Updated: 11/29/2019

Uterine Rupture

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Snapshot
  • A 27-year-old G2P1 presents at 40 weeks gestation in labor. Her last pregnancy was delivered by cesarean section. This time, she opted for at-home natural delivery. Two hours into labor, she felt her contractions abruptly stop. She subsequently developed vaginal bleeding and acute abdominal pain. She was rushed to the nearest emergency room, where a fetal monitor showed bradycardia. An emergent surgical and anesthesia team was paged and she was prepped for emergent laparotomy and delivery for suspected uterine rupture.
Introduction
  • Overview
    • uterine rupture is a rare cause of third trimester hemorrhage, a complication of pregnancy, and often occurs during labor
      • it significantly increases the risk of fetal and maternal mortality
      • this condition often requires emergency cesarean section for delivery of the fetus
    • other causes of 3rd trimester hemorrhage
      • placenta acreta
      • placenta previa
      • abruptio placentae
  • Epidemiology
    • incidence
      • very rare
    • risk factors
      • previous cesarean section
      • previous myomectomy
      • congenital uterine anomaly
      • placenta accrete, increta, previa, or abruption
      • uterine distention (i.e., from multiple gestations or polyhydramnios)
      • neglected labor
      • uterine instrumentation
      • oxytocin for induction of labor
  • Pathogenesis
    • weakened uterine wall
      • uterine distention, i.e., from multiple gestations of polyhydramnios
      • uterine scars, i.e., prior uterine procedures (cesarean section or myomectomy)
    • uterine rupture often occurs during labor due to the significant level of force exerted during contractions
      • use of oxytocin, which increase uterine contractions, can exacerbate this issue
  • Prognosis
    • worse when uterine tear is longitudinal
Presentation
  • Symptoms
    • common symptoms
      • uterine hemorrhage, often leading to shock
      • fetal distress seen on the fetal monitor
        • typically bradycardia
      • diminished baseline uterine pressure
      • acute loss of uterine contractions
      • abdominal pain
        • note, epidural anesthesia rarely mask the signs of uterine rupture
  • Physical exam
    • inspection
      • vaginal bleeding
      • hemodynamic instability
      • abdominal tenderness
      • loss of fetal station
Studies
  • Diagnostic approach
    • this clinical diagnosis is time-sensitive and requires emergent management  
  • Serum labs    
    • complete blood count
      • assess for need of transfusion
Differential
  • Uterine scar dehiscence
    • key distinguishing factor
      • scar dehiscence is not associated with disruption of visceral peritoneum, and the fetus, placenta, and umbilical cord remain in the uterine cavity
      • may progress into uterine rupture
  • Other causes of third trimester bleeding
    • placenta acreta
    • placenta previa
    • abruptio placentae
Treatment
  • Lifestyle
    • supportive care
      • indications
        • intravenous fluids
        • blood transfusions
  • Surgical
    • immediate cesarean delivery
      • indications
        • all patients
    • immediate laparotomy, surgical repair ­+ hysterectomy
      • indications
        • some patients may want to preserve uterus for future childbearing; this may be possible but depends on extent of tear, hemorrhage, and the patient’s overall condition
        • if uterine tear is extensive, or hemorrhage is uncontrolled, hysterectomy may be necessary
Complications
  • Fetal complications
    • hypoxia
    • death (50-75%)
  • Maternal complications
    • bladder injury
    • hysterectomy may be needed
    • death
 

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