Rupture uterus

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Uterine Rupture (the most dramatic serious obstetric Emergency) Muhammad M Al Hennawy Consultant Obstetrician & Gynacologist Ras ElBar Central Hospital , Dumyat , Egypt

Transcript of Rupture uterus

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Uterine Rupture

(the most dramatic serious obstetric Emergency)

Muhammad M Al Hennawy

Consultant Obstetrician & Gynacologist

Ras ElBar Central Hospital , Dumyat , Egypt

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Definition

• Uterine rupture is defined as• a non-surgical disruption or tear• of the myometrium with or without serosa of the

uterus• with or without expulsion of the fetus and placenta.

It is a life threatening condition for both the motherand the fetus.

• It occur Usually during labour, occasionally happenduring later weeks of pregnancy

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Incidence Of Uterus Rupture

0.05% for all pregnancies

0.8% after previous lower segment caesarean section(LSCS)

>5% after classical caesarean section

Scar dehiscence has an incidence of 0.6% in pregnancies with

previous C/S and has a more favorable outcome for both mother and

fetus than does uterine rupture

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Etiology

Scarred Uterus Rupture: History of cesarean section , hysterotomy , myomectomy, excision of a uterine septum, metroplasty , previous perforation of uterus (D&C,hysteroscopy, forceps delivery)

•Unscarred Uterus Rupture: Traumatic/ iatrogenic rupture

Surgical interventiono Internal version

o Forceps deliveryo Forcible dilatation(cervical tear)o Manual removal of placenta

o Destructive operations.

Medical interventiono Uterine hyper-stimulation (oxytocin with

pitocin induction or augmentation of

labor)

Spontaneous rupture

• Feto-pelvic disproportion

• Congenital uterine anomalies

• Soft tissue obstruction

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TypesA- Scarred Uterus Rupture

• Uterine scar dehiscence: herniation of intact amniotic membraneinto an existing uterine scar ( when there is separation of previous scarwith intact peritoneum)

• Uterine scar rupture: separation of scar along entire length oftenwith involvement of the amniotic membranes

B- Unscarred Uterus Rupture

• Complete Uterine rupture: total disruption of the wall of the pregnantuterus with or without extrusion of its content ( when uterine cavitycommunicate directly with peritoneal cavity )

• Incomplete Uterine rupture: partial disruption of the wall of thepregnant uterus without extrusion of its content ( uterine cavity is separatedfrom peritoneal cavity by visceral peritoneum or broad ligament )

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Rupture of the Scarred Uterus Due to Previous CS• 1.9% absolute uterine rupture rate in Previous classic cesarean delivery or invertedT, or J incision who either presented in advanced labor or refused repeat cesareandelivery.

• symptomatic uterine rupture in women undergoing a TOLAC with a low verticalcesarean scar Compared to women with low transverse cesarean scars, these datasuggest no significantly increased risk of uterine rupture or adverse maternal andperinatal outcomes.

• no association was found between an unknown uterine scar and the risk of uterinerupture;

• the spontaneous rupture rate among women with a single cesareandelivery scar who underwent scheduled repeat cesarean delivery withouta TOL was 0.16%.

• the uterine rupture rate among 10,789 women with a single previous cesareandelivery who labored spontaneously during a subsequent singleton pregnancywas 0.52%.

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Rupture of the Scarred Uterus Due to Previous CS

• Previous cesarean delivery with subsequent augmentation of laborthe rate of uterine rupture with oxytocin augmentation was 0.9% (52 of 6,009cases) versus 0.4% without oxytocin use.

• Previous cesarean delivery with subsequent induction of labormaternal and neonatal outcomes following induction of labor (4,038 women)and spontaneous labor (13,374 women) in women who previously underwentcesarean section, Rossi and Prefumo reported a lower incidence of vaginaldelivery with induced labor but higher rates of uterine rupture/dehiscence,repeat cesarean section, and postpartum hemorrhage.

• Use of prostaglandins for cervical ripening and induction of laborafter previous cesarean delivery no uterine ruptures among 227 patientswho underwent induction with prostaglandins alone

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Rupture of the Scarred Uterus Due to Previous CS• Previous cesarean delivery with previous successful vaginal delivery in

women with no prior vaginal delivery who underwent a TOLAC, there was anincreased risk of uterine rupture with induction versus spontaneous labor (1.5% vs0.8%, P =0.02). In contrast, no statistically significant difference was shown forwomen with a prior vaginal delivery who underwent spontaneous TOLAC comparedwith labor induction (0.6% vs 0.4%, P =0.42).

• Previous cesarean delivery with subsequent successful VBACs anincreased uterine rupture rate of 1.4% (1 per 73) in failed VBAC attempts thatrequired a repeat cesarean section in labor.

• Inter-delivery interval the combination of a short inter-deliveryinterval of ≤24 months and a single-layer hysterotomy closure was associatedwith a uterine rupture rate of 5.6%.

• One-layer versus 2-layer hysterotomy closure single-layer closure waslinked to an increased rate of uterine rupture (odds ratio [OR] 2.69; 95%confidence interval [CI] 1.37–5.28). The authors concluded that single-layer closure should be avoided in women who contemplate future VBACdelivery

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Rupture of the Scarred Uterus Due to Previous CS• Multiple prior cesarean deliveriesACOG recommendation was subsequently revised in an updated 2010 guideline tosuggest that women with two previous low transverse cesarean deliveries may beconsidered candidates for TOLAC regardless of their prior vaginal delivery status.

• Maternal ageThe rate of uterine rupture in women older than 30 years (1.4%) versus youngerwomen (0.5%) differed significantly

• Multiple gestation• VBAC with twin gestations report similar rates of uterine rupture for twin and

singleton gestations.

• Fetal macrosomia no difference between the rates of uterine rupture for womenwith neonates weighing ≥4000 gm versus < 4000 gm

• Gestation beyond 40 week• ACOG 2010 VBAC guidelines suggest that although the chance of success may be

lower for a vaginal delivery in more advanced gestations, gestational age beyond 40weeks alone should not preclude a TOLAC.

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Weak Cesarean Scar

• One layer cs

• Locked Suture

• Infection

• Suture material

• Upper segment or T or J incisions

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Classification of Uterine Rupture • Classification by etiology

oScarred Uterus Rupture: Previous caesarean scar or myomectomyoUnscarred Uterus Rupture

• Classification by PathogenesisoSpontaneous - Histochemical etiology of uterine rupture - occurs without

any function of uterus - Example: (i) Anatomy anomaly (ii) Dystrophydiseases (connective tissue autoimmune disease, Inflammatory disease ofuterus)

oVoluntary - result of hyperfunction of uterus - Example: (i) Disproportionbetween sizes of presenting part and maternal pelvis (malpresentation) (ii)Extra doses of uterotonic drugs

• Classification by Layers of Uterus involved in RuptureoComplete rupture : commonly spontaneousoIncomplete rupture : commonly traumatic.

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Classification of Uterine Rupture

• Classification by Location of Rupture oLower segment rupture

oRupture of corpus/fundus of uterus

• Classification by timeoDuring pregnancy

oDuring Labour

• Classification by Carelessness or Negligence? ocarelessness of the patient

onegligence of the doctor.

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The Most Common Site Of Ruptured Uterus

• Damage to the uterus prior to labour is usually in theuterine body while damage during labour is usually in the lowersegment.

• During labouroLower uterine segment (47%) in previous CS,

oLeft lateral rupture (23.5%) in obstructed labor,

oFundal rupture (20.6%) and

oRight lateral rupture (8.8%) in obstructed labor

oUpper Segment –in previous classical CS,

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Golden Rule

Uterine rupture

• should be first ruled out in all pregnant women presented with acute abdominal pain regardless of their gestational age.

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Signs of Threatened Uterine Rupture

Signs that occur just during the labor

• Excessive uterine activity. Uterine contractions are very fast and painful

• Overdistended Lower uterine segment, thinned and painful at palpation

• Edematous cervical os margins due to compression which may extends tothe vagina and the perineum

• Difficult Urination due to compression of the bladder and urethra betweenthe bony pelvis and the fetal head

• Some bloody discharge maybe presented (depends)

• Pathological contractile Bandl’s ring is presented

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Signs of Uterine Rupture During Pregnancy TypicallyoAcute abdominal painoFeatures of shock & intra-abdominal hemorrhageoEasily palpable fetal partsoAbsent fetal heart soundoContracted uterus felt on one site

AtypicallyoIncomplete rupture producing localized abdominal pain & tendernessoFrank signs of hemorrhage & shock develop slowlyoIt may confuse with accidental hemorrhage

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Early Pregnancy Uterine Rupture

• The most common cause of uterine rupture is dehiscence of a previousCaesarian section scar

• Rupture at the site of a previous uterine scar may occur with few warningsigns because the scar is relatively avascular

• It is a rare and potentially life threatening event which incidence isincreasing given the actual high cesarean section rate.

• Clinical signs of this condition are nonspecific and must be distinguishedfrom other acute abdominal emergencies and other obstetric events.

• Cesarean scar pregnancy must be considered as a major risk factor leadingto early uterine rupture.

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Signs of Uterine Rupture During Labour

• Sudden appearance of fetal distress during labour ( most commonsign)

• Uterine contractions suddenly stop

• Palpation of fetus in the abdomen (outside the uterus)

• Fetal death

• Hemorrhage then hypovolemic shock in mother Signs and Symptomsin the Uterine Rupture that has happened

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Investigations

• CTG

• Fetal distress (as evidence by abnormalities in fetal heart rate)

• Diminished baseline uterine pressure

• Loss of uterine contractility

• Radiographic features

• US

• MRI

• Intrauterine pressure catheters

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Ultrasonography

• It is probably the safest and most useful imaging technique duringpregnancy

• Before rupture: a uterine wall thinner than 2 mm, as determinedwith ultrasonography performed within 1 week of delivery,significantly increased the risk of uterine rupture. Positive andnegative predictive values were 73.9% and 100%, respectively.

• A French study suggests that a uterine wall thickness of greater than4.5 mm has negative predictive value of 100% but unfortunately thepositive predictive value of thickness less than 3.5 mm is poor atonly 11.8%

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Ultrasonography

• After rupture

Reported sonographic signs of uterine rupture include:Identification of the protruding portion of the amniotic sacEndometrial or myometrial defect ( an anterior hypo-

/anechogenic line corresponding to the uterine tear)Bulky empty uterus with gas bubblesThe fetus and placenta in the abdominal cavityExtra-uterine hematomaHemoperitoneum or free fluid

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MRI• It allows clear visualization of the uterine wall;

• therefore, it helps to diagnose both ante-partum uterinerupture in patients with indeterminate ultrasound evidence,

• showing the tear itself and other uterine wall defects includinguterine dehiscence (separation of the myometrium withpreservation of the overlying peritoneum and internal fetalmembranes) and

• uterine sacculation (uterine wall ballooning because of afunctional weakening of the myometrium)

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Intrauterine Pressure Catheters

• They are sometimes used but may fail to show loss of uterinetone or

• Loss of contractile patterns following uterine rupture.

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Differential Diagnosis

Abruptio Placentae (Similar presentation)

Hepatic Rupture in severe pre eclampsia (Look forother signs of pre-eclampsia)

Chorioamnionitis (Look for fever, PROM, Tender uterus)

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Treatments of Threatening Uterine Rupture

• Treatments of Uterine Rupture Whenever a threateninguterus rupture is seen,

• immediate Caesarian section must be done!

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Managements of Uterine Rupture

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Intensive resuscitation

• Correct hypovolemia from:Hemorrhage Sepsis Dehydration

• Intravenous broad spectrum antibiotics:Cephalosporin + Metronidazole combination

• Monitor to ensure adequate fluid and blood replacement

• Blood volume expansion may worsen the bleeding from damagedvessel.

So the laparotomy should not be delay, once patient condition has improved

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Emergency exploratory laparotomy with cesarean delivery

• Several studies have shown that delivery of the fetus within 10-37 minutes of uterine rupture is necessary to prevent serious fetal morbidity and mortality.

Types of surgical treatment depends on Type of uterine rupture :

• Extent of uterine rupture

• Degree of hemorrhage

• High parity

• Edges of rupture are ragged and irregular

• General condition of the mother

• Mother's desire for future childbearing.

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Emergency exploratory laparotomy with cesarean delivery

• Surgery

• Repair of uterus without tubal ligation

• Repair of uterus with tubal ligation

• Removal of uterus (hysterectomy), Total or Sub-total

• in cases of lateral rupture involving lower uterine segment anduterine artery where hemorrhage and hematoma obscure theoperative field, ligation of the ipsilateral hypogastric artery to stopbleeding may be needed.

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Conservative surgical management

• Involving uterine repair should be reserved for women who havethe following findings:Desire for future childbearingLow transverse uterine ruptureNo extension of the tear to the broad ligament, cervix, or

paracolposEasily controllable uterine hemorrhageGood general conditionNo clinical or laboratory evidence of an evolving coagulopathy

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Surgical Management

• Hysterectomy should be considered the treatment of choicewhen intractable uterine bleeding occurs or when theuterine rupture sites are multiple, longitudinal, or low lying.

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Complications

• Postoperative infection.

• Damage to ureter.

• Amniotic fluid embolus.

• Massive maternal hemorrhage

• Disseminated intravascular coagulation (DIC).

• Pituitary failure

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Outcome

•Death from uterine rupture is not uncommon.

•Mortality appears to be higher in women who have an

unscarred uterus and when the rupture occurs outside the

hospital.

•Overall mortality: 15.9%

•Perinatal morbidity rate associated with uterine rupture ranges

from 8-56%

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Preventive measures

Antenatal care • High risk cases

• Oxytocics

• Previous caesarean section

• Augmentation of labour

NOTE!!!

During trial of scar watch out for…….Fetal heart abnormalities

Maternal tachycardia

Vague abdominal pain in between contractions

Suprapubic tenderness

Vaginal bleeding

Bladder tenesmus

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Counselling for future pregnancies

• If tubal ligation was not performed at the time of laparotomy, explainthe increased risk of rupture with subsequent pregnancies, anddiscuss the option of permanent contraception

• If the defect is confined to the lower segment the risk of rupture in asubsequent pregnancy is similar to that of someone with a previouscaesarean section

• If there are extensive tears involving the upper segment, futurepregnancy may be contraindicated

• Women with a history of uterine rupture should have a plannedelective caesarean section (37 to 38 weeks’ gestation) in their nextpregnancy

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Conclusion• Uterine rupture is a rare but often catastrophic obstetric complication with

an overall incidence of (0.07%). pregnancies

• In modern industrialized countries, the uterine rupture rate duringpregnancy for a woman with a normal, unscarred uterus is (0.012%).pregnancies

• The vast majority of uterine ruptures occur in women who have uterinescars, most of which are the result of previous cesarean deliveries.

• A single cesarean scar increases the overall rupture rate to 0.5%, with therate for women with 2 or more cesarean scars increasing to 2%.

• Other subgroups of women who are at increased risk for uterine ruptureare those who have a previous single-layer hysterotomy closure, a shortinter-pregnancy interval after a previous cesarean delivery, a congenitaluterine anomaly,

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Conclusion• Macrosomic fetus, prostaglandin exposure, and a failed previous trial of a

vaginal delivery.

• Surgical intervention after uterine rupture in less than 10-37 minutes isessential to minimize the risk of permanent perinatal injury to the fetus.

• However, delivery within this time cannot always prevent severe hypoxiaand metabolic acidosis in the fetus or serious neonatal consequences.

• The most consistent early indicator of uterine rupture is the onset of aprolonged, persistent, and profound fetal bradycardia.

• Other signs and symptoms of uterine rupture, such as abdominal pain,abnormal progress in labor, and vaginal bleeding, are less consistent andless valuable than bradycardia in establishing the appropriate diagnosis.

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Conclusion• The general guideline that labor-and-delivery suites should be able to start

cesarean delivery within 20-30 minutes of a diagnosis of fetal distress is ofminimal utility with respect to uterine rupture.

• In the case of fetal or placental extrusion through the uterine wall,irreversible fetal damage can be expected before that time; therefore, sucha recommendation is of limited value in preventing major fetal and neonatalcomplications.

• However, action within this time may aid in preventing maternalexsanguination and maternal death, as long as proper supportive andresuscitation methods are available before definitive surgical interventioncan be successfully initiated.

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