[42] Uterine Rupture Flashcards
What is a uterine rupture?
A full thickness disruption of the uterine muscle and overlying serosa
When does uterine rupture occur?
Typically during labour
What can uterine rupture extend to affect?
Bladder or broad ligament
What are the main types of uterine rupture?
- Incomplete
- Complete
What is an incomplete uterine rupture?
When the peritoneum overlying the uterus is in tact, and so the uterine contents remain with the uterus
How does an incomplete uterine rupture present?
Usually asymptomatic
Does an incomplete uterine rupture require emergency surgery?
No
What is a complete uterine rupture?
Peritoneum is also torn, and uterine contents can escape into the peritoneal cavity
What are the types of complete uterine rupture?
- Traumatic
- Spontaneous
What can cause a traumatic uterine rupture?
- Motor vehicle accident
- Incorrect use of oxytocin agent
- Poorly conducted attempt at operative vaginal delivery
In whom can spontaneous uterine rupture occur in?
Patients with a history of C-section or trauma that could have caused permanent damage
What is the incidence of uterine rupture in an unscarred uterus?
Extremely rare - 6 in 10,000 deliveries
What is the incidence of uterine rupture following C-section when VBAC is attempted?
22-74/10,000
In general, what are the risk factors for uterine rupture?
Those that make the uterus inherently weaker
What are the risk factors for uterine rupture?
- Previous C-section
- Previous uterine surgery
- Induction or augmentation of labour
- Obstruction of labour
- Multiple pregnancy
- Multiparity
What is the biggest risk factor for uterine rupture?
Previous C-section
What % of cases of uterine rupture occur when there has been a previous C-section?
87%
What type of C-section carries the greater risk of uterine rupture?
Classical (vertical) incisions
Give an example of. uterine surgery that increases the risk of uterine rupture?
Myomectomy
What kind of induction in particular increases the risk of uterine rupture?
Prostaglandins
When is obstruction of labour an important risk factor to consider for uterine rupture?
In developing countries
Why can the diagnosis and prompt management of uterine rupture be difficult?
Because the initial clinical features of uterine rupture are non-specific
What is the most common presenting symptom of uterine rupture?
Sudden, severe abdominal pain, which persists between contractions
What other presenting symptoms might a patient with uterine rupture experience?
- Shoulder-tip pain
- Vaginal bleeding
What causes shoulder tip pain in uterine rupture?
Diaphragmatic irritation
What may be found on examination in uterine rupture?
- Regression of presenting part
- Abdominal palpation revealing scar tenderness and palpable fetal parts
- Features of hypovolaemic shock
When might there be features of hypovolaemic shock in uterine rupture?
If significant haemorrhage
What might fetal monitoring reveal in uterine rupture?
Distress or absent heart sounds
What are the differentials for uterine rupture?
- Placental abruption
- Placenta praevia
- Vasa praevia
What is vital monitoring in women at risk of uterine rupture?
Intrapartum monitoring with CTG
What are early indicators of uterine rupture on CTG?
- Recurrent or late decelerations
- Prolonged fetal bradycardia
What often happens when there is a pathological CTG with uterine rupture?
The pathological CTG prompts the emergency C-section, and uterine rupture is noted intra-operatively
What can be used for diagnosis if there is a suspicion of uterine rupture in the pre-labour setting?
Ultrasound
What features may be present on ultrasound in uterine rupture?
- Abnormal fetal lie or position
- Haemoperitoneum
- Absent uterine wall
What initial management is required as a result of uterine rupture being an obstetric emergency?
- A-E approach
- Call appropriate staff
- Where appropriate, invoke massive obstetric haemorrhage protocol
What is involved in resuscitation in uterine rupture?
- Protect airway
- 15L of 100% oxygen through non-rebreathe mask
- Assess circulatory compromise
- Monitor patients GCS
- Expose patient to identify any other bleeding sources
When might the airway be lost in uterine rupture?
With reduced levels of consciousness
How can circulatory compromise be assessed?
- Cap refill
- BP
- ECG
What should be inserted during resuscitation for uterine rupture?
2 large bore (14G) cannulas
What should be done with the cannulas inserted in uterine rupture?
lol what a bad question
- Take blood samples
- Start circulatory resuscitation
What is given in circulatory resuscitation in uterine rupture?
Give cross-matched blood as soon as available, but until then give up to 2L of warmed crystalloid and 1-2L of warmed colloids, then transfuse O negative or uncrossmatched group specific blood
What additional blood products may be required in uterine rupture?
- Fresh frozen plasma
- Platelets
- Fibrinogen
What is the definitive management for uterine rupture?
The fetus is delivered by C-section, and the uterus is either repair or removed
What are the UK guidelines for the decision-incision interval in uterine rupture?
Should be less than 10 minutes
What are the complications of uterine rupture?
- Post-op infection
- Damage to ureter
- Amniotic fluid embolus
- Massive maternal haemorrhage and DIC
- Pituitary failure
What % of uterine ruptures are associated with perinatal death?
6.2%
What % of women with uterine rupture require an emergency hysterectomy?
14-33%
