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ORIGINAL ARTICLE
Year : 2017  |  Volume : 6  |  Issue : 4  |  Page : 251-254

Uterine rupture: A catastrophic obstetric emergency


Department of Gynecology and Obstetrics, Mamata Medical College and General Hospital, Khammam, Andhra Pradesh, India

Date of Web Publication26-Dec-2017

Correspondence Address:
Dr. K Shaivalini
Department of Gynecology and Obstetrics, Mamata Medical College and General Hospital, Khammam - 507 002, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JDRNTRUHS.JDRNTRUHS_16_14

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  Abstract 


Background: Uterine rupture can be a catastrophic obstetrical emergency with high incidence of fetal and maternal morbidity and mortality, varying from 1 in 2000 to1 in 200 deliveries.
Aims and objective: To investigate the incidence, etiology, diagnosis, treatment and outcome of uterine rupture.
Material and Methods: Thirteen cases of major rupture of the pregnant uterus in which life of the mother and fetus were endangered are presented. This study examined all cases of ruptured uterus managed in the Department of Obstetrics and Gynaecology at Mamata General Hospital, Khammam over a 3 year period. Details were obtained from medical records retrospectively and analyzed manually.
Results: All 13 cases had varied etiologies and presentations such as poor antenatal care, previous cesarean section scar was present in 8, uterine anomalies were noted in 3, history of trauma was present in 1 case, and 1 case was grand multipara who set into spontaneous labour. Sonography findings in all cases showed an empty uterus surrounded by echogenic intra-abdominal fluid (haemoperitoneum) with dead fetus and placenta in maternal abdomen. Most patients were in shock and required basic life support, IV fluids, blood transfusion and emergency laparotomy. Few required intensive care and ventilator support. There were no maternal deaths and 100% perinatal deaths were seen.
Conclusion: This study confirms previous cesarean section scar as the predominant cause of uterine rupture which can be prevented by regular antenatal care and mandatory institutional delivery.

Keywords: Cesarean section, laparotomy, rudimentary horn, rupture uterus


How to cite this article:
Kavitha B, Prabhakar G C, Shaivalini K. Uterine rupture: A catastrophic obstetric emergency. J NTR Univ Health Sci 2017;6:251-4

How to cite this URL:
Kavitha B, Prabhakar G C, Shaivalini K. Uterine rupture: A catastrophic obstetric emergency. J NTR Univ Health Sci [serial online] 2017 [cited 2020 May 27];6:251-4. Available from: http://www.jdrntruhs.org/text.asp?2017/6/4/251/221522




  Introduction Top


Uterine rupture can be a catastrophic obstetrical emergency with high incidence of fetal and maternal morbidity and mortality, varying from 1 in 2000 to1 in 200 deliveries.

Most reported cases occur in patients with risk factors for uterine rupture, most notably labor after previous uterine surgery and grand multiparity.[1]

A uterine rupture is a life-threatening event for the mother and the baby. A uterine scar from a previous cesarean section is the most common risk factor, Other risk factors are full-thickness incisions, dysfunctional labor, labor augmentation by oxytocin or prostaglandins, and high parity and trauma. In this socioeconomic environment, the management of all obstetric emergencies is likely to be extremely difficult.


  Materials and Methods Top


This study examined all cases of ruptured uterus managed in the Department of Obstetrics and Gynaecology at Mamata General hospital, Khammam over a 3 year period.

Details were obtained from medical records retrospectively and analyzed manually.


  Results Top


Complete uterine rupture occurred in 13 cases, with an incidence of 1:248. The ages of the women ranged from 18 to 32 years. All were multigravida. Seven were term, 3 preterm, and 3 were second trimester ruptures in uteri with congenital anomalies. All 13 cases had varied etiologies and presentations such as poor antenatal care, previous cesarean section scar was present in 8, uterine anomalies were noted in 3, history of trauma was present in 1 case, and 1 case was grand multipara who set into spontaneous labour. Sonography findings in all cases showed an empty uterus surrounded by echogenic intraabdominal fluid (hemoperitoneum) with dead fetus and placenta in maternal abdomen. Most patients were in shock and required basic life support, intravenous fluids, blood transfusion, and emergency laparotomy. Few required intensive care and ventilator support. Operative management included uterine rent repair with bilateral tubal ligation in 8 cases [Figure 1], [Figure 2], [Figure 3], excision of ruptured uterine horn with unilateral tubal ligation in 3 cases [Figure 4] and [Figure 5], and subtotal hysterectomy in 2 cases [Figure 6] and [Figure 7]. There were no maternal deaths and 100% perinatal deaths were seen [Table 1], [Table 2].
Figure 1: G2P1L1 with term gestation with lower uterine segment rupture

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Figure 2: G2P1L1 with term gestation with lower segment scar rupture

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Figure 3: Fetus and placenta found on opening the abdomen. G3P1D1A1 19wks GA with bicornuate uterus

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Figure 4: G2P1L1 with 20 weeks GA with ruptured rudimentary horn

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Figure 5: G2P1L1 with 18wks gestational age with rupture of right horn of uterus

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Figure 6: G2P1L1 with term gestation with fundal rupture (road traffic accident)

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Figure 7: G5P4L4 with 36 weeks GA with fundal rupture in spontaneous labour

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Table 1: Risk Factors

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Table 2: Operative Management

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  Discussion Top


Among the women in this series, the lack of any antenatal care is strikingly frequent – 100%. However, this lack of antenatal care probably reflects the lack of access to obstetric care in general. It is the lack of access to emergency obstetric care, in particular emergency cesarean section and blood transfusion, that is the problem in many developing countries.[2],[3]

In this study, the most common etiology was previous cesarean section. One had road traffic accident who has underwent complete uterine rupture. Emergency laparotomy was done for a rent of 8cm on anterior surface of uterus which was extending till fundus. Rent repair was done. Three had bicornuate uterus with pregnancy in one horn who had a vaginal delivery during her first pregnancy.[4] The other underwent a prolonged second stage at home before seeking help at a local health post. Eventually she was referred to our hospital where she was promptly taken to the operating theatre for cesarean section. The uterus was found to be completely ruptured with the baby dead.

Most cases were diagnosed clinically and ultrasound aided to clinical diagnosis. Most were in shock and required 2–3 blood transfusions. Few required intensive care and ventilator support. Operative management included uterine rent repair with bilateral tubal ligation in 8 cases, excision of ruptured uterine horn with unilateral tubal ligation in 3 cases, and subtotal hysterectomy in 2 cases. There were no maternal deaths, and 100% perinatal deaths were seen.

However, with an increasing cesarean section rate, a further increase in the number of ruptured in uteri might be expected in the future. This leads to either injudicious intervention and/or further delay in transferring to a hospital. Most women in our series were illiterate and tribal people where transport and medical facilities are unsatisfactory.

The location of the uterine rupture was extremely varied. The majority, even those with no history of previous lower segment sections, involved the lower segment, often transversely across the anterior surface. It was frequently associated with extension to adjacent structures, causing difficulty in repairing the rupture, often necessitating hysterectomy. Hence, with regular antenatal care and mandatory institutional delivery we can avoid this obstetric tragedy.


  Conclusion Top


This study confirms previous cesarean section scar as the predominant cause of uterine rupture which can be prevented by regular antenatal care and mandatory institutional delivery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rashmi, Radhakrisknan G, Vaid NB, Agarwal N. Rupture Uterus: Changing Indian Scenario. J Indian Med Assoc 2001;99:634-7.  Back to cited text no. 1
[PUBMED]    
2.
Gardeil F, Daly S, Turner MJ. Uterine rupture in pregnancy reviewed. Eur J Obstet Gynecol Reprod Biol. 1994;56:107-10.  Back to cited text no. 2
[PUBMED]    
3.
Ofir K, Sheiner E, Levy A, Katz M, Mazor M. Uterine rupture: Risk factors and pregnancy outcome. Am J Obstet Gynaecol 2003;189:1042-6.  Back to cited text no. 3
[PUBMED]    
4.
Nahum GG. Uterine anomalies, induction of labor, and uterine rupture. Obstet Gynecol 2005;106:1150-2.  Back to cited text no. 4
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2]



 

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Abstract
Introduction
Materials and Me...
Results
Discussion
Conclusion
References
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