UTERINE RUPTURE
INTRODUCTION:
Uterine rupture is a potentially catastrophic event during childbirth by which the integrity of
the myometrial wall is breached. In an incomplete rupture the peritoneum is still intact. With
a complete rupture the contents of the uterus may spill into the peritoneal cavity or the broad
ligament. A uterine rupture is a life-threatening event for mother and baby.
DEFINITION:
A uterine rupture typically occurs during active labor, but may already develop during late
pregnancy.
Uterine dehiscence is a similar condition, but involves fewer layers, less bleeding, and
less risk.
RISK FACTORS AND CAUSES:
A uterine scar from a previous cesarean section is the most common risk factor. (In
one review, 52% had previous cesarean scars.)
Other forms of uterine surgery that result in full-thickness incisions (such as
a myomectomy),dysfunctional labor, labor augmentation
by oxytocin or prostaglandins, and high parity may also set the stage for uterine
rupture. In 2006, an extremely rare case of uterine rupture in a first pregnancy with no
risk factors was reported.
INCIDENCE AND RISK FACTORS:
The major patient characteristics for determining the risk of uterine rupture are noted below.
1. Uterine status is either native (unscarred) or scarred. Scarred status may include
previous cesarean delivery, including the following:
Single low transverse (further subcategorized by 1-layer or 2-layer hysterectomy
closure)
Single low vertical
Classic vertical
Multiple previous cesarean deliveries
2. Pregnancy considerations include the following:
Grand multiparity
Maternal age
Placentation (accreta, percreta, increta, previa, abruption)
Cornual (or angular) pregnancy
Uterine overdistension (multiple gestation, polyhydramnios)
Dystocia (fetal macrosomia, contracted pelvis)
Gestation longer than 40 weeks
Trophoblastic invasion of the myometrium ( hydatidiform mole,
choriocarcinoma)
3. Previous pregnancy and delivery history may include the following:
Previous successful vaginal delivery
No previous vaginal delivery
Interdelivery interval
4. Labor status is determined as follows:
Not in labor
Spontaneous labor
Induced labor - with oxytocin, with prostaglandins
Augmentation of labor with oxytocin
Duration of labor
Obstructed labor
5. Obstetric management considerations include the following:
Instrumentation ( forceps use)
Intrauterine manipulation (external cephalic version, internal podalic version,
breech extraction, shoulder dystocia, manual extraction of placenta)
Fundal pressure
6. Uterine trauma includes the following:
Direct uterine trauma (eg, motor vehicle accident, fall)
Violence (eg, gunshot wound, blunt blow to abdomen)
SIGNS AND SYMPTOMS:
Abdominal pain and tenderness. The pain may not be severe; it may occur suddenly at the
peak of a contraction. The woman may describe a feeling that something "gave way" or
"ripped."
Chest pain, pain between the scapulae, or pain on inspiration—Pain occurs because of the
irritation of blood below the woman's diphragm
Hypovolemic shock caused by hemorrhage—Falling blood pressure, tachycardia,
tachypnea, pallor, cool and clammy skin, and anxiety. The fall in blood pressure is often
a late sign of hemorrhage
Signs associated with fetal oxygenation, such as late decelerations, reduced variability,
tachycardia, and bradycardia
Absent fetal heart sounds with a large disruption of the placenta; absent fetal heart
activity by ultrasound examination
Cessation of uterine contractions
Palpation of the fetus outside the uterus (usually occurs only with a large, complete
rupture). The fetus is likely to be dead at this point.
Signs of an abdominal pregnancy
TREATMENT:
Emergency exploratory laparotomy with cesarean delivery accompanied by fluid
and blood transfusion are indicated for the management of uterine rupture.
Depending on the nature of the rupture and the condition of the patient, the uterus
may be either repaired or removed (cesarean hysterectomy).
Delay in management places both mother and child at significant risk.
PREVENTION:
The most direct prevention strategy for minimizing the risk of pregnancy-related uterine
rupture is to minimize the number of patients who are at highest risk. The salient variable that
must be defined in this regard is the threshold for what is considered a tolerable risk.
Although this choice is ultimately arbitrary, it should reflect the prevailing risk tolerance of
patients, physicians, and of society as a whole. If this threshold is chosen as 1 in 200 women
(0.5%) (see Table 1), the categories of patients that exceed this critical value are those with
the following:
Multiple previous cesarean deliveries
Previous classic midline cesarean delivery
Previous low vertical cesarean delivery
Previous low transverse cesarean delivery with a single-layer hysterotomy closure
Previous cesarean delivery with an interdelivery interval of less than 2 years
Previous low transverse cesarean delivery with a congenitally abnormal uterus
Previous cesarean delivery without a previous history of a successful vaginal birth
Previous cesarean delivery with either labor induction or augmentation
Previous cesarean delivery in a woman carrying a macrosomic fetus weighing >4000 g
Previous uterine myomectomy accomplished by means of laparoscopy or laparotomy
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1. Blackburn, D. G. and Flemming, A. F. (2011), Invasive implantation and
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3. Romer, Alfred Sherwood; Parsons, Thomas S. (1977). The Vertebrate
Body. Philadelphia, Pennsylvania: Holt-Saunders International.pp. 390–
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4. Manual of Obstetrics. (3rd ed.). Elsevier 2011. pp. 1-16. ISBN 9788131
225561.
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02-27
6. Tipped Uterus:Tilted
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7. "The world's first womb transplant: Landmark surgery brings hope to
millions of childless women - and it could be in Britain
soon". May 25, 2012.
