Uterine rupture: Risk factors and pregnancy outcome

Keren Ofir, BMS,a Eyal Sheiner, MD,a Amalia Levy, PhD,b Miriam Katz, MD,a and
Moshe Mazor, MDa
Beer-Sheva, Israel

OBJECTIVES: This study aimed at determining risk factors and pregnancy outcome in women with uterine
rupture.
STUDY DESIGN: We conducted a population-based study, comparing all singleton deliveries with and without
uterine rupture between 1988 and 1999.
RESULTS: Uterus rupture occurred in 0.035% (n = 42) of all deliveries included in the study (n = 117,685).
Independent risk factors for uterine rupture in a multivariable analysis were as follows: previous cesarean
section (odds ratio [OR] = 6.0, 95% CI 3.2-11.4), malpresentation (OR = 5.4, 95% CI 2.7-10.5), and dystocia
during the second stage of labor (OR = 13.7, 95% CI 6.4-29.3). Women with uterine rupture had more
episodes of postpartum hemorrhage (50.0% vs 0.4%, P < .01), received more packed cell transfusions (54.8%
vs 1.5%, P < .01), and required more hysterectomies (26.2% vs 0.04%, P < .01). Newborn infants delivered
after uterine rupture were more frequently graded Apgar scores lower than 5 at 5 minutes and had higher rates
of perinatal mortality when compared with those without rupture (10.3% vs 0.3%, P < .01; 19.0% vs 1.4%,
P < .01, respectively).
CONCLUSION: Uterine rupture, associated with previous cesarean section, malpresentation, and second-
stage dystocia, is a major risk factor for maternal morbidity and neonatal mortality. Thus, a repeated cesarean
delivery should be considered among parturients with a previous uterine scar, whose labor failed to progress.
(Am J Obstet Gynecol 2003;189:1042-6.)

Key words: Uterine rupture, cesarean section, perinatal mortality, maternal morbidity

Uterine rupture is a life-threatening event, resulting in
serious complications, including peripartum hysterec-
tomy, hemorrhage, shock, and even maternal and new-
born mortality.1-4 Uterine rupture occurs in 1:2500 to
1:5000 deliveries.4,5 Complete rupture involves the entire
uterine wall and results in a direct connection between the
peritoneal space and the uterine cavity. It is less common
than an incomplete rupture, when a cover of visceral
peritoneum or the broad ligament is left over the uterus.6
Uterine rupture most often involves a scarred uterus.7
In addition, most studies indicate that the majority of
ruptures in a scarred uterus are among parturient patients
who underwent a cesarean section (CS) in the past.4,8
Among these patients the risk is further increased when
two or more deliveries by CS were performed,9 when a trial
of labor is allowed,10,11 during instrumental deliveries,12
From the Department of Obstetrics and Gynecology,a Epidemiology
and Health Services Evaluation Department,b Faculty of Health
Services,a,b Soroka University Medical Center, Ben-Gurion University
of the Negev.
Presented at the Twenty-Third Annual Meeting of the Society for
Maternal-Fetal Medicine, San Francisco, Calif, February 3-8, 2003.
This work is in satisfaction of K. Ofir, MD, requirements.
Reprint requests: Eyal Sheiner, MD, Department of Obstetrics and
Gynecology, Soroka University Medical Center, PO Box 151, Beer-Sheva
84101, Israel. E-mail: sheiner@bgumail.bgu.ac.il
2003, Mosby, Inc. All rights reserved.
0002-9378/2003 $30.00 + 0
doi:10.1067/S0002-9378(03)01052-4
or when excessive induction is conducted,8,10,13 especially
by oxytocin12 or prostaglandines.10,12 Conversely, the risk
of rupture decreases in women who have had a successful
vaginal birth after a CS.12
The rising trend of performing more deliveries by CS
has increased the number of women exposed to the risk of
a ruptured uterus. Thus, there is great importance in early
risk factor detection, particularly as it is possible to pre-
vent several of them. The aim of this study was to define
the obstetric risk factors and outcomes of pregnancies
complicated by a uterine rupture.
Methods
All 117,685 singleton deliveries at the Soroka University
Medical Center between January1988 and December 1999
were reviewed. Data were obtained from a perinatal
database consisting of information recorded immediately
after each delivery by an obstetrician. Soroka University
Medical Center is the sole hospital in the Negev, the
southern part of Israel, containing the entire obstetric
population.
From all patients, information was collected regarding
demographic and clinical characteristics: maternal age,
gestational age, gravidity, parity, birth weight, and neo-
natal sex. In addition, the following obstetric risk factors
were recorded: previous CS, hypertensive disorders,
diabetes mellitus, hydramnios (amniotic fluid index

1042
Volume 189, Number 4
Am J Obstet Gynecol
Table I. Demographic and clinical characteristics of deliveries complicated by uterine rupture and of the
comparison group
Characteristics Uterine rupture (n = 42)
Maternal age (y SD) 29.9 6.3
Gestational age (wks SD) 38.8 3.1
Gravidity
1 14.3%
2-4 45.2%
$5 40.5%
Parity
1 16.7%
2-4 50.0%
$5 33.3%
Birth weight (g)
< 2500 9.5%
2500-3999 81.0%
4000+ 9.5%
Neonatal sex
Male 54.8%
Female 45.2%
Data are presented as percentages or means SD and P values for statistical significance.
[AFI] >24 cm) or oligohydramnios (AFI < 5 cm), and
premature rupture of membranes. The following preg-
nancy and labor complications were assessed: intrauterine
growth restriction; external version, labor induction by
Foley catheter, early amniotomy, oxytocin, or prostaglan-
din E2; oxytocin augmentation in general; and to patients
after CS in particular, failed induction, malpresenta-
tion, dystocia during the first or second stages of
labor, nonreassuring fetal heart rate (FHR) patterns,
cephalopelvic disproportion, assisted breech delivery,
meconium-stained amniotic fluid, vacuum extraction or
forceps delivery, and cesarean delivery. The following
birth and neonatal outcomes were evaluated: peripartum
hysterectomy, postpartum hemorrhage, blood transfu-
sion, hemoglobin levels and length of hospitalization,
Apgar scores at 1 and 5 minutes less than 5, and perinatal
mortality.
The classification of delivery as one that is complicated
by a uterine rupture was conducted according to the ICD-
9-CM (International Classification of Diseases, 9th re-
vision, Clinical Modification) code for uterine rupture,
665.11. The diagnosis of uterine rupture was a clinical
one, made by the attending physician. Only complete
ruptures were regarded for this study. For that, we
reviewed the archived hospitalization records of all
patients matching the ICD-9-CM criteria for a uterine
rupture from January 1988 to December 1999.
Oxytocin was initiated at 1 mU/min and the infusion rate
was increased by 1 mU/min every 15 to 20 minutes until
contractions were adequate. For patients with a previous
low transverse CS, oxytocin was usually withheld, and if
infused, the uterine activity was measured using an internal
uterine pressure catheter. Patients who have undergone
only one low transverse CS are permitted to have a vaginal
birth after cesarean delivery in our institution.
Or et al 1043
No rupture (n = 117,643) P value
28.2 5.9 .06
39.2 2.1 .16
19.8%
48.0%
32.2% .22
23.5%
51.5%
25.0% .17
8.0%
87.4%
4.6% .54
51.3%
48.7% .65
Statistical analysis was performed with the SPSS package
(SPSS, Chicago, Ill). To test the statistical significance of
the categorical variables, the v2 test or Fisher exact test
were used as appropriate. For continuous variables,
Student t test was used. A multiple logistic regression
model was used to assess independent risk factors for
uterine rupture, while controlling for potential con-
founders. Odds ratios (ORs) and their 95% CI were
calculated from the model. A P value less than .05 was
considered statistically significant.
Results
Uterine rupture occurred in 0.035% (n = 42 cases)
of all singleton deliveries included in the study
(n = 117,685). Table I presents demographic and clinical
characteristics of the pregnancies complicated by uterine
rupture in comparison to pregnancies without this
complication. No significant differences were noted
between the groups regarding maternal age, gestational
age, birth order, birth weight, or neonatal sex.
Table II displays the occurrence of obstetric risk factors
in the two groups. Women with uterine rupture had
significantly higher rates of previous CS and hypertensive
disorders compared with the control group. Of the
parturient women, 10.1% (n = 11,833) had previous CS
and the risk for rupture among them was 0.18%. The risk
for the 105,852 women who had not undergone a previous
CS was 0.02%.
Table III presents pregnancy and labor complications.
Pregnancies complicated by uterine rupture had higher
rates of failed labor induction, malpresentation, ceph-
alopelvic disproportion, dystocia during the first and
the second stages of labor and nonreassuring FHR
patterns compared with the control group. They also
showed more assisted breech deliveries and deliveries by
1044 Or et al October 2003
Am J Obstet Gynecol

Table II. Obstetric risk factors of deliveries complicated by uterine rupture

Uterine rupture No rupture

Characteristics (n = 42) (%) (n = 117,643) (%) OR 95% CI P value

Previous CS 50.0 10.0 9.0 4.7-17.1 < .01

Hypertensive disorders 14.3 5.8 2.73 1.03-6.8 .03
Diabetes mellitus 4.8 6.3 0.74 0.12-3.12 >.999
Hydramnios 2.4 4.5 0.52 0.03-3.48 >.999
Oligohydramnios 0 1.8 0.0 0.0-6.48 >.999
PROM 9.5 5.3 1.89 0.57-5.53 .28

Data are presented as percentages, OR, 95% CI, and P values for statistical significance.

Table III. Pregnancy and labor complications in pregnancies with uterine rupture and in those without this
condition

Uterine rupture No rupture

Characteristics (n = 42) (%) (n = 117,643) (%) OR 95% CI P value

Labor induction
Prostaglandin 7.1 5.9 1.22 0.3-4.11 .74
Foley catheter 7.1 4.4 1.69 0.42-5.68 .43
Oxytocin 4.8 2.1 2.32 0.56-9.61 .22
Early amniotomy 2.4 0.8 3.20 0.44-23.22 .27
Oxytocin augmentation 21.4 15.5 1.48 0.66-3.22 .29
Failed induction 4.8 0.4 12.4 3.1-52.9 .01
Malpresentation 31 4.9 8.6 4.2-17.2 < .01
Cephalopelvic disproportion 7.1 0.4 17.7 4.3-59.7 < .01
Dystocia during first stage of labor 9.5 1.9 5.3 1.6-15.6 < .01
Dystocia during second stage of labor 23.8 1.8 17.4 8.0-36.8 < .01
Non-reassuring FHR patterns 26.2 3.7 9.3 4.4-19.2 < .01
Meconium-stained amniotic fluid 23.8 16.7 1.55 0.72-3.29 .22
Assisted breech delivery 7.1 1.0 7.6 1.9-25.6 < .01
Vacuum delivery 4.8 2.5 1.93 0.47-7.98 .29
Forceps delivery 0 0.1 0.0 0.0-91.9 >.999
Cesarean delivery 61.9 10.7 13.6 7.0-26.5 < .01

Data are presented as percentages, OR, 95% CI, and P values for statistical significance.

CS. Five hundred forty-three patients undergoing vaginal Comment

birth after CS required oxytocin augmentation. After CS,
3 of 21 (14.3%) patients receiving oxytocin had uterine
ruptures compared with 540 of 11,272 (4.8%) patients
after CS without uterine rupture (OR = 3.5, 95% CI 0.8-
12.5; P = .07; data not shown in the table).
Birth and perinatal outcomes of the two groups are
presented in Table IV. The parturients who had uterine
rupture required more peripartum hysterectomies and
had more episodes of postpartum hemorrhage than the
comparison group and accordingly received more
packed cell transfusions. In addition, women after
uterine rupture had lower levels of hemoglobin and
had longer hospitalizations (9.6 1.4 g/dL vs
11.0 1.6 g/dL, P < .01; 6.4 3.1 days vs 2.9 2.0
days, P < .01, respectively; data not shown in the table).
Newborn infants delivered after uterine rupture were
more frequently graded Apgar scores lower than 5 at 1
and 5 minutes and had higher rates of perinatal
mortality compared with those without rupture.
Independent risk factors for uterine rupture, using
a multivariable analysis (Table V) were previous CS,
malpresentation, and second-stage dystocia.
This study found uterine rupture to involve 1:2900
deliveries (0.035%), substantiating previous publi-
cations.4,5 Our population-based study was able to
confirm several important independent risk factors for
uterine rupture, including previous CS, malpresentation,
and labor dystocia. A great degree of caution should be
taken when managing a trial of labor in women with
a previous uterine scar, especially if labor has failed to
progress. Indeed, Hamilton et al14 calculated that when
labor dystocia occurred (ie, cervical dilatation was lower
than the 10th percentile and was arrested for more than
2 hours), cesarean delivery would have prevented more
than 40% of ruptures. The option of repeated CS should
be strongly considered among patients with a scarred
uterus, when deviation from Friedmans curves occurs.
However, further research is needed to elucidate the
efficacy of such an approach.
Cesarean delivery is the most common cause for
a scarred uterus. This fact is especially important given
that the rate of CS is rising. In fact, CS is the most
frequently performed major operation in the United
States with about 1 million such operations are performed
Volume 189, Number 4 Or et al 1045
Am J Obstet Gynecol

Table IV. Birth and pregnancy outcome in pregnancies complicated by uterine rupture and of the comparison group

Uterine rupture No rupture

Characteristics (n = 42) (%) (n = 117,643) (%) OR 95% CI P value

Perinatal mortality 19 1.4 17.2 7.3-38.7 < .01

Apgar 1 min < 5 17.9 2.4 8.9 3.6-21.0 < .01
Apgar 5 min < 5 10.3 0.3 42.8 12.8-126.8 < .01
Postpartum hemorrhage 50 0.4 264.0 137.5-506.8 < .01
Peripartum hysterectomy 26.2 0.04 927.3 410.1-2064.8 < .01
Blood transfusion 54.8 1.5 78.0 40.8-149.4 < .01

Data are presented as percentages, OR, 95% CI, and P values for statistical significance.

each year.15 This trend, however, is not limited only to the Table V. Independent risk factors for uterine rupture:
United States. Statistics show that worldwide, CS birth results from a multiple logistic regression model
rates have quadrupled in less than 2 decades.16 Thus, the
Characteristics OR 95% CI P value
number of women presenting to the labor ward with
a scarred uterus is increasing, thereby exposing them to Maternal age 1.01 0.95-1.07 .70
an increased risk for maternal morbidity, including Parity 1.08 0.86-1.4 .52
Previous CS 6.0 3.2-11.4 < .01
uterine rupture.17,18 Hypertensive disorders 1.8 0.7-4.4 .20
Assisted breech delivery was found to be significantly Malpresentation 5.4 2.7-10.5 < .01
higher among women from the uterine rupture group Dystocia during first stage 2.9 0.98-8.8 .05
of labor
when compared with controls. Moreover, malpre- Dystocia during second 13.7 6.4-29.3 < .01
sentation was found to be a significant, independent stage of labor
risk factor for uterine rupture in a multivariate analysis. Failed induction 2.6 0.56-12.4 .22
Lately, at our institution, the rates of this risk factor have Data are presented as OR, 95% CI, and P values for statistical
declined, because in such circumstances, rather than to significance.
allow a vaginal delivery, we prefer to perform a CS. This
approach is based on a large, randomized, controlled these serious complications, great caution should be taken
trial, which found an unfavorable outcome of vaginal when managing a trial of labor in women with a previous
delivery as compared with CS in breech presentation.19 It uterine scar, especially if labor has failed to progress.
is not clear why women with hypertensive disorders had
higher rates of uterine rupture. A logical explanation
might be that these women had higher rates of labor REFERENCES
induction. Yet induction per se was not found as a risk 1. Farmer RM, Kirschbaum T, Potter D, Strong TH, Medearis AL.
factor for rupture. However, hypertension was not found Uterine rupture during trial of labor after previous caesarean
section. Am J Obstet Gynecol 1991;165:996-1001.
to be an independent risk factor for uterine rupture in the
2. Yap OW, Kim ES, Laros RK Jr. Maternal and neonatal outcomes after
multivariate analysis. An association between hypertensive uterine rupture in labor. Am J Obstet Gynecol 2001;184:1576-81.
disorders and other risk factors, such as advanced 3. Miles AL, Monga M, Waller DK, Dande D, Pschirrer ER. Risk factors
for symptomatic uterine rupture during a trial of labor: the 1990s.
maternal age and possibly a previous CS, may partially
Am J Perinatol 2000;17:385-9.
explain the univariate significance.16 4. Gardeil F, Daly S, Turner MJ. Uterine rupture in pregnancy reviewed.
Regarding neonatal morbidity and mortality, our Eur J Obstet Gynecol Reprod Biol 1994;56:107-10.
5. Watersone M, Bewley S, Wolfe C. Incidence and predictors of severe
findings confirm earlier data.3,4 Neonates born after
obstetric morbidity: case-control study. BMJ 2001;322:1089-94.
uterine rupture were graded lower Apgar scores and had 6. Cunningham FG, Gant NF, Leveno KJ, Gilstrap LC 3d, Hauth JC,
an increased risk of perinatal mortality compared with Wenstrom KD. Williams obstetrics. 21st ed. Philadelphia: McGraw-
Hill; 2001. p. 646-7.
controls. Likewise, an increased maternal morbidity was
7. Miller DA, Paul RH. Rupture of the unscarred uterus. Am J Obstet
found among parturient women with uterine rupture. Gynecol 1996;174:345.
Controversy exists in the literature regarding maternal 8. Baskett TF, Keiser KE. A 10-year population-based study of uterine
mortality. Our study, as well as most others, did not find rupture. Obstet Gynecol 2001;97:s69.
9. Caughey AB, Shipp TD, Repke JT, Zelop CM, Cohen A, Lieberman E.
any maternal death after a uterine rupture.1,2 However, in Rate of uterine rupture during a trial of labor in women with one or
several reports, especially those conducted in developing two prior cesarean deliveries. Am J Obstet Gynecol 1999;181:872-6.
countries, maternal mortality was found to range from 1% 10. Lydon-Rochelle M, Holt VL, Easterling TR, Martin DP. Risk of
uterine rupture during labor among women with a prior cesarean
to 13%.20,21 delivery. N Engl J Med 2001;345:3-8.
In conclusion, uterine rupture, which was found to be 11. Gregory KD, Korst LM, Cane P, Platt LD, Kahn K. Vaginal birth after
associated with previous CS, malpresentation, and labor cesarean and uterine rupture rates in California. Obstet Gynecol
1999;94:985-9.
dystocia during the second stage, is a major risk factor for 12. Shimonovitz S, Botosneano A, Hochner-Celnikier D. Successful first
maternal morbidity and neonatal mortality. Because of vaginal birth after cesarean section: a predictor of reduced risk for
1046 Or et al
uterine rupture in subsequent deliveries. Isr Med Assoc J 2000;2:
526-8.
13. Sims EJ, Newman RB, Hulsey TC. Vaginal birth after cesarean: to
induce or not to induce. Am J Obstet Gynecol 2001;184:1122-4.
14. Hamilton EF, Bujold E, McNamara H, Gauthier R, Platt RW. Dystocia
among women with symptomatic uterine rupture. Am J Obstet
Gynecol 2001;184:620-4.
15. Flamm BL, Berwick DM, Kabcenell A. Reducing cesarean section
rates safely: lessons from a breakthrough series collaborative. Birth
1998;25:117-24.
16. Sheiner E, Shoham-Vardi I, Hershkovitz R, Katz M, Mazor M.
Infertility treatment is an independent risk factor for cesarean
section among nulliparous women aged 40 and above. Am J Obstet
Gynecol 2001;185:888-92.
October 2003
Am J Obstet Gynecol
17. Chazotte C, Cohen WR. Catastrophic complications of previous
cesarean section. Am J Obstet Gynecol 1990;163:738-42.
18. Amu O, Rajendran S. Bolaji II. Should doctors perform an elective
caesarean section on request? Maternal choice alone should not
determine method of delivery. BMJ 1998;317:463-5.
19. Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan
AR. Planned caesarean section versus planned vaginal birth for
breech presentation at term: a randomised multicentre trial. Lancet
2000;356:1375-83.
20. Aboyeji AP, Ijaiya MD, Yahaya UR. Ruptured uterus: a study of 100
consecutive cases in Ilorin, Nigeria. J Obstet Gynaecol Res
2001;27:341-8.
21. Van der Merwe JV, Ombelet WU. Rupture of the uterus: a changing
picture. Arch Gynecol 1987;240:159-71.