Uterine rupture Definition.

Complete uterine rupture is a catastrophic event where a full thickness tear develops, opening the uterus directly into the abdominal cavity. It requires rapid surgical attention to safeguard maternal and infant outcomes. Uterine rupture is a rare but often catastrophic obstetric complication with an overall incidence of approximately 1 in 1514 pregnancies (0.07%). In modern industrialized countries, the uterine rupture rate during pregnancy for a woman with a normal, unscarred uterus is 1 in 7440 pregnancies (0.013%). The vast majority of uterine ruptures occur in women who have uterine scars, most of which are the result of previous cesarean deliveries. A single cesarean scar increases the overall rupture rate to 0.51%, with the rate for women with 2 or more cesarean scars increasing to 2%. Other subgroups of women who are at increased risk for uterine rupture are those who have a previous single-layer hysterotomy closure, a short interpregnancy interval after a previous cesarean delivery, a congenital uterine anomaly, a macrosomic fetus, a history of prostaglandin use, and a failed trial of a vaginal delivery.

Most occur during labour, except in the case of uterine scars following earlier caesarean where approximately 1/3 rupture during third trimester. Occult or incomplete rupture is where a surgical scar separates but the visceral peritoneum stays intact. It is usually asymptomatic and does not require emergency surgery. Classification. Complete rupture can be: Traumatic: o Motor vehicle accident o Incorrect use of oxytocic agent o Poorly conducted attempt at operative vaginal delivery (typically breech extraction with an incompletely dilated cervix) Other procedures with high risk of uterine rupture include internal podalic version and extraction, difficult forceps delivery, destructive operations and manoeuvres to relieve shoulder dystocia.

Spontaneous: o Most patients either have had caesarean section or a history of trauma that could have caused permanent damage.1 o Patients may have no history of surgery but a weakened uterus due to multiparity, particularly if they have an old lateral cervical laceration.

Epidemiology

Incidence
Occurs in 0.4-0.6 of all deliveries.2,3

Risk factors

Prior uterine surgery (including myomectomy, vigorous curettage, induced abortion, manual removal of the placenta). However, most frequent cause of a uterine scar is a previous caesarean section. Classical vertical and T-shaped incisions carry a higher risk of later uterine rupture than the standard modern low transverse approach. Uterine anomalies (e.g. undeveloped uterine horn) Trauma (e.g. RTA) Use of rotational forceps Obstructed labour Induction of labour (suspected association only) - prostaglandins should be used with caution during a trial of labour Cervical laceration Placenta percreta or increta Hydramnios Macrosomia and fetal anomaly (e.g. hydrocephalus) Malpresentation (brow or face) Multiple pregnancy Choriocarcinoma

Presentation The most consistent early indicator of uterine rupture is the onset of a prolonged, 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 and less valuable than bradycardia in establishing the appropriate diagnosis. Signs of uterine rupture that may or may not be present.

Vaginal bleeding Sharp pain between contractions Contractions that slow down or become less intense Abdominal pain or tenderness Recession of the fetal head (baby's head moving back up into the birth canal) Bulging under the pubic bone (baby's head has protruded outside of the uterine scar) Sharp onset of pain at the site of the previous scar Uterine atony (soft muscles)

Management of uterine rupture depends on prompt detection and diagnosis:

The classic signs (sudden tearing uterine pain, vaginal haemorrhage, cessation of uterine contractions, regression of the fetus) have been shown to be unreliable and frequently absent.4 Prolonged, late or variable decelerations and bradycardia seen on fetal heart rate monitoring are the most common and often the only manifestations of uterine rupture. In 3/4 of cases signs of fetal distress will appear before pain or bleeding. Sudden appearance of gross haematuria is indicative of rupture. Increasing pain and bleeding may occur as the size of rupture increases with possible signs of hypovolaemic shock and haemoperitoneum. Exsanguination prior to surgery is unlikely (because of reduced vascularity of scar tissue) unless a uterine artery has been lacerated but the placenta may completely separate and fetus pass either partially or totally out of the uterus and into the abdominal cavity with a high risk of intrapartum death.

Laparotomy may still be required even after a successful vaginal delivery if there is suspicion of uterine rupture to assess damage and control bleeding. Investigations Ultrasound can show abnormal fetal position or extension of fetal extremities or haemoperitoneum. Intrauterine pressure catheters are sometimes used but may fail to show loss of uterine tone or contractile patterns following uterine rupture.

Management As the presenting signs of uterine rupture are so frequently nonspecific, the initial management is the same as for other causes of acute fetal distress - urgent surgical delivery. Surgical intervention after uterine rupture in less than 10-37 minutes is essential to minimize the risk of permanent perinatal injury to the fetus. However, delivery within this time cannot always prevent severe hypoxia and metabolic acidosis in the fetus or serious neonatal consequences. Response time seems critical - best outcomes being achieved where surgical delivery is achieved within 17 minutes of the onset of fetal distress on electronic monitoring.5 In all cases of operative delivery, especially where there are risk factors for uterine rupture, a thorough examination of uterus and birth canal is required.4 In most cases of complete uterine rupture, hysterectomy is the preferred treatment either total or sub-total depending on site of rupture and patient's condition. In cases of lateral rupture involving lower uterine segment and uterine artery where haemorrhage and haematoma obscure the operative field, ligation of ipsilateral hypogastric artery to stop bleeding may be needed. Where future child bearing is important and risks are acceptable, can attempt rupture repair. Repeat rupture occurs in approximately 20% of cases. Complications Post-operative infection Damage to ureter Amniotic fluid embolus Massive maternal haemorrhage and disseminated intravascular coagulation (DIC) Pituitary failure Prognosis 4.2% maternal mortality6 46% perinatal mortality and morbidity7 Prevention Although it is not possible to predict which women are likely to experience a uterine rupture while laboring for a VBAC, recent studies have suggested that the risk for uterine rupture is higher when:

Labor is induced with oxytocin, prostaglandin preparations, or misoprostol (Cytotec). The prior cesarean incision was closed with a single-layer of sutures (single-layer closure- often done in recent years to shorten the time in the operating room) as opposed to two layers of sutures (double-layer closure).

Women become pregnant and labor for a VBAC within less than 24 months after a prior cesarean. Women are older than 30 years of age. Maternal fever was a consequence of a prior cesarean birth. A classical uterine incision was used in a prior cesarean birth. A woman has had two or more prior cesarean births.

Unfortunately uterine rupture cannot be adequately predicted for women wanting a trial of labour following a previous caesarean section.8 Doctors need to review a woman's medical history for risk factors and counsel regarding her relative risks, benefits, alternatives and probability of success.4 Usually, shared care undertaken with an obstetrician is appropriate for any woman with a previous section. For women with one prior cesarean delivery, the risk of uterine rupture is higher among those whose labor is induced than among those with repeated cesarean delivery without labor. Labor induced with a prostaglandin confers the highest risk. When planning a VBAC it is important to determine if the previous low vertical scar has not stretched to the body of the uterus in the current pregnancy. The risk of rupture for a low vertical scar has been reported to be the same as for a low horizontal scar and as high as 1-7%. Sometimes a woman may have a "T" or "J" shaped scar on the uterus or one that resembles an inverted "T". These scars are very rare. It is estimated that between 4 and 9% of "T" shaped uterine scars are at risk for rupture. Rarely, a woman may have a classical (vertical) scar in the upper part (the body) of the uterus. This type of incision is used for babies who are in a breech or transverse position, for women who may have a uterine malformation, for premature babies or in extreme circumstances when time is of the essence. The risk of rupture for this type of scar has been reported to be between 4% and 9%. A classical scar on the thinner and more vulnerable part of the uterus tends to rupture with more intensity and result in more serious complications for mothers and babies. Mothers who have had several children and have a classical uterine scar are at higher risk for uterine rupture. A few circumstances (prior classic or T-shaped incision, contracted pelvis, unavailability of facilities for emergency caesarean delivery) will preclude a trial of labour. In most instances, however, the decision about mode of birth following a previous caesarean should take into consideration:9

Maternal preferences and priorities A general discussion of overall risks and benefits of caesarean section Risk of uterine rupture - uterine rupture is a rare complication even in those who have had a previous caesarean (35 per 10,000 women undergoing trial of labour and 12 per 10,000 having a planned repeat caesarean section) Risk of perinatal mortality and morbidity: the risk of an intrapartum death is small in planned vaginal birth (10 per 10,000) but higher than those having a planned repeat caesarean (1 per 10,000). The effect of planned vaginal birth or repeat caesarean section on cerebral palsy is uncertain.

Those who opt for a trial of labour should be offered continuous electronic fetal monitoring during delivery and care during labour in a unity where there is immediate access to emergency caesareans and an on-site blood transfusion service. Ideally delivery should take place in a unit with more than 3000 births per year.10,11

NICE guidance states that women with a previous caesarean section can be offered induction of labour but they should be aware that the risk of uterine rupture is increased (to 80 per 10,000 using non-prostaglandin agents and to 240 per 10,000 with prostaglandins).9,11 Pregnant women with previous caesarean section and vaginal births have a higher likelihood of a vaginal birth compared to women who have only a previous caesarean delivery.10 Research supports a maximum oxytocin dose of 20 mU/min in trials of labour, to avoid an unacceptably high (4x greater) risk of uterine rupture.12 Women with more than one previous caesarean section seem to be at higher risk of uterine rupture (1.4% compared to 0.6% in women with only 1 previous section, not statistically significant).13

Document references 1. Kieser KE, Baskett TF; A 10-year population-based study of uterine rupture. Obstet Gynecol. 2002 Oct;100(4):749-53. [abstract] 2. Current obstetric and gynaecologic diagnosis and treatment. DeCherney AH and Nathan L 9th Edition. Lang Medical Books. 2003. Pp 365

3. Zwart JJ, Richters JM, Ory F, et al; Severe maternal morbidity during pregnancy, delivery and puerperium in the Netherlands: a nationwide population-based study of 371,000 pregnancies. BJOG. 2008 Jun;115(7):842-50. [abstract] 4. Toppenberg KS, Block WA Jr; Uterine rupture: what family physicians need to know. Am Fam Physician. 2002 Sep 1;66(5):823-8. [abstract] 5. Leung AS, Leung EK, Paul RH; Uterine rupture after previous cesarean delivery: maternal and fetal consequences. Am J Obstet Gynecol. 1993 Oct;169(4):945-50. [abstract] 6. Landon MB, Hauth JC, Leveno KJ, et al; Maternal and perinatal outcomes associated with a trial of labor after prior cesarean delivery. N Engl J Med. 2004 Dec 16;351(25):2581-9. Epub 2004 Dec 14. [abstract] 7. Bujold E, Gauthier RJ; Neonatal morbidity associated with uterine rupture: what are the risk factors? Am J Obstet Gynecol. 2002 Feb;186(2):311-4. [abstract] 8. Grobman WA, Lai Y, Landon MB, et al; Prediction of uterine rupture associated with attempted vaginal birth after cesarean delivery. Am J Obstet Gynecol. 2008 Apr 23;. [abstract] 9. Caesarean section, NICE Clinical Guideline (2004) 10. Smith GC, Pell JP, Pasupathy D, et al; Factors predisposing to perinatal death related to uterine rupture during attempted vaginal birth after caesarean section: retrospective cohort study. BMJ. 2004 Aug 14;329(7462):375. Epub 2004 Jul 19. [abstract] 11. Intrapartum care, NICE Clinical Guideline (2007) 12. Cahill AG, Waterman BM, Stamilio DM, et al; Higher maximum doses of oxytocin are associated with an unacceptably high risk for uterine rupture in patients attempting vaginal birth after cesarean delivery. Am J Obstet Gynecol. 2008 May 1;. [abstract] 13. Emembolu JO; Vaginal delivery after two or more previous caesarean sections: is trial of labour contraindicated? J Obstet Gynaecol. 1998 Jan;18(1):20-4. [abstract]

Classification. Complete rupture can be:

Traumatic: o Motor vehicle accident o Incorrect use of oxytocic agent o Poorly conducted attempt at operative vaginal delivery (typically breech extraction with an incompletely dilated cervix) Other procedures with high risk of uterine rupture include internal podalic version and extraction, difficult forceps delivery, destructive operations and manoeuvres to relieve shoulder dystocia.

Spontaneous: o Most patients either have had caesarean section or a history of trauma that could have caused permanent damage.1 o Patients may have no history of surgery but a weakened uterus due to multiparity, particularly if they have an old lateral cervical laceration.

Risk factors

Prior uterine surgery (including myomectomy, vigorous curettage, induced abortion, manual removal of the placenta). However, most frequent cause of a uterine scar is a previous caesarean section. Classical vertical and T-shaped incisions carry a higher risk of later uterine rupture than the standard modern low transverse approach. Uterine anomalies (e.g. undeveloped uterine horn) Trauma (e.g. RTA) Use of rotational forceps Obstructed labour Induction of labour (suspected association only) prostaglandins should be used with caution during a trial of labour Cervical laceration Placenta percreta or increta Hydramnios Macrosomia and fetal anomaly (e.g. hydrocephalus) Malpresentation (brow or face) Multiple pregnancy

Choriocarcinoma

Signs of uterine rupture that may or may not be present.

Vaginal bleeding Sharp pain between contractions Contractions that slow down or become less intense Abdominal pain or tenderness Recession of the fetal head (baby's head moving back up into the birth canal) Bulging under the pubic bone (baby's head has protruded outside of the uterine scar) Sharp onset of pain at the site of the previous scar Uterine atony (soft muscles)

Management of uterine rupture depends on prompt detection and diagnosis:

The classic signs (sudden tearing uterine pain, vaginal haemorrhage, cessation of uterine contractions, regression of the fetus) have been shown to be unreliable and frequently absent.4 Prolonged, late or variable decelerations and bradycardia seen on fetal heart rate monitoring are the most common and often the only manifestations of uterine rupture. In 3/4 of cases signs of fetal distress will appear before pain or bleeding. Sudden appearance of gross haematuria is indicative of rupture. Increasing pain and bleeding may occur as the size of rupture increases with possible signs of hypovolaemic shock and haemoperitoneum. Exsanguination prior to surgery is unlikely (because of reduced vascularity of scar tissue) unless a uterine artery has been lacerated but the placenta may completely separate and fetus pass either partially or totally out of the uterus and into the abdominal cavity with a high risk of intrapartum death.

Laparotomy may still be required even after a successful vaginal delivery if there is suspicion of uterine rupture to assess damage and control bleeding.

Management In all cases of operative delivery, especially where there are risk factors for uterine rupture, a thorough examination of uterus and birth canal is required.4

In most cases of complete uterine rupture, hysterectomy is the preferred treatment either total or sub-total depending on site of rupture and patient's condition. In cases of lateral rupture involving lower uterine segment and uterine artery where haemorrhage and haematoma obscure the operative field, ligation of ipsilateral hypogastric artery to stop bleeding may be needed. Where future child bearing is important and risks are acceptable, can attempt rupture repair. Repeat rupture occurs in approximately 20% of cases.

Risk for uterine rupture is higher when:

Labor is induced with oxytocin, prostaglandin preparations, or misoprostol (Cytotec).

The prior cesarean incision was closed with a single-layer of sutures (single-layer closure- often done in recent years to shorten the time in the operating room) as opposed to two layers of sutures (double-layer closure). Women become pregnant and labor for a VBAC within less than 24 months after a prior cesarean. Women are older than 30 years of age. Maternal fever was a consequence of a prior cesarean birth. A classical uterine incision was used in a prior cesarean birth. A woman has had two or more prior cesarean births.

Maternal preferences and priorities A general discussion of overall risks and benefits of caesarean section Risk of uterine rupture - uterine rupture is a rare complication even in those who have had a previous caesarean (35 per 10,000 women undergoing trial of labour and 12 per 10,000 having a planned repeat caesarean section)

Risk of perinatal mortality and morbidity: the risk of an intrapartum death is small in planned vaginal birth (10 per 10,000) but higher than those having a planned repeat caesarean (1 per 10,000). The effect of planned vaginal birth or repeat caesarean section on cerebral palsy is uncertain.

Those who opt for a trial of labour should be offered continuous electronic fetal monitoring during delivery and care during labour in a unity where there is immediate access to emergency caesareans and an on-site blood transfusion service. Ideally delivery should take place in a unit with more than 3000 births per year.10,11

NICE guidance states that women with a previous caesarean section can be offered induction of labour but they should be aware that the risk of uterine rupture is increased (to 80 per 10,000 using non-prostaglandin agents and to 240 per 10,000 with prostaglandins).9,11 Pregnant women with previous caesarean section and vaginal births have a higher likelihood of a vaginal birth compared to women who have only a previous caesarean delivery.10 Research supports a maximum oxytocin dose of 20 mU/min in trials of labour, to avoid an unacceptably high (4x greater) risk of uterine rupture.12 Women with more than one previous caesarean section seem to be at higher risk of uterine rupture (1.4% compared to 0.6% in women with only 1 previous section, not statistically significant).13