Maternal outcome after complete uterine rupture

Predicting the risks and recognizing the signs: a two-year prospective population-based study on pregnant women with uterine rupture in The Netherlands

OBJECTIVE

To estimate the incidence of uterine rupture in the Netherlands and evaluate risk indicators prelabour and during labor of women with adverse maternal and/or perinatal outcome.

METHODS

This is a population-based nationwide study using the Netherlands Obstetrics Surveillance System (NethOSS). We performed a two-year registration of pregnant women with uterine rupture. The first year of registration included both women with complete uterine rupture and women with incomplete (peritoneum intact) uterine rupture. The second year of registration included women with uterine rupture with adverse maternal and/or perinatal outcome. We collected maternal and obstetric characteristics, clinical signs, and symptoms during labor and CTG abnormalities. The main outcome measures were incidence of complete uterine rupture and uterine rupture with adverse outcome and adverse outcome defined as major obstetric hemorrhage, hysterectomy, embolization, perinatal asphyxia and/or (neonatal) intensive care unit admission.

RESULTS

We registered 41 women with a complete uterine rupture (incidence: 2.5 per 10,000 births) and 35 women with uterine rupture with adverse outcome (incidence: 0.9 per 10,000 births). No adverse outcomes were found among women with incomplete uterine rupture. Risk indicators for adverse outcome included previous cesarean section, higher maternal age, gestational age <37 weeks, augmentation of labor, migration background from Sub-Saharan Africa or Asia. Compared to women with uterine rupture without adverse outcomes, women with adverse outcome more often expressed warning symptoms during labor such as abdominal pain (OR 3.34, 95%CI 1.26-8.90) and CTG abnormalities (OR 9.94, 95%CI 2.17-45.65). These symptoms were present most often 20 to 60 min prior to birth.

CONCLUSION

Uterine rupture is a rare condition for which several risk indicators were identified. Maternal symptoms and CTG abnormalities are associated with adverse outcomes and time dependent. Further analysis could provide guidance to expedite delivery.

The incidence, indications, risk factors and pregnancy outcomes of peripartum hysterectomy at a tertiary hospital between 2013 and 2022

OBJECTIVE

To analyze the incidence, indications, risk factors and pregnancy outcomes of postpartum hemorrhage resulting in peripartum hysterectomy (PH).

METHODS

We retrospectively reviewed patients with postpartum hemorrhage requiring surgical procedures at ≥ 28 weeks of gestation from January 1, 2013 to December 31, 2022 at a tertiary hospital in Shanghai, China. The patients were divided into a PH group and a non-PH group. Maternal clinical characteristics, the management of postpartum hemorrhage, pregnancy outcomes were compared between groups. Logistic regression was used to analyze the correlations between risk factors and PH.

RESULTS

The incidence of hysterectomy was 0.2/1000 deliveries (31/150194). The variables significantly associated with PH were placenta previa with placenta increta/percreta (OR36.26), uterine rupture (OR266.16) and an estimated blood loss ≥ 3513 mL (OR431.11). The proportion of cases involving hemorrhagic shock, disseminated intravascular coagulation, bladder injury, neonatal severe asphyxia, neonatal death and hypoxic-ischemic encephalopathy were significantly higher in the PH group (P < 0.05).

CONCLUSION

The most common indications of PH were placental pathology. Efforts should be made to reduce the rate of cesarean deliveries and uterine curettage to lower the probability of abnormal placental invasion and appropriate medical indications for trial of labor after cesarean should be strictly followed to avoid the risk of uterine rupture.

Uterine wound healing after caesarean section: A systematic review

The rate of caesarean section (CS) is increasing worldwide. Defects in uterine healing have a major gynaecological and obstetric impact (uterine rupture, caesarean scar defect, caesarean scar pregnancy, placenta accreta spectrum). The complex process of cellular uterine healing after surgery, and specifically after CS, remains poorly understood in contrast to skin wound healing. This literature review on uterine wound healing was mainly based on histological observations, particularly after CS. The primary objective of the review was to examine the effects of CS on uterine tissue at the cellular level, based on histological observations. The secondary objectives were to describe the biomechanical characteristics and the therapies used to improve scar tissue after CS. This review was performed using PRISMA criteria, and PubMed was the data source. The study included all clinical and animal model studies with CS and histological analysis of the uterine scar area (macroscopic, microscopic, immunohistochemical and biomechanical). Twenty studies were included: 10 human and 10 animal models. In total, 533 female humans and 511 female animals were included. Review articles, meeting abstracts, case series, case reports, and abstracts without access to full-text were excluded. The search was limited to studies published in English. No correlation was found between cutaneous and uterine healing. The histology of uterine scars is characterized by disorganized smooth muscle, fibrosis with collagen fibres and fewer endometrial glands. As for skin healing, the initial inflammation phase and mediation of some growth factors (particularly connective tissue growth factor, vascular endothelial growth factor, platelet-derived growth factor, tumour necrosis factor α and tumour necrosis factor β) seem to be essential. This initial phase has an impact on the subsequent phases of proliferation and maturation. Collagen appears to play a key role in the initial granulation tissue to replace the loss of substance. Subsequent maturation of the scar tissue is essential, with a decrease in collagen and smooth muscle restoration. Unlike skin, the glandular structure of uterine tissue could be responsible for the relatively high incidence of healing defects. Uterine scar defects after CS are characterized by an atrophic disorganized endometrium with atypia and a fibroblastic highly collagenic stromal reaction. Concerning immunohistochemistry, one study found a decrease in tumour necrosis factor β in uterine scar defects. No correlation was found between biomechanical characteristics (particularly uterine strength) and the presence of a collagenous scar after CS. Based on the findings of this review, an illustration of current understanding about uterine healing is provided. There is currently no validated prevention of caesarean scar defects. Various treatments to improve uterine healing after CS have been tested, and appeared to have good efficacy in animal studies: alpha lipoic acid, growth factors, collagen scaffolds and mesenchymal stem cells. Further prospective studies are needed.

Risk factors for maternal complications following uterine rupture: a 12-year single-center experience

PURPOSE

To determine maternal outcomes and risk factors for composite maternal morbidity following uterine rupture during pregnancy.

METHODS

A retrospective cohort study including all women diagnosed with uterine rupture during pregnancy, between 2011 and 2023, at a single-center. Patients with partial uterine rupture or dehiscence were excluded. We compared women who had composite maternal morbidity following uterine rupture to those without. Composite maternal morbidity was defined as any of the following: maternal death; hysterectomy; severe postpartum hemorrhage; disseminated intravascular coagulation; injury to adjacent organs; admission to the intensive care unit; or the need for relaparotomy. The primary outcome was risk factors associated with composite maternal morbidity following uterine rupture. The secondary outcome was the incidence of maternal and neonatal complications following uterine rupture.

RESULTS

During the study period, 147,037 women delivered. Of them, 120 were diagnosed with uterine rupture. Among these, 44 (36.7%) had composite maternal morbidity. There were no cases of maternal death and two cases of neonatal death (1.7%); packed cell transfusion was the major contributor to maternal morbidity [occurring in 36 patients (30%)]. Patients with composite maternal morbidity, compared to those without, were characterized by: increased maternal age (34.7 vs. 32.8 years, p = 0.03); lower gestational age at delivery (35 + 5 vs. 38 + 1 weeks, p = 0.01); a higher rate of unscarred uteri (22.7% vs. 2.6%, p < 0.01); and rupture occurring outside the lower uterine segment (52.3% vs. 10.5%, p < 0.01).

CONCLUSION

Uterine rupture entails increased risk for several adverse maternal outcomes, though possibly more favorable than previously described. Numerous risk factors for composite maternal morbidity following rupture exist and should be carefully assessed in these patients.

Clinical analysis of complete uterine rupture during pregnancy

BACKGROUND

Uterine rupture in pregnant women can lead to serious adverse outcomes. This study aimed to explore the clinical characteristics, treatment, and prognosis of patients with complete uterine rupture.

METHODS

Data from 33 cases of surgically confirmed complete uterine rupture at Chenzhou No.1 People's Hospital between January 2015 and December 2022 were analyzed retrospectively.

RESULTS

In total, 31,555 pregnant women delivered in our hospital during the study period. Of these, approximately 1‰ (n = 33) had complete uterine rupture. The average gestational age at complete uterine rupture was 31+4 weeks (13+1-40+3 weeks), and the average bleeding volume was 1896.97 ml (200-6000 ml). Twenty-six patients (78.79%) had undergone more than two deliveries. Twenty-five women (75.76%) experienced uterine rupture after a cesarean section, two (6.06%) after fallopian tube surgery, one (3.03%) after laparoscopic cervical cerclage, and one (3.03%) after wedge resection of the uterine horn, and Fifteen women (45.45%) presented with uterine rupture at the original cesarean section incision scar. Thirteen patients (39.39%) were transferred to our hospital after their initial diagnosis. Seven patients (21.21%) had no obvious symptoms, and only four patients (12.12%) had typical persistent lower abdominal pain. There were 13 cases (39.39%, including eight cases ≥ 28 weeks old) of fetal death in utero and two cases (6.06%, both full term) of severe neonatal asphyxia. The rates of postpartum hemorrhage, blood transfusion, hysterectomy were 66.67%, 63.64%, and 21.21%. Maternal death occurred in one case (3.03%).

CONCLUSIONS

The site of the uterine rupture was random, and was often located at the weakest point of the uterus. There is no effective means for detecting or predicting the weakest point of the uterus. Rapid recognition is key to the treatment of uterine rupture.

[Maternal mortality due to obstetric haemorrhage in France 2016-2018]

Between 2016 and 2018, 20 maternal deaths were related to obstetric haemorrhage, excluding haemorrhage in the first trimester of pregnancy, representing a mortality ratio of 0.87 per 100,000 live births (95% CI 0.5 -1.3). Obstetric haemorrhage is the cause of 7.4% of all maternal deaths up to 1 year, 10% of maternal deaths within 42days, and 21% of deaths directly related to pregnancy (direct causes). Between 2001 and 2018, maternal mortality from obstetric haemorrhage has been considerably reduced, from 2.2deaths per 100,000 live births in 2001-2003 to 0.87 in the period presented here. Nevertheless, obstetric haemorrhage is still one of the main direct causes of maternal death, and remains the cause with the highest proportion of deaths considered probably (53%) or possibly (42%) preventable according to the CNEMM's collegial assessment (see chapter 3). The preventable factors reported are related to inadequate content of care in 94% of cases and/or organisation of care in 44% of cases. In this triennium, maternal death due to haemorrhage occurred mainly in the context of caesarean delivery (65% of cases, i.e. 13/20), and mostly in the context of emergency care (12/13). The main causes of obstetric haemorrhage were uterine rupture (6/20) in unscarred uterus or in association with placenta accreta, and surgical injury during the caesarean delivery (5/20). Every maternity hospital, whatever its resources and/or technical facilities, must be able to plan any obstetric haemorrhage situation that threatens the mother's vital prognosis. Intraperitoneal occult haemorrhage following caesarean section and uterine rupture require immediate surgery with the help of skilled surgeon resources with early and appropriate administration of blood products.

Trial of labor after cesarean, vaginal birth after cesarean, and the risk of uterine rupture: an expert review

The decision to pursue a trial of labor after cesarean delivery is complex and depends on patient preference, the likelihood of successful vaginal birth after cesarean delivery, assessment of the risks vs benefits of trial of labor after cesarean delivery, and available resources to support safe trial of labor after cesarean delivery at the planned birthing center. The most feared complication of trial of labor after cesarean delivery is uterine rupture, which can have catastrophic consequences, including substantial maternal and perinatal morbidity and mortality. Although the absolute risk of uterine rupture is low, several clinical, historical, obstetrical, and intrapartum factors have been associated with increased risk. It is therefore critical for clinicians managing patients during trial of labor after cesarean delivery to be aware of these risk factors to appropriately select candidates for trial of labor after cesarean delivery and maximize the safety and benefits while minimizing the risks. Caution is advised when considering labor augmentation and induction in patients with a previous cesarean delivery. With established hospital safety protocols that dictate close maternal and fetal monitoring, avoidance of prostaglandins, and careful titration of oxytocin infusion when induction agents are needed, spontaneous and induced trial of labor after cesarean delivery are safe and should be offered to most patients with 1 previous low transverse, low vertical, or unknown uterine incision after appropriate evaluation, counseling, planning, and shared decision-making. Future research should focus on clarifying true risk factors and identifying the optimal approach to intrapartum and induction management, tools for antenatal prediction, and strategies for prevention of uterine rupture during trial of labor after cesarean delivery. A better understanding will facilitate patient counseling, support efforts to improve trial of labor after cesarean delivery and vaginal birth after cesarean delivery rates, and reduce the morbidity and mortality associated with uterine rupture during trial of labor after cesarean delivery.

Incidence and outcomes of uterine rupture in women with unscarred, preterm or prelabour uteri: data from the international network of obstetric survey systems

OBJECTIVE

Analysis of atypical cases of uterine rupture, namely, uterine rupture occurring in unscarred, preterm or prelabour uteri.

DESIGN

Descriptive multi-country population-based study.

SETTING

Ten high-income countries within the International Network of Obstetric Survey Systems.

POPULATION

Women with unscarred, preterm or prelabour ruptured uteri.

METHODS

We merged prospectively collected individual patient data in ten population-based studies of women with complete uterine rupture. In this analysis, we focused on women with uterine rupture of unscarred, preterm or prelabour ruptured uteri.

MAIN OUTCOME MEASURES

Incidence, women's characteristics, presentation and maternal and perinatal outcome.

RESULTS

We identified 357 atypical uterine ruptures in 3 064 923 women giving birth. Estimated incidence was 0.2 per 10 000 women (95% CI 0.2-0.3) in the unscarred uteri, 0.5 (95% CI 0.5-0.6) in the preterm uteri, 0.7 (95% CI 0.6-0.8) in the prelabour uteri, and 0.5 (95% CI 0.4-0.5) in the group with no previous caesarean. Atypical uterine rupture resulted in peripartum hysterectomy in 66 women (18.5%, 95% CI 14.3-23.5%), three maternal deaths (0.84%, 95% CI 0.17-2.5%) and perinatal death in 62 infants (19.7%, 95% CI 15.1-25.3%).

CONCLUSIONS

Uterine rupture in preterm, prelabour or unscarred uteri are extremely uncommon but were associated with severe maternal and perinatal outcome. We found a mix of risk factors in unscarred uteri, most preterm uterine ruptures occurred in caesarean-scarred uteri and most prelabour uterine ruptures in 'otherwise' scarred uteri. This study may increase awareness among clinicians and raise suspicion of the possibility of uterine rupture under these less expected conditions.

Uterine rupture and factors associated with adverse outcomes

PURPOSE

To review cases of uterine rupture and identify risk factors associated with adverse outcomes.

METHODS

This study is a retrospective cohort of complete uterine ruptures diagnosed in a large hospital system in Massachusetts between 2004 and 2018. Baseline demographics, labor characteristics and outcomes of uterine rupture were collected from medical records.

RESULTS

A total of 173 cases of uterine rupture were identified. There were 30 (17.3%) women with an unscarred uterus, while 142 (82.1%) had a scarred uterus. Adverse outcomes (n = 89, 51.4% of cases) included 26 (15.0%) hysterectomies, 55 (31.8%) blood transfusions, 18 (10.4%) bladder/ureteral injuries, 5 (2.9%) reoperations, 25 (14.5%) Apgar scores lower than 5 at 5 min and 9 (5.2%) perinatal deaths. Uterine rupture of a scarred uterus was associated with decreased risk of hemorrhage (OR 0.40, 95% CI 0.17-0.93), blood transfusion (OR 0.27, 95% CI 0.11-0.69), hysterectomy (OR 0.23, 95% CI 0.08-0.69) and any adverse outcome (OR 0.34, 95% CI 0.13-0.91) compared with unscarred rupture. Uterine rupture during vaginal delivery was associated with increased risk of transfusion (OR 6.55, 95% CI 1.53-28.05) and hysterectomy (OR 8.95, 95% CI 2.12-37.72) compared with emergent C-section.

CONCLUSIONS

Although rare, uterine rupture is associated with adverse outcomes in over half of cases. Unscarred rupture and vaginal delivery demonstrate increased risk of adverse outcomes, highlighting the need for early diagnosis and operative intervention.

Case-control study on determinants of uterine rupture among mothers who gave birth at Hawassa University comprehensive specialized hospital

BACKGROUND

Uterine rupture is defined as tearing of the uterine wall during pregnancy or delivery. It can occur during pregnancy or labor and delivery. Rupture of the uterus is a catastrophic event resulting in the death of the baby, and severe maternal morbidity and mortality Despite different interventions done by stakeholders, it remained one of the leading public problems in developing countries like Ethiopia.

OBJECTIVE

This study assessed the prevalence and determinants of uterine rupture among mothers who gave birth at Hawassa University comprehensive specialized hospital from July 2015 to June 2020G.C.

METHOD

A case-control study was conducted by reviewing data from a total of 582 patient charts which include 194 cases and 388 controls with a case-to-control ratio of 1:2. Then the data was extracted using a pre-tested and structured data extraction sheet. Data were entered using Epi data 3.1 and exported to SPSS and analyzed using SPSS 20. The association between independent variables and uterine rupture was estimated using an odds ratio with 95% confidence intervals. The statistical significance of the association was declared at P-value < 0.05.

RESULT

There were a total of 22,586 deliveries and 247 confirmed cases of uterine rupture which makes the prevalence 1.09%. Lack of ANC (Ante-natal care) (AOR = 7.5; 95% CI: 1.9-30.3) inadequate ANC (AOR = 2.45; 95% CI: 1.1-5.57), gravidity ≥5 (AOR = 3.3; 95% CI: 1.36-8.12), obstructed labor (AOR = 38.3; 95% CI: 17.8-82.4) and fetal macrosomia (AOR = 8; 95% CI: 17.8-82.4) are variables which increase the odds of developing uterine rupture. Mothers without additional medical or obstetric conditions are more likely (AOR = 4.2; 95% CI: 2.1-8.65) to develop uterine rupture than mothers with additional medical or obstetric conditions.

CONCLUSION

The prevalence of uterine rupture is high in the study area. The study also revealed that a decrease in ANC follow-up, gravidity of ≥5, obstructed labor, and fetal weight of >4kg are significantly associated with uterine rupture. Improving the quality of ANC follow-up, intrapartum follow-up and proper estimation of fetal weight are recommended interventions from the study.

Human Mesenchymal Stem Cell Sheets Improve Uterine Incision Repair in a Rodent Hysterotomy Model

OBJECTIVE

The study aimed to assess the feasibility of creating and transplanting human umbilical cord mesenchymal stem cell sheets applied to a rat model of hysterotomy, and additionally to determine benefits of human umbilical cord mesenchymal stem cell sheet transplantation in reducing uterine fibrosis and scarring.

STUDY DESIGN

Human umbilical cord mesenchymal stem cell sheets are generated by culturing human umbilical cord mesenchymal stem cells on thermo-responsive cell culture plates. The temperature-sensitive property of these culture dishes facilitates normal cell culture in a thin contiguous layer and allows for reliable recovery of intact stem cell sheets without use of destructive proteolytic enzymes.We developed a rat hysterotomy model using nude rats. The rat uterus has two distinct horns: one horn provided a control/untreated scarring site, while the second horn was the cell sheet transplantation site.On day 14 following surgery, complete uteri were harvested and subjected to histologic evaluations of all hysterotomy sites.

RESULTS

The stem cell sheet culture process yielded human umbilical cord mesenchymal stem cell sheets with surface area of approximately 1 cm².Mean myometrial thickness in the cell sheet-transplanted group was 274 μm compared with 191 μm in the control group (p = 0.02). Mean fibrotic surface area in the human umbilical cord mesenchymal stem cell sheet-transplanted group was 95,861 μm² compared with 129,185 μm² in the control group. Compared with control horn sites, cell sheet-transplanted horns exhibited significantly smaller fibrotic-to-normal myometrium ratios (0.18 vs. 0.27, respectively, p = 0.029). Mean number of fibroblasts in cell sheet-transplanted horns was significantly smaller than the control horns (483 vs. 716/mm², respectively, p = 0.001).

CONCLUSION

Human umbilical cord mesenchymal stem cell sheet transplantation is feasible in a rat model of hysterotomy. Furthermore, use of stem cell sheets reduces fibroblast infiltration and uterine scar fibrotic tissue formation during hysterotomy healing, potentially mitigating risks of uterine scar formation.

KEY POINTS

· Stem cell sheet transplanted to hysterotomy promotes myometrial regeneration and reduced fibrotic tissue formation.. · This study demonstrates the feasibility of using human umbilical cord mesenchymal stem cell sheets..

Uncertain fetal head engagement: a prospective randomized controlled trial comparing digital exam with angle of progression

BACKGROUND

Uncertain fetal head engagement represents 4% of obstetrical situations associated with an increased risk of postpartum hemorrhage, notably in cases of cesarean delivery and increased neonatal impairment owing to failed vaginal instrumental delivery. In this obstetrical condition, cesarean delivery is recommended, but vaginal delivery is possible in two-thirds of the cases. During the second stage of labor, the descent of the fetal head can be assessed by sonography, particularly by measuring the angle of progression.

OBJECTIVE

To evaluate, after a prolonged second stage of labor, the impact of measuring the angle of progression in addition to a digital examination on cesarean delivery rates when fetal head engagement remains uncertain.

STUDY DESIGN

This open multicenter randomized pragmatic trial included women at term with a singleton cephalic fetus in a clinical occiput anterior position after a prolonged 2-hour second stage of labor with uncertain fetal head engagement. After inclusion in the study, an independent investigator performed ultrasound systematically to confirm the occiput anterior position and measured the angle of progression at the climax of Valsalva pushing. This operator did not participate in labor management. In the study group but not in the control group, the angle of progression was communicated to the obstetrician in charge of labor management. Obstetricians were encouraged to attempt vaginal birth if the angle of progression was >120°. The primary outcome was the cesarean delivery rate. Secondary outcomes were operative delivery rate (cesarean delivery and operative vaginal delivery), maternal complications (third and fourth-degree perineal tears, failed vaginal instrumental delivery, postpartum hemorrhage, hysterectomy), and neonatal outcomes (Apgar score <5 at 10 minutes, umbilical arterial pH <7.10, neonatal wounds, neonatal intensive care unit admission).

RESULTS

A total of 45 women were included in the study. Occiput anterior position was confirmed in 33 women: 16 in the study group and 17 in the control group. Women's characteristics at baseline were similar between the groups. The median (range) angles of progression were similar: 138.4° (15) and 140.3° (16.9) in the study and control group, respectively. Cesarean delivery rates were 12.5% in the study group and 41.1% in the control group (P=.06). Secondary outcomes were similar between the 2 groups. No failed vaginal instrumental delivery was reported.

CONCLUSION

Measurement of the angle of progression in addition to digital examination when fetal head engagement remained uncertain showed promising results in decreasing cesarean delivery rates. A larger multicenter randomized controlled trial is needed to confirm these results.

Risk factors and outcomes associated with type of uterine rupture

PURPOSE

To identify risk factors associated with the occurrence of complete uterine rupture (CUR) in comparison to partial uterine rupture (PUR) to further investigate to what extent a standardized definition is needed and what clinical implications can be drawn.

METHODS

Between 2005 and 2017 cases with CUR and PUR at Charité University Berlin, Germany were retrospectively identified. Demographic, obstetric and outcome variables were analyzed regarding the type of rupture. Binary multivariate regression analysis was conducted to identify risk factors associated with CUR. In addition, the intended route of delivery (trial of labor after cesarean delivery (TOLAC) and elective repeat cesarean delivery (ERCD)), divided according to the type of rupture, was compared.

RESULTS

92 cases with uterine rupture were identified out of a total of 64.063 births (0.14%). Puerperal complications were more frequent in CUR (67.9 versus 41.1%, p = 0.021). Multiparity ≥ 3 was more frequent in CUR (31 versus 10.7%, p = 0.020). Factors increasing the risk for CUR were parity ≥ 3 (OR = 3.8, p = 0.025), previous vaginal birth (OR = 4.4, p = 0.011), TOLAC (OR = 6.5, p < 0.001) and the use of oxytocin (OR = 2.9, p = 0.036). After multivariate analysis, the only independent risk factor associated with CUR was TOLAC (OR = 7.4, p = 0.017).

CONCLUSION

TOLAC is the only independent risk factor for CUR. After optimized antenatal counselling TOLAC and ERCD had comparable short-term maternal and fetal outcomes in a high resource setting. A high number of previous vaginal births does not eliminate the risk of uterine rupture. A clear distinction between CUR and PUR is essential to ensure comparability among studies.

Ten years of uterine rupture in an Australian tertiary hospital

AIMS

Complete uterine rupture is a rare and serious complication of pregnancy. Although most commonly associated with attempted vaginal birth after caesarean (VBAC), rupture also occurs in atypical/non-VBAC cases. This retrospective, single-tertiary-institution observational study aimed to assess the prevalence and morbidity of complete uterine rupture during 2010-2020.

METHODS

Hospital discharge codes and local maternity databases identified uterine rupture cases, with medical record reviews confirming the diagnosis, distinguishing complete rupture from dehiscence, and extracting additional data. VBAC attempt was defined as planned labour trial after one prior caesarean.

RESULTS

Over the decade, 27 complete ruptures occurred among 58 614 women, a rate of 4.6 per 10 000 births. One woman with three successive fundal ruptures had only the first included in further analysis, leaving 25 discrete women; 19 ruptures occurred in term planned VBAC attempts and six in preterm atypical/non-VBAC cases (two nulliparas and four women with multiple prior caesareans). The VBAC-attempt rupture rate was 0.74%, similar to published reports. All five perinatal deaths occurred in preterm atypical/non-VBAC cases. In the term VBAC-attempt group, rupture-related perinatal morbidity included four cases (21%) of hypoxic-ischaemic encephalopathy, with two cases (11%) of cerebral palsy at follow-up. Overall, perinatal morbidity was highest with total fetal extrusion. Maternal blood loss ≥1500 mL or transfusion was almost threefold higher, and postnatal length-of-stay was three days longer, after vaginal than caesarean birth, with delay in rupture recognition being a factor.

CONCLUSION

A high suspicion index for uterine rupture is imperative during any labour, particularly in the scarred uterus, with vigilance continuing after successful vaginal birth.

Prevalence and determinants of uterine rupture in Ethiopia: a systematic review and meta-analysis

Uterine rupture is a serious public health concern that causes high maternal and perinatal morbidity and mortality in the developing world. Few of the studies conducted in Ethiopia show a high discrepancy in the prevalence of uterine rupture, which ranges between 1.6 and 16.7%. There also lacks a national study on this issue in Ethiopia. This systematic and meta-analysis, therefore, was conducted to assess the prevalence and determinants of uterine rupture in Ethiopia. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for systematic review and meta-analysis of studies. All observational published studies were retrieved using relevant search terms in Google scholar, African Journals Online, CINHAL, HINARI, Science Direct, Cochrane Library, EMBASE and PubMed (Medline) databases. Newcastle–Ottawa assessment checklist for observational studies was used for critical appraisal of the included articles. The meta-analysis was done with STATA version 14 software. The I² test statistics were used to assess heterogeneity among included studies, and publication bias was assessed using Begg's and Egger's tests. Odds ratio (OR) with a 95% confidence interval (CI) was presented using forest plots. A total of twelve studies were included in this study. The pooled prevalence of uterine rupture was 3.98% (95% CI 3.02, 4.95). The highest (7.82%) and lowest (1.53%) prevalence were identified in Amhara and Southern Nations, Nationality and Peoples Region (SNNPR), respectively. Determinants of uterine rupture were urban residence (OR = 0.15 (95% CI 0.09, 0.23)), primipara (OR = 0.12 (95% CI 0.06, 0.27)), previous cesarean section (OR = 3.23 (95% CI 2.12, 4.92)), obstructed labor(OR = 12.21 (95% CI 6.01, 24.82)), and partograph utilization (OR = 0.12 (95% CI 0.09, 0.17)). Almost one in twenty-five mothers had uterine rupture in Ethiopia. Urban residence, primiparity, previous cesarean section, obstructed labor and partograph utilization were significantly associated with uterine rupture. Therefore, intervention programs should address the identified factors to reduce the prevalence of uterine rupture.

Laparoscopic repair of uterine rupture following successful second vaginal birth after caesarean delivery: A case report

BACKGROUND

With the increasing trend of vaginal birth after caesarean delivery (VBAC), evaluation of the feasibility and safety of a second VBAC with grand multiparity is worth considering. Intrapartum uterine rupture is diagnosed in approximately one-fifth of all VBAC cases following successful vaginal delivery. To our knowledge, no report is available on the application of laparoscopy to repair postpartum uterine rupture after a successful second VBAC in China.

CASE SUMMARY

A 31-year-old woman (gravida 5, para 2) at 39 wk and 5 d of gestation was admitted to the hospital in labour. After a successful VBAC and observation for approximately 13 h, the patient complained of progressive abdominal pain. Given the symptoms, signs, and auxiliary examination results, intraperitoneal bleeding was considered. Because the patient was stable and ultrasound imaging was the only method available to assess the possibility of rupture, we recommended laparoscopy to clarify the diagnosis and for prompt laparoscopic uterine repair or exploratory laparotomy if necessary. Operative findings included transverse uterine scar rupture at the lower uterine segment of approximately 5.0 cm in length and 800 mL of intraoperative pelvic haemoperitoneum. Finally, she successfully underwent laparoscopic repair of uterine rupture and recovered very well according to three-dimensional magnetic resonance imaging at 42 d postpartum.

CONCLUSION

Routine postpartum intrauterine exploration is not beneficial to the mother and may even increase the risk of rupture. This case highlights a laparoscopic approach for repairing uterine rupture in the immediate postpartum period.

Uterine rupture in a gravid, unscarred uterus: A case report

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The risk of uterine rupture in a gravid, unscarred uterus is largely unknown.

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The risk factors for uterine rupture, when summed, can accumulate to a devastating and unforeseen end-result, such as fetal and maternal demise.

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Low suspicion for rare occurrences such as uterine rupture in an unscarred uterus can delay diagnosis, with increased likelihood of fetal and maternal morbidity and mortality.

When advising a pregnant patient who has previously had a cesarean section about the risks of trial of labor, it is important to explain the risk of uterine rupture. Subjective symptoms of abdominal pain or objective findings of non-reassuring fetal status and loss of fetal station are often indicative of this disease process, which most commonly is caused by a defect on the uterus from the cesarean delivery. Any uterine surgical intervention (myomectomy, for example) is the leading risk factor for uterine rupture. This case report presents a patient who had no such history. However, the maternal and fetal clinical status rapidly deteriorated and required emergency cesarean delivery, at which point a complete uterine rupture was diagnosed. Low suspicion for rare occurrences such as uterine rupture in an unscarred uterus can delay diagnosis, with increased likelihood of fetal and maternal morbidity and mortality.