Uterine rupture in pregnancy reviewed

Uterine rupture is associated with maternal and fetal mortality and morbidity. In developed countries there have been many recent advances in the management of labour. This study, therefore, reviewed this Hospital's experience of uterine rupture in the decade 1982 to 1991. Excluding cases of asymptomatic scar dehiscence, there were 15 cases of uterine rupture in 65,488 deliveries, giving an overall incidence of 1 in 4,366. There was no case of rupture in 21,998 primigravidas. Of the 15 cases, only two occurred in 39,529 multigravidas without a previous uterine scar (1 in 19,765), and 13 cases occurred in the 3,961 multigravidas with a previous caesarean section scar (1 in 304). Twelve of the 13 ruptures after caesarean section occurred in the delivery immediately after the section. There were no maternal deaths but five (33%) patients required a hysterectomy. Three of the five perinatal deaths were attributable to the rupture. Ten of the 15 patients had labour induced, and a total of 13 patients received an oxytocic agent. Of the 15 cases, 8 were diagnosed during labour and 7 postpartum. Compared with earlier reports from Dublin, the incidence of uterine rupture was low due to a decrease in the number of ruptures associated with trauma or obstetric manipulation. The main associated feature was previous caesarean section. This review highlights the risk of uterine rupture when an oxytocic agent is administered to a multigravid patient with a previous caesarean section scar.

Elective repeat cesarean delivery versus trial of labor: a prospective multicenter study

OBJECTIVE

To report a prospective multicenter comparison of outcomes of patients who attempted trial of labor and those who underwent elective repeat cesarean.

METHODS

During the study interval, all pregnant women with previous cesarean delivery cared for at Kaiser Permanente Hospitals in Southern California were studied regardless of whether trial of labor or elective repeat cesarean was planned.

RESULTS

Of 7229 study patients, 5022 (70%) had a trial of labor and 2207 had elective repeat cesarean operations. Seventy-five percent (3746) of those opting for trial of labor went on to deliver vaginally. The rate of uterine rupture was less than 1% and there were no maternal deaths related to uterine rupture. The hospital length of stay, incidence of postpartum transfusion, and incidence of postpartum fever were all significantly higher in the elective repeat cesarean group than in the trial of labor group.

CONCLUSIONS

Labor after previous cesarean delivery has a 75% success rate, with a risk of uterine rupture of less than 1%. Neither repeat cesarean delivery nor trial of labor is risk-free. With careful supervision, trial of labor eliminates the need for a large proportion of repeat cesarean operations.

Trial of labor following cesarean delivery

OBJECTIVE

To examine several variables that may affect the success rate for a trial of labor after previous cesarean delivery, as well as those affecting the rate of uterine rupture.

METHODS

Between June 1, 1990 and December 31, 1991, we performed a consecutive, prospective study of 593 pregnant women who had had at least one abdominal delivery in the past, and attempted a trial of labor in each. Particular attention was given to the success rate of vaginal delivery, the type of previous uterine incision, use of oxytocin, estimated maternal blood loss, 5-minute Apgar scores, and reason for the previous cesarean operation.

RESULTS

Four hundred seventy-eight patients (81%) had a successful vaginal delivery. Oxytocin induction or augmentation was successful in 46 of 67 (69%) and 117 of 167 cases (70%), respectively. Estimated maternal blood loss was less than 500 mL in 453 cases (95%). Five patients (0.8%) experienced true uterine rupture, resulting in severe neurologic sequelae in one infant. The only consistent indication of uterine rupture was an abrupt and prolonged fetal bradycardia. The majority (463; 97%) of infants who were delivered vaginally had 5-minute Apgar scores of 8 or greater.

CONCLUSION

Our success rate of 81% suggests that a trial of labor after previous cesarean delivery is a safe and desirable option, but only after thorough patient counseling. An abrupt and persistent fetal bradycardia may be the only indication that uterine rupture has occurred.

Uterine rupture. A seat belt hazard

A case is described of a uterine rupture resulting from a car accident occurring in a woman who was wearing a seat belt as generally recommended. The rupture was initially not recognised and only became apparent after attempts to induce labor which led to expulsion of the fetus into the abdominal cavity.

Intrapartum uterine rupture in a primiparous patient previously treated for invasive mole

BACKGROUND

Intrapartum rupture of the uterus in a primiparous patient is an exceedingly rare event. This case report describes uterine rupture in a woman with previous invasive hydatidiform mole.

CASE

A 27-year-old primiparous woman with a history of gestational trophoblastic neoplasia treated successfully with chemotherapy experienced intrapartum uterine rupture with subsequent neonatal death. Magnetic resonance imaging of the uterus had shown evidence of myometrial invasion by the mole. Weakening of the uterine wall secondary to myometrial destruction is believed to have caused the uterine rupture.

CONCLUSION

Many women will attempt to conceive following treatment for gestational trophoblastic neoplasia. It is important to determine whether there is any local invasion of the myometrium, as this can affect intrapartum management in subsequent pregnancies.

Uterine rupture during pregnancy in a patient with a history of hysteroscopic metroplasty

BACKGROUND

Uterine septa may be responsible for spontaneous abortion. Hysteroscopic metroplasty may improve pregnancy outcome.

CASE

A patient with a history of hysteroscopic resection of a uterine septum presented in preterm labor. This was her second pregnancy following the procedure; the first resulted in a term vaginal delivery. This second pregnancy ended with a preterm cesarean delivery. A 3.5 x 3.5-cm fundal rupture was discovered during the cesarean. The metroplasty had been performed with the KTP laser under direct laparoscopic visualization. No surgical complications had occurred.

CONCLUSIONS

Uterine rupture during a pregnancy may occur following hysteroscopic metroplasty, even when no complications occur at surgery and even if a normal pregnancy outcome follows the procedure. Physicians providing care for patients who have had hysteroscopic metroplasty should be aware of the potential for uterine rupture during pregnancy.

Obstetric uterine ruptures in a rural area in Zaïre

Uterine ruptures with their deplorable sequelae constitute a major obstetrical problem in the rural areas of Africa. The maternal and perinatal mortality remain high as a result, mainly due to the lack of early and adequate care for these patients. Grande-multiparity is one of the major predisposing factors. Prevention must necessarily include the availability of family planning advice, improved organization of and access to maternal care, and good supervision during delivery and the post-partum period. The general improvement of the overall socio-economic condition is a pre-condition to the improvement of access to care.

[Rupture of a scarred gravid uterus at 28 weeks of amenorrhea. Conservative surgical management and results]

Rupture of a scarred uterus during pregnancy is unusual, but remains a complication with serious consequences for both mother and fetus. It usually occurs towards the term of gestation and the case reported here is of interest because, atypically, the rupture of the uterus occurred some time before term in a scarred uterus and the immediate care provided was conservative surgery. The rest of the pregnancy proceeded to a successful outcome at term under clinical and obstetrical follow-up. The authors also highlight the additional precautions required in medically-assisted pregnancies in patients over 40 years of age.

[Induced labor with prostaglandin E2 gel after previous cesarean section]

With the rising rate of Caesarean sections, the number of pregnant patients with a previous Caesarean is increasing. Taking into consideration certain contraindications, it seems to be justified, to attempt induction of labour for vaginal delivery without major risk. However, the use of prostaglandins for cervical ripening in women with an unfavourable cervical status is particularly controversial. Thus, we analysed data from 385 trials of vaginal labour induction in a total of 522 patients with previous Caesarean section. Single or multiple cervical doses of prostaglandin-E2-gel had to be administered because of an unripe cervix (Bishop-score < 8) in 161 women for induction of labour for medical indications. 84.9% of those patients, in which labour induction was attempted after previous Caesarean section, delivered vaginally; 70% after two Caesareans. The highest success rates were seen after previous Caesarean for breech presentation, while there was still a vaginal delivery rate above 60% even after Caesarean for cephalopelvic disproportion or failure to progress. Maternal and foetal complications were seen with equal incidence in both study groups. Uterine ruptures totalling 0.5% were seen only in patients without cervical priming. Taking into consideration contraindications, intracervical application of PGE2-gel is a safe and effective method, even in patients after previous Caesarean section with clear advantages in case of an unripe cervix.

Uterine rupture at 33 weeks' gestation subsequent to hysteroscopic uterine perforation

A 40-year-old woman underwent operative hysteroscopy for suspected submucosal myoma, during which the uterine fundus was perforated. At laparotomy the perforation site was sutured. In a subsequent pregnancy she had a sudden onset of abdominal pain. Laparotomy revealed a uterine rupture with a partially protruding placenta. A healthy newborn was delivered by a low-segment cesarean section.

[Uterine ruptures. 32 cases]

On the basis of qqq 32 cases of rupture of the uterus observed over a 5-year period at the Monastir University hospital (Tunisia), the authors recall the high incidence of this obstetrical emergency: 1 incident per 548 deliveries. The usual aetiological factors were present: multiparity, caesarean scar, mechanical dystocia, oxytocic dystocia and obstetric manoeuvres. The foeto-maternal prognosis is poor with a maternal mortality rate of 3.13% and a perinatal mortality rate of 46.9%. Treatment should be conservative whenever possible. The authors attempt to define a prophylactic approach on the basis of the aetiological context.

[Pregnancy in a rudimentary uterine horn: rupture in the 15th week of amenorrhea]

A case of pregnancy in a rudimentary uterine horn with rupture 15 weeks after the LMP is described. Ultrasonography at the beginning of such a pregnancy should allow the diagnosis of these uterine malformations. Closer monitoring of the pregnancy is necessary because of the seriousness of potential complications. The frequent finding of placenta accreta in such situations is pointed out. Management approaches are described.

[Pregnancy in a rudimentary uterine horn: main clinical forms. 5 cases]

Five cases of pregnancy developing in a rudimentary uterine horn are reported. The incidence of this association is 1/40,000 pregnancies. Three patients underwent surgery in a context of massive intraperitoneal bleeding due to rupture of the uterus during the second three months of pregnancy. Pregnancy continued into the third three months in 2 patients. The diagnosis was made at laparotomy, the uterus having ruptured in both cases. In the first case, rupture was clinically silent with development of the fetus in the abdominal cavity. In the second case, the pregnancy stopped developing at 34 weeks after the LMP. Histological examination of hemi-hysterectomy specimens showed that the placenta was accreta in all cases. Analysis of these 5 cases and a review of the literature form the basis of a review of the current contribution of investigations to the diagnosis of this association.

Audit of uterine rupture in Maputo: a tool for assessment of obstetric care

Records of 96 women who had rupture of the uterus in labor were audited to find circumstances significantly associated with pregnancy outcome. The prevalence was 1 rupture in 424 deliveries. In 74 cases (77.1%) uterine rupture occurred after hospitalization, the remaining 22 cases being emergency transfers with rupture secondary to a delivery attempt elsewhere. History of a previous cesarean section was present in 46%, whereas 54% of the women had an unscarred uterus. Maternal mortality was 7.3% whilst perinatal mortality was 62.9%. Adverse outcome for the mother was associated with ruptures occurring in unscarred uteri (p < 0.02) and outside the Maternity (p < 0.01); this latter condition also contributed to higher fetal mortality (p < 0.002). The findings confirm that delay in reaching medical care is an aggravating factor in the evolution of uterine rupture in developing countries and suggest the need for better medical attention and timely diagnosis in laboring women with unscarred uterus.

[Trial of labor after cesarean section. Two years' experience]

A retrospective study was undertaken to evaluate the incidence of vaginal delivery in women that previously undergone a cesarean section; in addition, incidence of complications such as uterine rupture and scar dehiscence were evaluated. During the two years reviewed, 251 out of 324 women with a previous cesarean section were allowed to labor; 64.1% had a vaginal delivery. Uterine rupture occurred in 0.8% of the patients of the trial of labor group: no other significant maternal and/or fetal complications were seen; scar dehiscence occurred in 3.3%. Statistical analysis didn't show any increase in complications when oxytocin was used to stimulate uterine activity. It is concluded that trail of labor and delivery after cesarean section is a safe option in a large number of patients.

[Induction of labor in fetal death in utero using a Foley catheter and extra-amniotic perfusion of physiologic serum]

Nineteen cases of induction of labour by Foley catheter and extra-amniotic perfusion of normal saline for fetal death in utero occurring more than 24 weeks after the LMP were collected in the La Rabta Maternity and Neonatology Centre, Tunis, during the final 6 months of 1987. The mean age of the women was 27.8 and their mean parity 2.9. Two patients had uterine scars. The mean duration of the pregnancy was 33.3 weeks and initial Bishop score was 4 or less. When the catheter fell out, after 26.4 hours on average, the Bishop score had improved by 4.5 points. Labour occurred spontaneously in 5 cases and required oxytocin stimulation in 5 cases. The interval between induction and fetal expulsion was 44.4 hours. Delivery was followed by routine manual evacuation of the uterus. Two complications were seen: one case of accidental rupture of the membranes and one of rupture of the uterus affecting a scarred uterus. The authors point out certain risk factors concerning rupture of the uterus which should be considered to be contraindications to the method. With the exception of these situations, this method of induction is recommended because of its advantages of efficacy, safety and low cost, in particular in developing countries.

Rupture of the uterus in labor: a review of 150 cases

We analyzed 150 cases of uterine rupture in late pregnancy that occurred over an 8-year period at the State Maternity Hospital in Ankara, Turkey. The incidence of uterine rupture was 1 in 966 deliveries, and 114 uterine ruptures occurred in previously scarred uteri. Rupture of the unscarred uterus is a more catastrophic event. There is a marked difference in fetal and maternal outcome between the group with a previously scarred uterus and the group without a previous scar. Common etiological factors for uterine rupture were grandmultiparity, cephalopelvic disproportion, fetal malpresentation, and oxytocin stimulation of labor. The fetal wastage was high, a perinatal mortality of 32.2% being recorded, but 98% of mothers were saved. Hysterectomy was commonly performed in this group. Repair of the uterus should only be performed when the rupture is simple, is in the lower segment and has no sign of infection.

Rupture of the uterus

Fifty cases of uterine rupture were managed in 4 years giving a frequency of 1 per 89.9 deliveries. There was an obvious difference between those with a previously scarred uterus (34) vs those without a scar (16) cephalopelvic disproportion, grand multiparity and mismanagement of cases by traditional birth attendant (TBAs) were the common etiologic factors in the unscarred uterus, cephalopelvic disproportion, forceps delivery, grand multiparity and prolonged first stage of labour were the common etiologic factors in patients with previously scarred uterus. In the unscarred group both maternal and foetal (81.6%) mortality was high (JPMA 43: 174, 1993).

A review of 126 cases of ruptured gravid uterus

Ruptured uterus is a grave obstetric complication, associated with high maternal mortality and morbidity, perinatal mortality and loss of future fertility as hysterectomy is inevitable in many cases. This study reviews the incidence, causes and other factors, to define problem areas and propose preventive measures. During 1979-1988, 126 cases of ruptured uterus occurred in 46,207 deliveries; these 126 cases were retrospectively analyzed in relation to causes, age, parity, maternal mortality and morbidity, perinatal mortality and management. Some of the results were compared with other authors. The incidence was 1/367 (2.7/1000 deliveries), traumatic rupture accounted for 42.86% while spontaneous rupture accounted for 57.14%. Maternal mortality was 21.43% and the perinatal mortality was 73.19%. Supravaginal hysterectomy, repair with sterilization and repair without sterilization were the selected lines of management. Proper quick diagnosis and prompt management will reduce maternal mortality and morbidity. Finally, recommendations to reduce the occurrence of this problem are proposed.