Evaluation of obstetricians' surgical decision making in the management of uterine rupture

In-hospital outcomes of repair and hysterectomy for uterine rupture: A nationwide observational study

OBJECTIVE

Uterine rupture, though rare, poses significant risks to both mother and child. Its occurrence varies globally, with a noted 0.015% prevalence in Japan. This condition usually requires surgical intervention, either as uterine repair or hysterectomy. Past studies, largely single-center and outdated, offer limited insights into these treatment options. To assess and compare the clinical outcomes of repair and hysterectomy for uterine rupture among patients included in a large inpatient database in Japan.

STUDY DESIGN

We analyzed the Diagnosis Procedure Combination inpatient database from July 2010 to March 2022. Patients with uterine rupture who underwent uterine repair or hysterectomy were extracted. Patient characteristics, in-hospital care, and outcomes were compared between the uterine repair group and the hysterectomy group. Main outcomes are reoperation during hospitalization, total volume of blood transfusion, complications (bowel injury, urinary tract injury, wound infection, deep vein thrombosis, or pulmonary embolism), maternal mortality, and postoperative length of stay.

RESULTS

We identified 644 patients with uterine rupture. Of those, 287 (44.6 %) underwent uterine repair and 357 (55.4 %) underwent hysterectomy. The hysterectomy group was significantly older, had significantly more comorbidities, and had a significantly higher prevalence of consciousness impairment than the uterine repair group. Compared with the uterine repair group, the hysterectomy group required significantly more in-hospital care and had a significantly greater incidence of reoperation (1.0 % versus 6.4 %; P<0.001). Other complications were not significantly different between the groups. The hysterectomy group had significantly more blood transfusions and a significantly longer postoperative length of hospital stay than the uterine repair group. The results remained consistent even after the adjusted analysis.

CONCLUSION

This study highlights the differences between repair and hysterectomy for uterine rupture, providing valuable insights for clinical decision-making in these cases.

Subsequent Pregnancy Outcome in Women with Prior Complete Uterine Rupture: A Single Tertiary Care Centre Experience

Limited data is available to assess the burden of maternal morbidity, mortality, and perinatal outcome after subsequent pregnancy in women with prior uterine rupture. Therefore, this retrospective descriptive study was conducted to determine subsequent pregnancy outcomes in a larger series of women with prior complete uterine rupture. All pregnant women who had complete uterine rupture were managed according to the standard Institute protocol. The women who conceived following a uterine repair from July 2011 to June 2020 were recruited into the study. Outcome measures included severe maternal morbidities and perinatal outcomes. Fifty-three women with prior complete uterine rupture were conceived subsequently. Two women had an abortion in the first and second trimester, respectively. None of the women developed recurrence of uterine rupture. However, three women developed uterine dehiscence in a total of 16 women who went into spontaneous labour before elective cesarean delivery at 32, 36, and 37 weeks, respectively. None of the women had placenta previa, placenta accreta, bowel injury, bladder injury and none required a hysterectomy. However, 16.7% of women needed a blood transfusion. None of the women required mechanical ventilation, inotropic support, and intensive care unit stay. Seventeen babies required neonatal intensive care admission, and prematurity (90%) was the most common reason, followed by low APGAR scores. In conclusion, subsequent pregnancy outcomes in women with prior uterine rupture appear acceptable in institutionalized care. Timing of cesarean delivery may have to be weighed against the risk of prematurity-associated neonatal morbidity and mortality.

A Review on the Etiology, Prevention, and Management of Ureteral Injuries During Obstetric and Gynecologic Surgeries

Iatrogenic ureteral injuries are a rare but serious complication of some gynecological and obstetric procedures with both high morbidity and legal implications. The incidence varies widely depending on the type and extent of the surgeries with about 70% unrecognized intraoperatively. When recognized intraoperatively and promptly managed, the prognosis is good. Ureteral injuries recognized postoperatively come with dire consequences for the patients and are litigation prone. Due to the proximity of the lower half of the ureters to the pelvic organs, 50% of the cases of injuries to the ureter occur within the jurisdiction of gynecological and obstetric practice. A good knowledge of the etiology, predisposing factors, appropriate surgical skills, proper identification of the course and deviation of the ureters, and intraoperative recognition of inadvertent damage to the ureter and its vasculature is required by all obstetricians and gynecologists to reduce the incidence of ureteral injuries by at least 50%. This review aims to add to what is already known, particularly among obstetricians and gynecologists practicing in resource-constrained settings.

Ultrasonic manifestations and clinical analysis of 25 uterine rupture cases

PURPOSE

To explore the risk factors, ultrasonic manifestations, clinical features, and maternal and neonatal outcomes associated with complete uterine rupture.

BASIC PROCEDURES

All cases of complete uterine rupture diagnosed and treated in Jiangxi Maternal and Child Health Hospital from January 2012 to July 2018 were retrospectively analyzed. Risk factors, ultrasonic manifestations, clinical features, and maternal and infant outcomes were analyzed.

RESULT

All patients had a history of uterine surgery or induced abortion. Ultrasound examination revealed 15 cases of complete rupture of the uterus, five cases of missed diagnosis, three cases of misdiagnosis, and two cases of direct emergency operation without ultrasonography because of typical clinical manifestations and critical conditions. The clinical manifestations of 25 cases of uterine rupture varied from asymptomatic to clinical signs of "resting" rupture of the uterus to severe pain, hypotension, shock, and coma. All patients underwent surgical treatment, of which one case underwent DIC and died after rescue. The maternal mortality rate was 4% (1/25), the mortality rate of newborns (two pregnant women was twins) was 44% (12/27).

CONCLUSION

A history of uterine surgery is a major risk factor for uterine rupture. Attention should be paid not only to women who are pregnant again after cesarean section but also to those who have undergone other uterine operations (such as laparoscopic myomectomy, laparoscopic cornual pregnancy removal, etc.), delivery plans should be formulated accordingly. In cases of sudden abdominal pain during pregnancy or childbirth, the possibility of uterine rupture should be considered to achieve a timely and correct diagnosis and treatment.