Uterine rupture

Refers to a rupture of the gravid uterus with a rent through the entire thickness of the myometrium.

As a result of such a rupture the fetus and the placenta can be extruded intraperitoneally with the final uterine contraction.

Uncommon in developed nations.

Risk increased two-three times in women with one prior cesarean delivery and that labor induced with the use of a prostaglandin confers a greater risk.

With a partial or complete separation of the uterus from the cervix, or a tear of the myometrium and expulsion of the pregnancy contents stops uterine contractions.

May be spontaneous or traumatically induced.

May result in a complete or incomplete rupture.

The anatomical site may vary from anterior transverse lateral, fundal, or a combination of the above.

May occur and ante, intra or postpartum.

Prevalence in developed nations is one case in 4800 deliveries, in developing countries it is one in 325 deliveries and in resource poor areas of the world it occurs in one in 56 deliveries.

In developed nations it is generally due to trauma and occurs most often if the uterus is scarred.

Uterine scarring may be secondary to prior cesarean section, myomectomy or metroplasties.

Trauma related uterine rupture may occur during the use of an uterotonic drug, instrumentation, and obstetrical procedures such as version of the uterus.

The spontaneous rupture of a scarred uterus can occur without labor or as a complication of labor.

Spontaneous ruptures account for 75% of gravid uterine ruptures where obstetrical care is limited.

Spontaneous ruptures can occur in unscarred uteri secondary to prolonged and/or obstructed labor.

Spontaneous rupture during labor is most often due to cephalopelvic disproportion, but may be related to breach, brow, and face presentations along with congenital malformations.

Patients present with sharp abdominal pain, followed by cessation of contractions, the cessation of the urge to push, and vaginal bleeding.

Clinically uterine rupture is associated with easily palpable fetal parts, tendinous, absence of fetal heart tones, and signs of fluid collection..

The patients are typically in shock with secondary tachycardia, tachypnea, dehydration, fever, and impaired mentation.

Vaginal exam will reveal cervical dilatation and cephalopelvic disproportion.

With and trial of labor risk 1% after cesarean delivery.

Complications in mothers and babies after uterine rupture less than 1%.

The most common sight of spontaneous rupture is the anterior lower transverse segment followed by the left lateral segment.

The left lateral segment predominates in gravid uterine ruptures, compared to the right lateral segment, because the gravid uterus angulates to the left lateral side due to normal dextrorotation, making it weaker and more likely to rupture.

The management of a ruptured gravid uterus begins with fluid resuscitation, blood transfusions, gastric decompression, urinary catheterization and broad-spectrum anabiotics.

Laparotomy is the standard approach, and treatment decisions may range from repair, with or without tubal ligation, to total of abdominal hysterectomy.

Treatment decisions are based on the patient’s future fertility desires, the anatomical type of the rupture, duration of the rupture, and the presence of complications such as infection.

The presence of uterine atony is a primary factor in deciding about uterinr repair versus total of abdominal hysterectomy.

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