RUPTURE OF THE UTERUS

Associate Professor

Iolanda Blidaru, MD, PhD

RUPTURE OF THE UTERUS

a potential obstetric catastrophe

a major cause of maternal death.

The incidence of uterine rupture is approximately 1/ 1500 deliveries.

RUPTURE OF THE UTERUS

RUPTURE OF THE UTERUS

ETIOLOGYA.Before current pregnancy1. surgery involving the myometrium1. surgery involving the myometrium * cesarean section or hysterotomy * cesarean section or hysterotomy * previously repaired uterine rupture * previously repaired uterine rupture * myomectomy, cornual resection, metroplasty* myomectomy, cornual resection, metroplasty2. uterine trauma2. uterine trauma * abortion with instrumentation* abortion with instrumentation * sharp or blunt trauma (accidents, bullets, knives)* sharp or blunt trauma (accidents, bullets, knives) * silent rupture in previous pregnancy* silent rupture in previous pregnancy3. congenital anomaly3. congenital anomaly * pregnancy in undeveloped uterine horn* pregnancy in undeveloped uterine horn

RUPTURE OF THE UTERUS

B. During current pregnancy 1.Before delivery

external trauma

labor stimulations (oxytocin or PG)

external version

uterine overdistention (multiple pregnancy,

hydramnios) Utero-placental pathology (sacculation of

entrapped retroverted uterus, cornual pregnancy, adenomyosis)

RUPTURE OF THE UTERUS

B. During current pregnancy 2. During delivery fetal anomaly distending lower segment

(hydrocephalus) internal version, breech extraction difficult forceps delivery difficult manual removal of placenta abnormal presentations contracted pelvis tumors of the birth canal multiparity placenta increta or percreta gestational trophoblastic neoplasia

RUPTURE OF THE UTERUS

The most common cause of uterine rupture is

separation of a previous cesarean

section scar.

RUPTURE OF THE UTERUS

CLASIFICATIONIncomplete rupture → a laceration separated by

the visceral peritoneum.

““ Occult” Occult” ((“incomplete rupture”“incomplete rupture”)) →→ dehiscence of a dehiscence of ann uterine incision from previous surgery.uterine incision from previous surgery.

Complete rupture traumatic

spontaneous

→→ during the course of laborduring the course of labor

RUPTURE OF THE UTERUS

Vertical uterine incision through the uterine body - probability of rupture is several times greater than that of a lower segment scar.

The corporeal scar ruptures before labor (1/3).

Dehiscence of a lower segment cesarean section scar is more frequent than actual rupture.

RUPTURE OF THE UTERUS Pathological anatomy

Incomplete ruptures frequently extend into the broad ligament.

Hemorrhage tends to be less severe than in complete rupture and the blood acumulates between the leaves of the broad ligament.

Ruptured vertical cesarean section scar (arrow)identified at time of repeat cesarean delivery early in labor.

Spontaneously ruptured uterus at left lateral edgeof lower uterine segment.

RUPTURE OF THE UTERUS Pathological anatomy

Rupture of the previously intact uterus at the time of labor → the lower uterine segment ( left margin)

After complete rupture, the uterine contents escape into peritoneal cavity, unless the presenting part is firmly engaged, when only a portion of the fetus may be extruded from the uterus.

RUPTURE OF THE UTERUS CLINICAL FINDINGS. DIAGNOSIS

Impending uterine rupture Impending uterine rupture → the sudden → the sudden appearance of appearance of gross hematuriagross hematuria is suggestive. is suggestive.

Prior to the onset of labor, a beginning rupture Prior to the onset of labor, a beginning rupture may produce may produce local painlocal pain and and tendernesstenderness associated with associated with increased uterine irritability increased uterine irritability and, and, in some cases, a small amount of in some cases, a small amount of vaginal vaginal bleeding.bleeding.

If the fetus is partly or totally extrauterine, If the fetus is partly or totally extrauterine, abdominal palpation or vaginal examinationabdominal palpation or vaginal examination →→ the presenting part the presenting part has has moved away from the moved away from the pelvic inletpelvic inlet (loss of station)(loss of station)..

RUPTURE OF THE UTERUSThe classic SIGN & SYMPTOMS of spontaneous rupture during labor

cessation of uterine contractions

suprapubic pain and tenderness

disappearance of fetal heart tones

recession of the presenting part

vaginal hemorrhage → signs and

symptoms of hypovolemic shock and

hemoperitoneum.

RUPTURE OF THE UTERUS

RUPTURE OF A CESAREAN SCAR complicates about 1 in 200 trials of labor. in most cases = a dehiscence of little

consequence.Criteria for vaginal delivery following previous

cesarean section only one previous cesarean section; low transverse uterine incision; original indication for cesarean not necessarily

recurring in subsequent pregnancies; benign postoperative course; non-complicated current pregnancy (macrosomia,

malposition, multiple gestation).

RUPTURE OF THE UTERUS

PREVENTION

good prenatal care

correct trial of labor

correct supervised administration of oxytocin

during labor.

correct closure of a cesarean section incision

correct estimation of fetal weight

RUPTURE OF THE UTERUS

TREATMENTWhenever uterine rupture is diagnosed –

EMERGENCY SURGERY two effective, large-bore intravenous infusion

type-specific whole blood in large quantities is

rapidly infused;

a surgical team, including anesthesia personnel;

pediatric personnel skilled in neonatal

resuscitation.

RUPTURE OF THE UTERUS

Immediate laparotomy Suture or Total hysterectomy If a large hematoma in the broad ligament,

identification and ligation of the internal iliac arteries (reduces the hemorrhage appreciably).

Prompt diagnosis, immediate operation, the availability of large amounts of blood and antimicrobial therapy have greatly improved the maternal prognosis.

RUPTURE OF THE UTERUS PROGNOSIS

Maternal Prognosis the maternal mortality rate is 10 to

40%. if the patient survives: pituitary

failure (Sheehan syndrome), infertility/sterility

vesico-vaginal fistula.

RUPTURE OF THE UTERUS

FETAL PROGNOSIS

If the fetus is alive at the time of the rupture, the only chance of continued survival is afforded by immediate delivery, most often by laparotomy. Otherwise, hypoxia and death from both, placental separation and maternal hypovolemia, is inevitable.