Associate Professor Iolanda Blidaru, MD, PhD RUPTURE OF THE UTERUS Associate Professor Iolanda Blidaru, MD, PhD

RUPTURE OF THE UTERUS a potential obstetric catastrophe a major cause of maternal death. The incidence of uterine rupture is approximately 1/ 1500 deliveries.

RUPTURE OF THE UTERUS

A.Before current pregnancy RUPTURE OF THE UTERUS ETIOLOGY A.Before current pregnancy 1. surgery involving the myometrium * cesarean section or hysterotomy * previously repaired uterine rupture * myomectomy, cornual resection, metroplasty 2. uterine trauma * abortion with instrumentation * sharp or blunt trauma (accidents, bullets, knives) * silent rupture in previous pregnancy 3. congenital anomaly * pregnancy in undeveloped uterine horn

B. During current pregnancy RUPTURE OF THE UTERUS B. During current pregnancy 1.Before delivery external trauma labor stimulations (oxytocin or PG) external version uterine overdistention (multiple pregnancy, hydramnios) Utero-placental pathology (sacculation of entrapped retroverted uterus, cornual pregnancy, adenomyosis)

RUPTURE OF THE UTERUS B. During current pregnancy 2. During delivery fetal anomaly distending lower segment (hydrocephalus) internal version, breech extraction difficult forceps delivery difficult manual removal of placenta abnormal presentations contracted pelvis tumors of the birth canal multiparity placenta increta or percreta gestational trophoblastic neoplasia

RUPTURE OF THE UTERUS The most common cause of uterine rupture is separation of a previous cesarean section scar.

RUPTURE OF THE UTERUS CLASIFICATION Incomplete rupture → a laceration separated by the visceral peritoneum. “Occult” (“incomplete rupture”) → dehiscence of an uterine incision from previous surgery. Complete rupture traumatic spontaneous → during the course of labor

RUPTURE OF THE UTERUS Vertical uterine incision through the uterine body - probability of rupture is several times greater than that of a lower segment scar. The corporeal scar ruptures before labor (1/3). Dehiscence of a lower segment cesarean section scar is more frequent than actual rupture.

RUPTURE OF THE UTERUS Pathological anatomy Incomplete ruptures frequently extend into the broad ligament. Hemorrhage tends to be less severe than in complete rupture and the blood acumulates between the leaves of the broad ligament.

Ruptured vertical cesarean section scar (arrow) identified at time of repeat cesarean delivery early in labor.

Spontaneously ruptured uterus at left lateral edge of lower uterine segment.

RUPTURE OF THE UTERUS Pathological anatomy Rupture of the previously intact uterus at the time of labor → the lower uterine segment ( left margin) After complete rupture, the uterine contents escape into peritoneal cavity, unless the presenting part is firmly engaged, when only a portion of the fetus may be extruded from the uterus.

RUPTURE OF THE UTERUS CLINICAL FINDINGS. DIAGNOSIS Impending uterine rupture → the sudden appearance of gross hematuria is suggestive. Prior to the onset of labor, a beginning rupture may produce local pain and tenderness associated with increased uterine irritability and, in some cases, a small amount of vaginal bleeding. If the fetus is partly or totally extrauterine, abdominal palpation or vaginal examination → the presenting part has moved away from the pelvic inlet (loss of station).

The classic SIGN & SYMPTOMS of spontaneous rupture during labor RUPTURE OF THE UTERUS The classic SIGN & SYMPTOMS of spontaneous rupture during labor cessation of uterine contractions suprapubic pain and tenderness disappearance of fetal heart tones recession of the presenting part vaginal hemorrhage → signs and symptoms of hypovolemic shock and hemoperitoneum.

RUPTURE OF THE UTERUS complicates about 1 in 200 trials of labor. RUPTURE OF A CESAREAN SCAR complicates about 1 in 200 trials of labor. in most cases = a dehiscence of little consequence. Criteria for vaginal delivery following previous cesarean section only one previous cesarean section; low transverse uterine incision; original indication for cesarean not necessarily recurring in subsequent pregnancies; benign postoperative course; non-complicated current pregnancy (macrosomia, malposition, multiple gestation).

RUPTURE OF THE UTERUS PREVENTION good prenatal care correct trial of labor correct supervised administration of oxytocin during labor. correct closure of a cesarean section incision correct estimation of fetal weight

RUPTURE OF THE UTERUS EMERGENCY SURGERY TREATMENT Whenever uterine rupture is diagnosed – EMERGENCY SURGERY two effective, large-bore intravenous infusion type-specific whole blood in large quantities is rapidly infused; a surgical team, including anesthesia personnel; pediatric personnel skilled in neonatal resuscitation.

RUPTURE OF THE UTERUS Immediate laparotomy Suture or Total hysterectomy If a large hematoma in the broad ligament, identification and ligation of the internal iliac arteries (reduces the hemorrhage appreciably). Prompt diagnosis, immediate operation, the availability of large amounts of blood and antimicrobial therapy have greatly improved the maternal prognosis.

Maternal Prognosis RUPTURE OF THE UTERUS the maternal mortality rate is 10 to 40%. if the patient survives: pituitary failure (Sheehan syndrome), infertility/sterility vesico-vaginal fistula.

RUPTURE OF THE UTERUS FETAL PROGNOSIS If the fetus is alive at the time of the rupture, the only chance of continued survival is afforded by immediate delivery, most often by laparotomy. Otherwise, hypoxia and death from both, placental separation and maternal hypovolemia, is inevitable.