Uterine Rupture

A rare but serious complication during childbirth where the uterine wall tears.

Uterine Rupture: A Rare But Serious Complication of Childbirth

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If you are pregnant and planning to have a vaginal birth after a previous caesarean delivery (VBAC), you may have heard of the risk of uterine rupture. Uterine rupture is a rare but serious complication that can occur during labour and delivery. It happens when the muscular wall of the uterus tears open, usually along the scar line of a prior caesarean incision. This can cause severe bleeding, shock, and foetal distress. In some cases, it can be fatal for both the mother and the baby.

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What are the Causes and Symptoms of Uterine Rupture?

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Uterine rupture is caused by excessive pressure on the uterus during contractions, especially if the uterus has a weakened spot from a previous surgery or injury. The most common cause of uterine rupture is a previous caesarean delivery, which leaves a scar on the uterine wall. Other factors that can increase the risk of uterine rupture include:

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  • Having multiple previous caesarean deliveries or other uterine surgeries, such as myomectomy (removal of fibroids) or hysterotomy (incision into the uterus).
  • Having a vertical (classical) caesarean incision, which is more likely to rupture than a horizontal (low transverse) incision.
  • Having labour induced or augmented with drugs, such as oxytocin or prostaglandins, which can cause stronger contractions.
  • Having an infection or inflammation in the uterus, such as chorioamnionitis or endometritis.
  • Having a large or malpositioned baby, such as breech or transverse lie, which can put more stress on the uterus.
  • Having a history of uterine rupture or dehiscence (partial separation of the scar) in a previous pregnancy.

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Uterine rupture can be difficult to diagnose because the symptoms are often nonspecific and vary depending on the extent and location of the tear. Some possible symptoms include:

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  • Sudden or severe abdominal pain, especially at the site of the previous scar.
  • Vaginal bleeding or fluid leakage.
  • Abnormal foetal heart rate or movement.
  • Loss of foetal station (the baby's head recedes into the pelvis).
  • Bulging or protrusion of the uterus or foetal parts under the pubic bone.
  • Decreased or absent uterine contractions.
  • Rapid maternal heart rate, low blood pressure, and shock.

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How is Uterine Rupture Treated?

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Uterine rupture is a medical emergency that requires immediate intervention. The main goals of treatment are to stop the bleeding, deliver the baby as quickly as possible, and repair the uterus or remove it if necessary. The treatment options depend on several factors, such as:

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  • The severity and location of the rupture.
  • The gestational age and condition of the baby.
  • The maternal hemodynamic status and blood loss.
  • The availability of blood products and surgical facilities.
  • The maternal preference and reproductive plans.

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The most common treatment for uterine rupture is an emergency caesarean delivery, followed by either uterine repair or hysterectomy (removal of the uterus). Uterine repair may be possible if the rupture is small, localised, and not associated with significant bleeding or damage to other organs. However, if the rupture is large, extensive, or complicated by severe haemorrhage or infection, hysterectomy may be necessary to save the mother's life. Hysterectomy is also indicated if the mother does not want to have more children or if she has had multiple previous uterine ruptures.

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In some cases, conservative management may be an option for uterine rupture. This involves delivering the baby vaginally or by caesarean section without repairing or removing the uterus. This may be considered if:

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  • The rupture is incomplete (not involving all layers of the uterine wall) and not bleeding actively.
  • The baby is alive and not in distress.
  • The mother is hemodynamically stable and not in shock.
  • The mother wants to preserve her fertility and is willing to accept the risks of future pregnancies.

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Conservative management requires close monitoring and follow-up to ensure that the uterus heals properly and does not develop complications, such as infection, abscess, fistula, or chronic pain.

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What are the Outcomes and Complications of Uterine Rupture?

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The outcomes and complications of uterine rupture depend on several factors, such as:

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  • The timing and mode of diagnosis and treatment.
  • The extent and location of the rupture.
  • The amount and duration of blood loss and shock.
  • The gestational age and condition of the baby.
  • The presence of coexisting maternal or foetal conditions.

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The maternal mortality rate from uterine rupture is estimated to be between 0.5% and 18%, depending on the setting and resources. The main causes of maternal death are haemorrhage, infection, and organ failure. The maternal morbidity rate is also high, with possible complications such as:

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  • Hysterectomy, which results in infertility and psychological distress.
  • Uterine infection, abscess, or fistula, which can cause chronic pelvic pain, fever, foul-smelling discharge, and urinary or faecal incontinence.
  • Damage to other organs, such as the bladder, bowel, ureters, or blood vessels, which can require additional surgeries or interventions.
  • anaemia, coagulopathy, or transfusion reactions, which can affect the blood quality and clotting ability.
  • Post-traumatic stress disorder (PTSD), depression, or anxiety, which can affect the mental health and quality of life.

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The foetal mortality rate from uterine rupture is estimated to be between 6% and 75%, depending on the setting and resources. The main causes of foetal death are asphyxia (lack of oxygen), exsanguination (blood loss), or trauma. The foetal morbidity rate is also high, with possible complications such as:

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  • Hypoxic-ischemic encephalopathy (HIE), which is brain damage caused by oxygen deprivation. This can lead to cerebral palsy, developmental delay, intellectual disability, or epilepsy.
  • Prematurity, which can cause respiratory distress syndrome, intraventricular haemorrhage, necrotizing enterocolitis, or retinopathy of prematurity.
  • Birth injuries, such as fractures, nerve damage, or lacerations.

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How Can Uterine Rupture Be Prevented?

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The best way to prevent uterine rupture is to avoid factors that increase the risk of it. Some preventive measures include:

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  • Choosing a planned caesarean delivery if you have a history of uterine rupture or multiple previous caesarean deliveries or other uterine surgeries.

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  • Choosing a low transverse caesarean incision instead of a vertical one if you plan to have a VBAC in the future.

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  • Avoiding labour induction or augmentation with drugs unless medically indicated and under close supervision.

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  • Monitoring the foetal heart rate and uterine contractions continuously during labour to detect signs of uterine rupture or foetal distress.

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  • Seeking immediate medical attention if you experience any symptoms of uterine rupture during pregnancy or labour.

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Sources

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[1] Debbo Africa: https://debbo.africa

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[2] Uterine Rupture: Signs, Symptoms, Risks & Treatment - Cleveland Clinic

https://my.clevelandclinic.org/health/diseases/24480-uterine-rupture

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[3] Uterine Rupture: Causes, Symptoms, and Treatment - Healthline

https://www.healthline.com/health/pregnancy/complications-uterine-rupture

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[4] Uterine rupture - Wikipedia

https://en.wikipedia.org/wiki/Uterine_rupture

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[5] Uterine Rupture - Gynecology and Obstetrics - MSD Manual Professional Edition

https://www.msdmanuals.com/professional/gynecology-and-obstetrics/abnormalities-and-complications-of-labor-and-delivery/uterine-rupture

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[6] Uterine Rupture During Labor and Delivery - What to Expect

https://www.whattoexpect.com/pregnancy/pregnancy-health/complications/uterine-rupture.aspx