UTERINE RUPTURE

2011

What constitutes uterine rupture?

What constitutes dehiscence of caesarean scar?

Incidence
Global: 1/1536 pregnancies (0.07%) High income countries: 0.012%
Emedicine 2010

RUPTURE OF UNSCARRED UTERUS

RUPTURE OF UNSCARRED UTERUS

Incidence:
High-income countries: 0.012% (1/8,834 deliv.) Low-income countries: 0.11% (1/920 deliv.)

Happens almost always during labour

RUPTURE OF UNSCARRED UTERUS Main factor of risk: OBSTRUCTED LABOR

(undiagnosed, poorly monitored, augmented with oxytocin)

RUPTURE OF UNSCARRED UTERUS

Maternal risk factors: (Grand) multiparity Older age (>30) Uterine risk factors: Congenital abnormalities (uterus thinner in places)
Pregnancy in rudimentary horn + induction of labour

Pendulous uterus Uterine sacculation

RUPTURE OF UNSCARRED UTERUS Pendulous uterus

RUPTURE OF UNSCARRED UTERUS

Maternal risk factors: (Grand) multiparity Older age (>30) Uterine risk factors: Congenital abnormalities (uterus thinner in places)
Pregnancy in rudimentary horn + induction of labour

Pendulous uterus Uterine sacculation

RUPTURE OF UNSCARRED UTERUS: Uterine sacculation

RUPTURE OF UNSCARRED UTERUS Neglected transverse lie

RUPTURE OF UNSCARRED UTERUS

Placental factors of risk: Increta / percreta Abruptio Uterine overdistension: Multifetal pregnancy Polyhydramnios

RUPTURE OF UNSCARRED UTERUS

Forceps extraction (?)

External cephalic version

Internal podalic version Breech extraction (?) Shoulder dystocia Manual extraction of placenta Fundal pressure

RUPTURE OF UNSCARRED UTERUS

Before labour (0.012%): Trauma (MVA, falls from heights, blunt trauma, shooting/stabbing) Placenta increta / percreta Malformations Sacculation

RUPTURE OF UNSCARRED UTERUS

Fall off a bridge
N. N. Mahajan & A. Kale Internet J Gynecol Obstet 2008, 9 (2)

RUPTURE OF UNSCARRED UTERUS: DIAGNOSIS (1)

Presence of risk factors

Most dangerous context: lack of progress in active phase

of dilatation is it due to obstructed labour? Most frequent sign: foetal distress (80%).
Prolonged decelerations Bradycardia

Uterine hyperactivity, spontaneous or stimulated

Impending rupture: Bandls retraction ring

RUPTURED OF UNSCARRED UTERUS: DIAGNOSIS (2)

Absence of contractions
Abdominal pain: only in 5% of cases as first sign.

Epidural? Ascension of presenting part Vaginal bleeding Shock (30-50%) Post-partum bleeding

RUPTURE OF SCARRED UTERUS DUE TO CAESAREAN SECTION

RUPTURE OF SCARRED UTERUS DUE TO CAESAREAN SECTION

Classical caesarean (0.5% of all births in USA): Various rates of rupture in labour reported: 0.68% to 11.5% On 105 cases: 1.9% ACOG 4-5% RCOG 2-9% Low vertical incision: 1,1 1.2%

RUPTURE OF SCARRED UTERUS DUE TO CAESAREAN SECTION

Transverse incision on lower segment: When? During labour 0.5% Before labour 0.16% (compare with 0.012% in unscarred uteri) What if labour is augmented with oxytocin? Conflicting data. Augmentation and induction considered together. Large variety of dosages.

RUPTURE OF SCARRED UTERUS DUE TO CAESAREAN SECTION

Transverse incision on lower segment: What if labour is induced? Amniotomy and oxytocin: 1.4 4% rupture rate Balloon (Foley): 1.6% without oxytocin (NS in resp. study); with oxytocin 3.67 Prostaglandins:
No rupture (225 cases) Others: 2.45 5.2%

RUPTURE OF SCARRED UTERUS DUE TO CAESAREAN SECTION

Transverse incision on lower segment: What is the risk if NVD prior to CS?
1,021 with previous NVD: 0.2% rupture at TOL 2762 with no previous NVD: 1.1% rupture (p=0.01)
Zelop et al, 2000

What is the risk if already VBAC once or more?

No VBAC: 0.87% rupture, one VBAC: 0.43% (13,532 women)

RUPTURE OF SCARRED UTERUS DUE TO CAESAREAN SECTION

Transverse incision on lower segment: Interdelivery interval:
Under 2 years: 2.8% rupture, over 2 years 0.9% in 1527 women

(p=0.01)
Bujold et al , 2002

One or two layers of suture?

3.1% vs 0.5%
Bujold et al , 2002

RUPTURE OF SCARRED UTERUS DUE TO CAESAREAN SECTION

Transverse incision on lower segment: What is the risk after 2 or more CS?
1.36% rupture (17 studies, 5,666 patients)
Tahseen et al, 2010

Fetal macrosomia?
Risk increased 2 above 4000 g

Maternal age:
over 30 risk 3

Thickness of lower segment at 36-38wks:

3.5 mm, others 2 mm

Diagnosis of rupture of scar on CT

Eller A G, Fisher B, N Engl J Med 2009; 360:170

Oyelese et al. J Ultrasound Med.2003; 22: 977-980

Cesarean Scar Ectopic Pregnancy - A Case Presentation Arthur C. Fougner, MD

Obgyn.net

Cesarean Scar Ectopic Pregnancy - A Case Presentation Arthur C. Fougner, MD

Obgyn.net

PREVENTION OF SCAR RUPTURE

The following would increase the risk of rupture above 0.5%:
Multiple previous cesarean deliveries Previous classic midline cesarean delivery

Previous low vertical cesarean delivery

Previous low transverse cesarean delivery with a

single-layer hysterotomy closure Previous cesarean delivery with an interdelivery interval of less than 2 years Previous low transverse cesarean delivery with a congenitally abnormal uterus

PREVENTION OF SCAR RUPTURE

Previous cesarean delivery without a previous

history of a successful vaginal birth Previous cesarean delivery with either labor induction or augmentation Previous cesarean delivery in a woman carrying a macrosomic fetus weighing >4000 g Previous uterine myomectomy accomplished by means of laparoscopy or laparotomy

MANAGEMENT

MANAGEMENT
Intensive resuscitation

Surgery within 10 37 min - before major foetal hypoxic

damage Good exposure: midline incision superior Short exploration: type and size of rupture; bladder involved? Delivery of foetus if not already expelled in abdomen

MANAGEMENT
Hysterectomy or suture? Various rates of hysterectomy reported: 6-78% Suture only if:
Transversal rupture No extension to cervix, paracolpos or parametrium Good haemostasis achieved No uterine inertia Resuscitation efficient Mother wants more children

TYPES OF RUPTURES

BROAD LIGAMENT HAEMATOMA

PROGNOSIS
Maternal mortality: 0 1% in high-income countries 5 10% in low-income Perinatal mortality: 2 6% in recent studies from high-income countries May be as high as 84% in areas in Africa
Eze JN, Ibekwe PC 2010