Uterine Rupture

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Chapter 226 Uterine Rupture

INTRODUCTION

Description: Uterine rupture is characterized by breach of the uterine wall (new or after previous uterine surgery such as cesarean delivery) that may result in significant maternal or fetal morbidity or mortality. This should be distinguished from uterine scar dehiscence, in which there is separation of an old scar that does not penetrate the uterine serosa or result in complications. Rupture of an intact uterus (without scars) does occur on rare occasions (1 in 15,000 deliveries) and is generally associated with significant uterine distention (polyhydramnios, multiple gestation).
Prevalence: Found in 0.5% to 3.7% of patients with a previous cesarean delivery and 5% of patients for whom vaginal birth after cesarean delivery (VBAC) fails. Uterine rupture rates in women with previous classical incisions and T-shaped incisions range between 4% and 9%. Roughly 7% of emergency cesarean hysterectomies are for rupture.
Predominant Age: Reproductive.
Genetics: No genetic pattern.

ETIOLOGY AND PATHOGENESIS

Causes: Abnormal healing of a previous uterine scar, mechanical disruption of the uterine wall weakened by previous surgery, congenital anomalies, or abnormalities of placentation. (The uterine wall may also be breached by injudicious manual removal of the placenta or manual exploration of the uterus after delivery of the placenta.) Traumatic rupture of the uterus may occur with blunt trauma to the abdomen such as occurs to an unrestrained passenger during an automobile accident. (The proper use of automobile lap and shoulder belts significantly reduces the risk of injury to both mother and fetus.)
Risk Factors: Previous uterine surgery (cesarean delivery; greatest for vertical incisions, myomectomy, septoplasty), multiple gestation, grand multiparity (20-fold increase), short interval between pregnancies, fetal malpresentation, polyhydramnios, oxytocin stimulation (unproved), congenital anomalies, and disuse or misuse of vehicle passenger restraints. There is considerable evidence that cervical ripening with prostaglandin preparations increases the likelihood of uterine rupture (15-fold increase).

CLINICAL CHARACTERISTICS

Signs and Symptoms

• Abrupt fetal distress (80% of cases)
• Abrupt loss of station (presenting part may cease to be present in the vagina)
• Vaginal bleeding (may not be present)
• Abdominal pain (may not be present; pain may be referred to the chest or diaphragm)
• Maternal circulatory collapse
• Uterine activity may persist despite expulsion of the fetus

DIAGNOSTIC APPROACH

Differential Diagnosis

• Uterine dehiscence
• Placental abruption
• Umbilical cord prolapse (causing abrupt fetal distress)
• Adnexal torsion
• Pulmonary or amniotic fluid embolism
• Abdominal pregnancy

Associated Conditions: Fetal demise, maternal blood loss.

Workup and Evaluation

Laboratory: Interoperative and postoperative blood counts. Evaluation of clotting when significant bleeding has occurred.
Imaging: Ultrasonography may demonstrate uterine dehiscence, but the need for clinical intervention often precludes the examination.
Special Tests: Intensive fetal and maternal monitoring may be indicated.
Diagnostic Procedures: History and physical examination (vaginal and abdominal).

Pathologic Findings

Separation of previous uterine scar or a new failure of the uterine wall muscle.

MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: Rapid evaluation, supportive measures as needed (fluids, blood products).
Specific Measures: Immediate operative delivery (most often by laparotomy), surgical exploration with the possibility of repair or hysterectomy. Ligation of one or both hypogastric arteries may be necessary.
Diet: Nothing by mouth once the diagnosis is made (pending surgical intervention).
Activity: Strict bed rest (pending surgical intervention).
Patient Education: American College of Obstetricians and Gynecologists Patient Education Pamphlet AP070 (Vaginal Birth After Cesarean Delivery).

Drug(s) of Choice

None. (Supportive measures including fluids, blood products, and anesthetics [for immediate delivery] as needed. Prophylactic antibiotics are often recommended.)

FOLLOW-UP

Patient Monitoring: Fetal and maternal monitoring must be maintained for those at risk and intensified when the diagnosis is considered.
Prevention/Avoidance: Care in all uterine manipulations (e.g., manual removal of the placenta, version, external pressure during delivery). Patients with a prior successful vaginal delivery have a greater likelihood of successful vaginal birth after cesarean delivery and a lower risk of uterine rupture than those without a successful vaginal delivery. One study has suggested that there is a lower rate of uterine rupture when a double-layer closure of the uterus is used at the time of cesarean delivery.
Possible Complications: Maternal morbidity or mortality possible (significantly reduced by fetal and maternal monitoring). Damage to the cervix, vagina, or bladder may occur as a part of the rupture. Fetal demise may occur in up to 50% to 75% of fundal incision ruptures and 10% to 15% of lower uterine segment ruptures. Long-term neurologic sequelae are common in infants who survive. Vertical uterine scars are associated with the greatest morbidity and mortality when a rupture occurs.
Expected Outcome: When diagnosed early and acted on promptly, a good outcome can be expected. (If the uterus is repaired and preserved, the risk of recurrence in a subsequent pregnancy is roughly 20%.)

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MISCELLANEOUS

ICD-9-CM Codes: 665.1 (During labor), 665.0 (Before labor), 763.8 (Affecting the fetus or newborn), 867.4 (Traumatic).

REFERENCES

Level II

Bujold E, Bujold C, Hamilton EF, et al. The impact of a single-layer or double-layer closure on uterine rupture. Am J Obstet Gynecol. 2002;186:1326.

Bujold E, Mehta SH, Bujold C, Gauthier RJ. Interdelivery interval and uterine rupture. Am J Obstet Gynecol. 2002;187:1199.

Caughey AB, Shipp TD, Repke JT, et al. Rate of uterine rupture in women with one or two prior cesarean deliveries. Am J Obstet Gynecol. 1999;181:872.

Choy-Hee L, Raynor BD. Misoprostol induction of labor among women with a history of cesarean delivery. Am J Obstet Gynecol. 2001;184:1115.

Conde-Agudelo A, Rosas-Bermudez A, Kafury-Goeta AC. Effects of birth spacing on maternal health: a systematic review. Am J Obstet Gynecol. 2007;196:297.

Eden RD, Parker RT, Gall SA. Rupture of the pregnant uterus: a 53 year review. Obstet Gynecol. 1986;68:671.

Esposito MA, Menihan CA, Malee MP. Association of interpregnancy interval with uterine scar failure in labor: a case-control study. Am J Obstet Gynecol. 2000;183:1180.

Guise JM, McDonagh MS, Osterweil P, et al. Systematic review of the incidence and consequences of uterine rupture in women with previous caesarean section. BMJ. 2004;329:19.

Kieser KE, Baskett TF. A 10-year population-based study of uterine rupture. Obstet Gynecol. 2002;100:749.

Landon MB, Spong CY, Thom E, Hauth JC, et alNational Institute of Child Health, Human Development Maternal-Fetal Medicine Units Network. Risk of uterine rupture with a trial of labor in women with multiple and single prior cesarean delivery. Obstet Gynecol. 2006;108:12.

Levrant SG, Wingate M. Midtrimester uterine rupture. J Reprod Med. 1996;41:186.

Lydon-Rochelle M, Holt VL, Easterling TR, Martin DP. Risk of uterine rupture during labor among women with a prior cesarean delivery. N Engl J Med. 2001;345:3.

Macones GA, Peipert J, Nelson DB, et al. Maternal complications with vaginal birth after cesarean delivery: a multicenter study. Am J Obstet Gynecol. 2005;193:1656.

Miller DA, Goodwin TM, Gherman RB, Paul RH. Intrapartum rupture of the unscarred uterus. Obstet Gynecol. 1997;89:671.

Ravasia DJ, Wood SL, Pollard JK. Uterine rupture during induced trial of labor among women with previous cesarean delivery. Am J Obstet Gynecol. 2000;183:1176.

Shipp TD, Zelop CM, Repke JT, et al. Interdelivery interval and risk of symptomatic uterine rupture. Obstet Gynecol. 2001;97:175.

Zelop CM, Shipp TD, Repke JT, et al. Effect of previous vaginal delivery on the risk of uterine rupture during a subsequent trial of labor. Am J Obstet Gynecol. 2000;183:1184.

Level III

American College of Obstetricians and Gynecologists. Obstetric aspects of trauma management. ACOG Educational Bulletin 251. Washington, DC: ACOG, 1998.

American College of Obstetricians and Gynecologists. Vaginal birth after previous cesarean delivery. ACOG Practice Bulletin 54. Obstet Gynecol. 2004;104:203.

American College of Obstetricians and Gynecologists. Induction of labor for vaginal birth after cesarean delivery. ACOG Committee Opinion 342. Obstet Gynecol. 2006;108:465.

American College of Obstetricians and Gynecologists. Postpartum hemorrhage. ACOG Practice Bulletin 76. Obstet Gynecol. 2006;108:1039.

Asakura H, Myers SA. More than one previous cesarean delivery: a 5-year experience with 435 patients. Obstet Gynecol. 1995;85:924.

Buhimschi CS, Buhimschi IA, Patel S, et al. Rupture of the uterine scar during term labour: contractility or biochemistry? BJOG. 2005;112:38.

Macones GA, Cahill AG, Stamilio DM, et al. Can uterine rupture in patients attempting vaginal birth after cesarean delivery be predicted? Am J Obstet Gynecol. 2006;195:1148.

Miller DA, Diaz FG, Paul RH. Vaginal birth after cesarean: a 10-year experience. Obstet Gynecol. 1994;84:255.

Miller DA, Goodwin TM, Gherman RB, Paul RH. Intrapartum rupture of the unscarred uterus. Obstet Gynecol. 1997;89:671.

Scott JR. Avoiding labor problems during vaginal birth after cesarean delivery. Clin Obstet Gynecol. 1997;40:533.

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