Uterine Rupture

Question 1

Definition of uterine rupture

Answer 1

Refers to a full-thickness disruption of the uterine muscle and overlying serosa. Typically occurs during labour and can extend to affect the bladder or broad ligament.

Question 2

Classification of uterine rupture

Answer 2

• In an incomplete rupture (uterine dehiscence) the uterine serosa (perimetrium) surrounding the uterus remains intact
• With a complete rupture, the serosa ruptures along with the myometrium, and the contents of the uterus are released into the peritoneal cavity

Question 3

Incidence of uterine rupture

Answer 3

• Associated with significant mortality and morbidity
• Incidence is around 1 in 200 in VBAC (increased to 1 in 100 with the use of syntocinon)

Question 4

Risk factors for uterine rupture

Answer 4

• In pregnancy: Previous uterine scar/ uterine surgery where cavity was breached (hysterectomy/ myomectomy/ uterine perfusion), grand multiparity, RTAs, mullerian anomalies, other (rare- Ehlers Danlos, steroid or cocaine use)
• Intrapartum: Abnormal placentation (placenta accreta, increta or percreta) tumour obstructing the birth canal, pelvic deformity, ECV, induction of labour (use of oxytocics or prostaglandins, especially in VBAC), high doses of misoprostol in parous women, uterine hypertonus, precipitate labour, malpresentation, obstructed labour.
• Post-delivery: placenta accreta, manual removal of retained placenta, uterine manipulation (balloon)

VBAC with any of the following:
* Maternal age> 40, obesity, foetal macrosomia, post-date pregnancy, lower pre-labour Bishops score, decreased lower segment myometrial thickness on USS

Question 5

Presentation of uterine rupture

Answer 5

• Abnormal CTG (66-76%)
• Severe abdominal pain, especially between contractions
• Scar tenderness and abnormal vaginal bleeding (or haematuria)
• Cessation of previously efficient uterine activity and loss of station
• Maternal tachycardia, hypotension, fainting or shock

Question 6

Complications of uterine rupture

Answer 6

• Maternal complications include major obstetric haemorrhage with possible need for peripartum hysterectomy
• Foetal complications include hypoxic ischaemic encephalopathy, permanent brain injury, death

Question 7

Differentials for uterine rupture

Answer 7

Question 8

Management of uterine rupture

Answer 8

• ABCDE approach and call senior

Resuscitation:
* Insert 2 large bore intravenous cannulae
* IV fluids infusion as clinically indicated
* Request 6 units of group specific blood and alert Blood Bank - Send urgent bloods for FBC, Clotting/FDP’s, U&E’s
* Expedite delivery and repair uterus with emergency laparotomy (aim delivery of baby within 15 mins). Give appropriate thromboprophylaxis and intraoperative/postoperative antibiotics