higher than that of a low transverse scar, but lower than that of a high vertical scar.
▪︎ Previous uterine surgery – such as myomectomy.
▪︎ Induction – (particularly with prostaglandins) or augmentation of labour.
▪︎ Obstruction of labour – this is an important risk factor to consider in developing countries.
▪︎ Multiple pregnancy.
• Postoperative infection.
• Damage to ureter.
• Amniotic fluid embolism.
• Massive maternal haemorrhage and disseminated intravascular coagulation (DIC).
• Pituitary failure.
Uterine rupture happens suddenly and can be difficult to diagnose because the symptoms are often nonspecific. If doctors suspect uterine rupture, they’ll look for signs of a baby’s distress, such as a slow heart rate. Doctors can only make an official diagnosis during surgery.
Ultrasound can be used to diagnose rupture prior to labour when it may show an abnormal fetal position, haemoperitoneum or absent or thin uterine wall. Ultrasound is being analysed as a tool to predict uterine rupture.
Differential Diagnoses –
The main differential diagnoses to consider are:
• Placental abruption – presents with abdominal pain +/- vaginal bleeding. The uterus is often described ‘woody’ and tense on palpation.
• Placenta praevia – typically causes a painless vaginal bleeding.
• Vasa praevia – characterised by a triad of ruptured membranes, painless vaginal bleeding, and fetal bradycardia.
Early detection is the key to treatment. During pregnancy, uterine rupture often results in the prompt delivery of your baby. This allows your baby the opportunity to receive life-saving neonatal care if necessary.
It also gives your doctor the chance to repair your uterine wall via surgery. After a cesarean section, your doctor stitches up the rupture site. You may receive prescription medication to address pain following the procedure. Keep in mind that resting and allowing your body to heal after a uterine rupture is very important.
If a uterine rupture causes major blood loss, surgeons may need to remove a woman’s uterus to control her bleeding. After this procedure, a woman can no longer become pregnant. Women with excessive blood loss receive blood transfusions.
• 6.2% of uterine ruptures are associated with perinatal (infant) death.
• 14-33% of women with uterine rupture require an emergency hysterectomy.
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