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.