Uterine rupture

Question 1

Definition of uterine rupture

Answer 1

Separation of all layers of the uterine wall (endometrium, myometrium, serosa) and opens the uterine cavity into peritoneal cavity, often followed by all or a part of a fetus extruding into the abdominal cavity

Question 2

Definition of uterine dehiscence/ closed rupture

Answer 2

Incomplete rupture of uterine wall involving endometrium and myometrium, sparing serosa

Question 3

Definition of uterine window

Answer 3

Involves only thinning of myometrium

Question 4

Risk factors of uterine rupture

Answer 4

1. Previous uterine surgery++
2. Previous Classical C-section / LSCS
3. Ongoing induction of labour with prostaglandin/ oxytocin
   - Increased strength of contraction
4. Prolonged labour
5. Macrosomia
6. Polyhydramnios
7. Multiparity
8. Known CTD

Question 5

Signs & Symptoms of uterine rupture

Answer 5

Maternal: Severe abdominal pain
- Lancinating pain (sudden, sharp electric shock-like sensations) between contractions (regular, comes and goes in waves, pain free intervals)
- Acute onset scar tenderness
- Radiates to chest/ shoulder tip
- Vaginal bleeding

• Bandl ring: constriction between woman’s thickened upper contractile uterine segment & thinned lower uterine segment

Fetal
- Loss of fetal station
- Inability to pick up fetal heart rate at the old transducer site
- Reduce fetal movements
- Meconium stained liquor
- CTG showing sudden bradycardia and cessation of contractions

Question 6

Physical examination for uterine rupture

Answer 6

Aim: assess maternal and fetal wellbeing and identify supporting signs of uterine rupture

Vitals: Signs of hypovolemic shock - hypotension, tachycardia

CTG: For signs of fetal distress or bradycardia with loss of uterine activity

Abdomen: Palpate for scar tenderness and peritonism

IDC: Inspect urine for hematuria as bladder lies anterior to LUS and can be injured

VE: Vaginal bleeding and loss of fetal station** as baby might be extruded intra-abdominally

Question 7

Management of uterine rupture (emergency)

Answer 7

1. Activate obstetric code –consultant obstetrician, anesthetist, senior midwife and neonatologist
2. Secure mom’s ABCs
   - Airway: ensure airway is patent, check for signs of respiratory distress
   - Breathing: provide supplemental oxygen via hudson mask/NRM (1.5L) to increase O2 delivery to fetus
   - Circulation: 2 large bore IV cannulas, fluid resuscitation, activate massive transfusion protocol if necessary
   - Place patient in a left lateral tilt position to relieve aortocaval compression by gravid uterus to increase preload, CO & placental perfusion
3. In-utero fetal resuscitation
4. Verbal consent for crash cesarean section KIV hysterectomy
5. Give oral sodium citrate en-route to OT for gastric acid aspiration prophylaxis
6. Post delivery management:
   - Send mom to SICU postop for hemodynamic monitoring
   Maternal assessment
   - Inspect damage – any extension of tears into broad ligament, cervix, bladder? All these have to be repaired
   - PPH prophylaxis – high risk of uterine atony after delivery; give empiric IV oxytocin infusion, PR misoprostol, IV TXA
   - Repeat FBC postop: high risk of anemia
   - Repeat DIC screen postop: high risk of consumptive coagulopathy from blood loss – transfuse as necessary
   - Watch for postop paralytic ileus due to hemoperitoneum
   Fetal assessment
   - Paired cord pH: determine severity of metabolic acidosis & predicts HIE
7. Document event, debrief next-of-kin and discuss the case at risk management meeting

Question 8

Investigations for uterine rupture

Answer 8

Bloods:
FBC, RP, LFTs, GXM, PT/PTT (pre-op)

Imaging:
Bedside ultrasound scan
- fetal lie, presentation, compromise
- uterine rupture: free fluid in pouch of douglas & morrison’s pouch

Question 9

CTG signs suggestive of uterine rupture

Answer 9

• Cessation of previously efficient uterine activity
• Fetal tachycardia
• Sudden bradycardia
• Recurrent decelerations