• Clinical science

Uterine rupture

Abstract

Uterine rupture is a pregnancy complication that is life-threatening for the mother and the baby. It occurs in approximately one in every 4,000 births, and in most cases, during labor. This condition is caused by gross uterine distention or uterine scarring; patients who have had a C-section in a previous pregnancy are particularly prone to uterine rupture. Signs and symptoms may vary depending on the location and the extent of the rupture. A sudden pause in contractions takes place after rupture, along with an abnormal fetal heart rate (usually bradycardia), severe abdominal pain, vaginal bleeding, and hemodynamic instability. Women with this condition must undergo laparotomy and emergency C-section. If the uterus is severely damaged and cannot be repaired –or the bleeding does not cease– hysterectomy is necessary.

Epidemiology

Incidence: 1/4000 births

References:[1][2]

Epidemiological data refers to the US, unless otherwise specified.

Etiology

Uterine rupture is primarily caused by uterine distention. Theoretically, this can occur at any stage of pregnancy; however, it usually takes place during active labor because of the massive force exerted during contractions.

  • Uterine distention
    • Delay in labor progression because of fetal malpresentation
    • Fetal macrosomia and multiple gestations
    • Overdose of oxytocin
  • Uterine scar/prior uterine surgery (e.g., C-section or myomectomy)
  • Traumatic rupture (e.g., iatrogenic or caused by an accident)

References:[3][4][5][6]

Classification

  • Uterine rupture: connection to the abdomen
  • Uterine dehiscence (closed rupture): perforation covered by the visceral peritoneum

Clinical features

Imminent rupture

  • Severe abdominal pain
  • Increased contractions followed by hyperactive labor
  • Bandl's ring

Uterine rupture

  • Severe abdominal pain
  • Sudden pause in contractions
  • Fetal distress (e.g., deteriorating fetal heart rate)
  • Vaginal bleeding
  • Hemodynamic instability (as a result of abdominal bleeding)
  • Loss of fetal station
  • Palpable fetal parts through the rupture

References:[5][7][8][4][9][3]

Subtypes and variants

  • Uterine dehiscence
    • Closed rupture
    • Occurs mostly as a result of a scar rupture in the late months of pregnancy or when contractions begin
    • Most cases of uterine dehiscence are an incidental finding during repeat cesarean delivery.

References:[5][10]

Differential diagnoses

See → Differential diagnosis of vaginal bleeding in women of reproductive age

The differential diagnoses listed here are not exhaustive.

Treatment

  • Imminent rupture:
  • Uterine rupture:
    • Immediate laparotomy with emergency C‑section
    • Hysterectomy necessary if the bleeding does not cease
  • Uterine dehiscence: Cesarean delivery before labor begins is recommended to avoid a complete rupture.

References:[4][5][10]

Prognosis

  • Traumatic and spontaneous ruptures increase the mortality rate of the mother and the baby.
  • Open ruptures lead to hypovolemia and hypoxia; as a result, the fetal mortality rate is between 50–75%.

References:[5][10]

  • 1. UK Obstetric Surveillance System (UKOSS). Uterine Rupture. https://www.npeu.ox.ac.uk/ukoss/current-surveillance/ur#r6. Updated December 9, 2014. Accessed January 2, 2017.
  • 2. Al-Zirqi I, Stray-Pedersen B, Forsén L et al. Uterine rupture: trends over 40 years. BJOG: An International Journal of Obstetrics and Gynaecology. 2016; 123(5): pp. 780–7. doi: 10.1111/1471-0528.13394.
  • 3. Augustin G. Acute Abdomen During Pregnancy. Springer; 2014.
  • 4. Carr PL, Ricciotti HA, Freund KM, Kahan S. In a Page OB/GYN & Women's Health . Blackwell Publishing; 2003.
  • 5. Nahum GG. Uterine Rupture in Pregnancy. In: Isaacs C. Uterine Rupture in Pregnancy. New York, NY: WebMD. http://reference.medscape.com/article/275854. Updated March 25, 2016. Accessed January 2, 2017.
  • 6. National Institutes of Health Consensus Development Conference. National Institutes of Health Consensus Development Conference Statement: Vaginal Birth After Cesarean: New Insights March 8-10, 2010. Seminars in Perinatology. 2010; 34(4): pp. 293–307. doi: 10.1053/j.semperi.2010.05.001.
  • 7. Callahan TL, Caughey AB. Blueprints Obstetrics and Gynecology. Lippincott Williams&Wilki; 2013.
  • 8. Iyer PW. Nursing Malpractice. Lawyers & Judges Pub Co; 2001.
  • 9. Pollak AN, Murphy M, Stathers CL et al. Critical Care Transport. Jones and Bartlett Publishers; 2011.
  • 10. Lang CT, Landon MB. Uterine rupture after previous cesarean delivery. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/uterine-rupture-after-previous-cesarean-delivery. Last updated November 1, 2016. Accessed January 2, 2017.
last updated 09/04/2018
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