Uterine Rupture - An Overview

Introduction:

The goal of gynecological treatment is to protect the health of the mother and child. But certain emergencies can be potentially life-threatening for both mother and child. Uterine rupture is a potentially dangerous condition that needs emergency care to save the life of the mother and child.

What Is Uterine Rupture?

Loss of integrity of all the layers of the uterine wall is known as uterine rupture. In this condition, the integrity of the visceral peritoneum (the abdominal cavity membrane) is lost. Complete division of the three layers of the uterus: the endometrium (inner epithelial layer), myometrium (smooth muscle layer), and perimetrium (the outer serous surface) are observed. The incidence of such conditions is extremely rare. In developing countries, uterine rupture may happen in 1 out of 500 cases. In developed countries, such incidence is even rare and can only be seen in 1 out of 3000 to 5000 cases. Uterine rupture can be of two types:

1. Complete Uterine Rupture: In this condition, complete separation of uterine muscles and all the layers occurs. As a result, the fetus, placenta, or both are extruded into the abdominal cavity.

2. Incomplete Uterine Rupture: The uterine muscle layer is disrupted in this condition. But the peritoneum remains intact.

What Are the Conditions Associated With Uterine Rupture?

• Uterine Scar: One of the main factors associated with uterine rupture is the presence of scarred uterus. Upper-segment cesarean section (c-section), where the incision is given vertically in the upper portion of the abdomen, is most commonly associated with uterine scar tissue formation.Low-segment cesarean section is not associated with such conditions. Other surgical procedures like hysterotomy (removal of uterine contents during the second trimester or later), and myomectomy (surgical removal of uterine fibroids) increase the prevalence of uterine rupture. The etiology of the involvement of the following factors is unknown. But improper healing, invasive placenta (placenta grows into the uterine wall), and hematoma (collection of blood) are associated with such pathologies.

• Use of Uterotonic Medications: The prevalence of the use of uterotonic drugs is increasing day by day. These drugs are used for the induction of labor and increased uterine contraction. Excessive use of drugs like Oxytocin, Ergometrine, Misoprostol, and Carbetocin is responsible for the excessive contraction of the uterus. This is associated with an increased generation of stress and uterine rupture.

• Uterine Abnormalities: Excessive growth of the fetus with respect to gestational age is responsible for increased uterine stress. The normal threshold of the placenta is 4.5 kilograms. Fetal weight more than this is responsible for excessive pressure on the placenta. Polyhydramnios, or excessive fluid accumulation in the placenta, is also associated with uterine rupture. The use of IVF (In vitro fertilization, assisted reproductive procedure) is often associated with multiple gestation pregnancies. Such incidences are also responsible for excessive pressure on the placenta.

• Presence of Disorders: The presence of connective tissue disorders like Loeys Dietz syndrome (connective tissue disorder characterized by enlarged aorta), and Ehlers-Danlos syndrome (characterized by skin abnormalities, joints, and blood vessels) is often associated with such conditions.

• Vaginal Birth After Cesarean (VBAC): Women with a history of cesarean section and a reduced gap between pregnancies belong to the high-risk zone. In such cases, planning a vaginal birth may lead to uterine rupture. The incidence rate of uterine rupture in the case of VBAC is around 9.8 %.

• Cervical Ripening: Cervical ripening is a procedure in which the uterus is prepared for delivery. In this procedure, different devices and chemicals are used to induce uterine contractions. Trans-cervical Foley catheters are often used in such cases. But these devices are associated with the risk of uterine rupture.

• Injury of the uterus following blunt trauma and accidents are often associated with uterine rupture.

What Are the Signs and Symptoms?

Patients experience the following symptoms:

• Severe abdominal pain.

• Abdominal discomfort, chest, and shoulder pain.

• Patients experience sharp pain between contractions.

• Patients experience sudden pain in the previous scar portion.

• Sudden change in the shape of the abdomen, often two swellings can be seen.

• Bulging under the pubic bone is seen due to the protrusion of the baby’s head outside of the uterine scar.

• Persistent vaginal bleeding.

This condition leads to fetal distress and maternal shock. This can be identified by:

• Palpable fetal body parts.

• The fetal head is moved back into the birth canal.

• Uterine pressure and uterine contractility are decreased.

• Low fetal heart rate or absence of fetal heart sound.

• Presence of blood in the urine.

• Reduced maternal blood pressure and increased maternal heart rate.

How to Manage Uterine Rupture?

• The first treatment choice is cesarean delivery- with or without an exploratory laparotomy (a surgical procedure to open up the abdomen).

• The process is done under general anesthesia. This helps to maintain the vital conditions of the patient, and helps to maintain acid-base balance. Also, the airway is stabilized and neuromuscular blockade facilitates laparotomy.

• An intravenous channel should be established. This channel will be utilized for the transfusion of the electrolytic solutions. In case of patients with excessive blood loss, blood transfusion is done.

• Assessment of rupture and identification of the spot is needed to make an incision. For lower segment rupture, a Pfannenstiel incision is given. In severe cases or fundal rupture, a midline incision is given.

• The fetus is visible most of the time as it is partially extruded out of the uterus. The delivery is done in such cases from ruptured placenta only. The uterus is pulled out, which reduces the bleeding and gives a better view of the rupture site.

• Green Armitage forceps are used to stop the bleeding. Ligation is done across the round ligament and fallopian tube, along the uterine body to reduce bleeding from the ovarian arterial supply. In case of a small rupture, a foley catheter is used to occlude ruptured blood vessels and to stop bleeding.

In case of small and simple ruptures, a continuous absorbable suture is given. To prevent dehiscence, suture margins are trimmed. Tubal ligation is indicated in all cases. Subtotal hysterectomy (removal of the uterus) is done to moderate large cases of rupture. A total hysterectomy should be performed if the cervix and pelvic fascia are injured in such cases.

Conclusions:

Uterine rupture is a rare emergency condition. Proper medical history must be taken, and investigations should be done to rule out potential risk factors. Any case of sudden abdominal pain or vaginal bleeding should be checked to rule out uterine rupture. Such emergency conditions should be managed by prompt actions.