Rupture of the pregnant uterus--a 21-year review

A Rare and Unique Case Report of Lateral Uterine Wall Rupture and Its Review

Rupture of the uterus is a deadly obstetric complication. Its occurrence is uncommon and much less common in the second trimester. Given that the mother and fetus are in danger, it is a catastrophe for both. The incidence has increased in recent years as the cesarean section rate has increased, but in developing nations, multiparity and the inappropriate use of uterotonics are more common. This potentially disastrous event may have a vague initial presentation. Here forth, we present a case with solitary right lateral wall uterine rupture covering the entire length of the uterus, the fetus and placenta enclosed in between the broad ligament leaves, most likely due to injudicious misoprostol use at a private health care center superimposed on multiparity, and a literature review. As far as we know, this is the first instance of an isolated right lateral uterine wall rupture sparing the lower segment and, with the fetus trapped between the broad ligaments simulating abdominal pregnancy.

Spontaneous postpartum rupture of an intact uterus: a case report

Rupture of uterus is an obstetrical complication characterized by a breach in the uterine wall and the overlying serosa. We report an unusual case of spontaneous rupture of an unscarred uterus in a 33-year-old woman, a day after her third successful vaginal delivery. A 33-year-old pregnant woman, gravid 3, para 3, was referred to our department at 39 gestational week because of rupture of membranes. Despite tocolysis administration, her pregnancy was delivered vaginally after 2 days, giving birth to a male neonate of 3,020 g with normal Apgar scores at first and fifth minute. Her uterus was intact and gynecological examination after delivery was normal without any potential signs or symptoms of pathology. However, the day following her labor, patient complained of left iliac fossa pain. Her blood tests revealed a CRP value at 27.6 mg/L, whereas the X-rays revealed an extensive impacted fecal mass in the colon. MRI revealed that the left lower myometrial part of the uterus was depicted abrupt, with simultaneous presence of hemorrhagic stuff. The decision of laparotomy was therefore made in order to further evaluate rupture of uterus and properly treat patient. And subtotal hysterectomy was performed. Postoperative follow-up period was not characterized by any complications and patient was finally discharged 4 days after hysterectomy.

Uterine rupture revisited: Predisposing factors, clinical features, management and outcomes from a tertiary care center in Turkey

Objective: To determine the predisposing factors, modes of clinical presentation, management modalities and fetomaternal outcomes of uterine rupture cases at a tertiary care center in Turkey.

Methodology: A 14-year retrospective analysis of 61 gravid (>20 weeks of gestation) uterine rupture cases between January 1998 to March 2012 was carried out.

Results: The incidence of ruptured uteri was calculated to be 0.116%. Persistence for vaginal delivery after cesarean was the most common cause of uterine rupture (31.1%). Ablatio placenta was the most common co-existent obstetric pathology (4.9%). Bleeding was the main symptom at presentation (44.3%) and complete type of uterine rupture (93.4%) was more likely to occur. Isthmus was the most vulnerable part of uterus (39.3%) for rupture. The longer the interval between rupture and surgical intervention, the longer the duration of hospitalization was. Older patients with increased number of previous pregnancies were likely to have longer hospitalization periods.

Conclusion: Rupture of gravid uterus brings about potentially hazardous risks. Regular antenatal care, hospital deliveries and vigilance during labor with quick referral to a well-equipped center may reduce the incidence of this condition.

Rupture of the Gravid Utensis

Records were reviewed of 81 cases of ruptured gravid uteri seen in the hospitals of Hamad Medical Corporation, Doha, in the 32 years 1977–2008, an overall incidence of 0.025%, although the incidence 1977–1997 was 0.01 % and that of 1998–2008 was 0.036%. Grand multiparity was a prominent cause (56.5%) in the first 21 years but less so in the later period 1998–2008 (10%) although involvement of a uterine scar from a previous caesarian section was noted more (84%) in the later period than in 1977– 1997 (43.5%). Other associated factors were the use of oxytocin or PGE2. Epidural anesthesia in the later period might have provoked abnormal fetal heart rates. The need for hysterectomy decreased from 65% to 10%. Perinatal mortality decreased slightly. Although we conclude that uterine rupture is rare (0.025%) it can be catastrophic for mother and newborn and might be prevented by multi-layer uterine hysterotomy closure, a longer interpregnancy interval following a caesarian section, and no or limited use of prostaglandins.

Eight years' experience of uterine rupture cases

Ruptured uterus is a serious obstetric emergency with a high maternal and perinatal mortality. It is a preventable and common obstetric problem in developing countries. The objective of this study was to review the incidence, methods of diagnosis and maternal and perinatal morbidity and mortality associated with uterine rupture. Case notes were reviewed for all patients with a ruptured uterus at Yüzüncü Yil University Medical Faculty Department of Obstetrics and Gynaecology from January 1995 to August 2003. Relevant data relating to the clinical characteristics of labour, operative procedures, maternal and perinatal outcome were assessed. There were 20 cases of ruptured uteri. The incidence was 0.40%. When patients referred from other hospitals were excluded, the revised ratio was 0.12%. There were 13 (65%) complete and seven (35%) incomplete ruptures. Nine (45%) cases occurred in patients with scarred uteri. Ten (50%) cases were grand multiparous. Subtotal abdominal hysterectomy was performed in five (25%) cases, total abdominal hysterectomy was performed in two (10%) cases and the remaining 13 (65%) cases had uterine rupture repair. There were two (10%) maternal deaths. Both of them were referred from other hospitals. There were seven (35%) perinatal deaths attributable to uterine rupture. Occurrence of uterine rupture is significantly associated with grand multiparity, scarred uterus, lack of antenatal care, unsupervised labour at home and low socioeconomic status of the patients. These factors are largely preventable.

Pregnancy After Uterine Rupture: A Report of 5 Cases and a Review of the Literature

Management and outcome of 5 cases of pregnancy after uterine rupture are discussed. All women in these cases were delivered by cesarean delivery and no repeat ruptures occurred. After reviewing the literature, it is concluded that women with a previous uterine rupture have a favorable outcome in a subsequent pregnancy. With a rupture in a lower segment scar, an elective cesarean delivery should be performed before labor starts after assessing fetal lung maturity or administration of corticosteroids.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to describe the risk associated with a subsequent pregnancy after a previous uterine rupture, summarize the complications of uterine rupture during a subsequent pregnancy, and to list the treatment plans for a patient in a subsequent pregnancy after uterine rupture.

Rupture of the pregnant uterus: a 9-year review

OBJECTIVE

To investigate the frequency of ruptured uterus, possible etiologic factors and fetomaternal outcomes.

STUDY DESIGN

A retrospective chart view of all patients with ruptured uterus over a 9-year period from 1995 to 2003 was carried out. Relevant data relating to the clinical features, characteristics of labour, operative procedures, and fetomaternal outcomes were assessed.

RESULTS

During the study period there were 17 cases of ruptured uterus among a total of 117,095 deliveries, giving an incidence of 1 in 6,888 deliveries. Thirteen patients (76.5%) were multiparous and mean parity was 1.9. Uterine rupture occurred following vaginal delivery in ten patients. Caesarean delivery was performed in seven (41.2%) patients, of which five (29.4%) patients had a history of previous caesarean section. Abdominal hysterectomy was performed in 12 patients (70.6%), of which 9 (75.0%) were total and 3 (25.0%) were subtotal. The other five patients (29.4%) had suture repairs. In seven patients (41.2%), uterine rupture was associated with oxytocin use. There were one maternal and three perinatal (17.6%) deaths.

CONCLUSION

Sudden fetal heart abnormalities in labouring patients should be taken as a potential sign of danger. Early diagnosis and immediate preoperative resuscitation are of great importance in cases of ruptured uterus. The fetomaternal outcomes can be improved with the experience and skill of the surgical team.

Uterine rupture: differences between a scarred and an unscarred uterus

OBJECTIVES

This study aimed to compare risk factors, site of rupture, and outcome of uterine rupture among patients with a scarred versus an unscarred uterus. Study design We conducted a comparison between all cases of uterine rupture (n=53) in women with a scarred versus an unscarred uterus, occurring between January 1988 and July 2002.

RESULTS

During the study period, there were ruptures among 26 patients with a scarred uterus and 27 patients without a uterine scar. No significant differences were noted between the scarred and unscarred groups while comparing risk factors such as birth order, birth weight, hydramnios, oxytocin induction, diabetes, and malpresentation. The main site of involvement in both groups was the lower uterine segment representing 92.6% of the ruptures in the unscarred group and 92.3% of the ruptures in the scarred uterus group. Cervical involvement was significantly more common among patients without a previous uterine scar (33.3% vs 7.7%; odds ratio [OR]=6.0, 95% CI, 1.16-31.23, P=.04). Conversely, uterus corpus involvement did not differ between the groups. Perinatal mortality did not differ between the groups. In addition, no significant differences were noted regarding maternal morbidity such as the need for hysterectomy, blood transfusion, or length of hospitalization.

CONCLUSION

Although cervical involvement was significantly more prevalent in the rupture of an unscarred uterus, no significant differences in maternal or perinatal morbidity were noted between rupture of a scarred versus an unscarred uterus.

Our Experience with Vaginal Prostaglandin-E2 for Induction of Labor in Qatar: Six Months Review

In order to review our experience with prostaglandin-E2 for the induction of labour and to evaluate its safety and outcomesa retrospective study was carried out at the Women's Hospital, Hamad Medical Corporation, over a six-month period. Three hundred and thirty four patients (7% of total deliveries) were induced by PGE2 (Dinoprostone), including 105 (30%) nulliparae and 229 (70%) multiparae. Patients with a history of one previous lower segment caesarean section were also included. Post date pregnancy and diabetes were the most common indications for induction.

There were significant differences in the two groups regarding the number of doses and the mean total dose of PGE2 used. The need for syntocinon augmentation was more in the nulliparae (41% vs 22%). Failed induction occurred only in nulliparae. The rate of caesarean section in induced labour remained significantly low compared with a spontaneous labour (11.6% vs 10.7%). The caesarean section rate was higher in the nulliparae (16.0% vs 9.6%) but this was not statistically significant. The caesarean section rate was higher when Bishop score 0-4 (76% vs 24%). Only two of the babies in the study group had an Apgar score less than 7 at 5 minutes. There was one caesarean hysterectomy because of postpartum hemorrhage associated with the PGE2 induction.

Conclusion: The calculated induction rate with PGE2 was 7% of total deliveries. Induction of labour with PGE2 in a grandmultiparae and previous caesarean section is relatively safe but further multicentre studies are needed to confirm our findings.

Abdominal pain during pregnancy

Numerous medical, surgical, psychiatric, gynecologic, and obstetric disorders can cause abdominal pain during pregnancy. The patient history, physical examination, laboratory data, and radiologic findings usually provide the diagnosis. The pregnant woman has physiologic alterations that affect the clinical presentation, including atypical normative laboratory values. Abdominal ultrasound is generally the recommended radiologic imaging modality; roentgenograms are generally contraindicated during pregnancy because of radiation teratogenicity. Concerns about the fetus limit the pharmacotherapy. Maternal and fetal survival have recently increased in many life-threatening conditions, such as ectopic pregnancy, appendicitis, and eclampsia, because of improved diagnostic technology, better maternal and fetal monitoring, improved laparoscopic technology, and earlier therapy.

Ruptured uterus: a seven-year review of cases from Accra, Ghana

OBJECTIVE

To determine the incidence, causes, management, and the means of prevention of uterine rupture, as well as the characteristics of women with the condition, recorded in the Department of Obstetrics and Gynaecology at Korle-Bu Teaching Hospital in Accra, Ghana.

DESIGN

A retrospective study between January 1, 1995, and December 31, 2001.

RESULTS

During the study period, of 82061 deliveries at the Korle-Bu Teaching Hospital, 193 women developed uterine rupture, an incidence of 2.4 per 1000 deliveries. Of these 193 women, 24.6% had had a previous Caesarean section. The most frequent associated factor of uterine rupture was prolonged labour (33.6%). The perinatal mortality rate was 74.3%. Almost 70% (66.9%) of women underwent a total abdominal hysterectomy as management. The case fatality rate was 1.0%.

CONCLUSION

A more vigilant approach to preventing prolonged and obstructed labour in delivery units within and around Accra, Ghana, is required to reduce the incidence of this condition.

Epidemiological features of uterine rupture in West Africa (MOMA Study)

The aim of the study was (1) to assess the incidence of uterine rupture in West Africa; (2) to identify its risk factors there; (3) to assess their predictiveness. The study (MOMA study) was prospective and population based. Data on a large cohort of pregnant women were collected. Univariable and multivariable analysis was used including stepwise logistic regression. We identified 25 cases of clinically symptomatic uterine rupture in a population of 20 326 pregnant women giving an incidence rate of 1.2 uterine ruptures per 1000 deliveries. Five variables were significantly associated with uterine rupture (in both the univariable and multivariable analyses): uterine scars, malpresentation, limping, cephalopelvic disproportion and high parity (>or=7). In conclusion, the incidence of uterine rupture is high in West Africa, even in large cities where essential obstetric care is available and despite the low prevalence of uterine scars. A uterine scar multiplies the risk of uterine rupture by 11. Uterine rupture cannot be predicted from currently known risk factors, including uterine scars. The high case fatality rate (33.3%) and the associated perinatal mortality (52%) bear witness to the absence or inadequacy of health facilities in providing essential obstetric care and to the poor quality of maternal health care, even in major cities.

Uterine rupture during induced trial of labor among women with previous cesarean delivery

OBJECTIVE

This study was undertaken to compare the rates of uterine rupture during induced trials of labor after previous cesarean delivery with the rates during a spontaneous trial of labor.

STUDY DESIGN

All deliveries between 1992 and 1998 among women with previous cesarean delivery were evaluated. Rates of uterine rupture were determined for spontaneous labor and different methods of induction.

RESULTS

Of 2119 trials of labor, 575 (27%) were induced. The overall rate of uterine rupture was 0.71% (15/2119). The uterine rupture rate with induced trial of labor (8/575; 1.4%) was significantly higher than with a spontaneous trial of labor (7/1544; 0.45%; P =.0004). Uterine rupture rates associated with different methods of induction were compared with the rate seen with spontaneous labor and were as follows: prostaglandin E(2) gel, 2.9% (5/172; P =.004); intracervical Foley catheter, 0.76% (1/129; P =.47); and labor induction not requiring cervical ripening, 0.74% (2/274; P =.63). The uterine rupture rate associated with inductions other than with prostaglandin E(2) was 0.74% (3/474; P =.38). The relative risk of uterine rupture with prostaglandin E(2) use versus spontaneous trial of labor was 6.41 (95% confidence interval, 2. 06-19.98).

CONCLUSION

Induction of labor was associated with an increased risk of uterine rupture among women with a previous cesarean delivery, and this association was highest when prostaglandin E(2) gel was used.

Vaginal bleeding associated with pregnancy

Vaginal bleeding during pregnancy provokes physical and emotional stress to patients and physicians. Physicians must be prepared to assess the medical implications of acute blood loss to these patients and their unborn children quickly. When mother and fetus are stable, the recognition and treatment of the underlying cause is essential to decreasing additional maternal and fetal morbidity and mortality associated with the bleeding episode.