Uterine Rupture

!!! OBSTETRIC EMERGENCY !!!

A full-thickness tear of uterine muscle develops, creating an opening into the abdominal cavity

• It typically occurs during labour but may occur during the 3rd trimester

• Associated with significant maternal and fetal morbidity and mortality

Risk Factors 

Mostly common sense - all are reasons why uterus may be weaker 

• Previous caesarean section – this is the greatest risk factor for uterine rupture.

  • • Classical (vertical) incisions are highest risk

• Previous uterine surgery eg. myomectomy

• Induction of labour (particularly with prostaglandins)

• Augmentation of labour

• Obstruction of labour

  • • Important to consider in developing countries

• Multiple pregnancy

• Multiparity

Presentation

• Sudden, severe and constant abdo pain 

• Shoulder tip pain (diaphragmatic irritation) 

• Vaginal bleeding

O/E:

• Tachycardia and hypotension (hypovolaemic shock)

• Regression of the presenting part

Differentials

• Placental abruption

  • • Abdo pain +/- vaginal bleeding

    • Uterus hard and 'woody’ on palpation

• Vasa praevia

  • • TRIAD of ruptured membranes, painless vaginal bleeding, and fetal bradycardia

• Placenta praevia

  • • Painless vaginal bleeding

• Amniotic Fluid Embolism 

  • • Signs of shock: Hypotension, tachycardia, fetal distress 

Investigation 

CTG:

• • Prolonged fetal bradycardia 

  • In many cases, prompts an emergency C section

Ultrasound:

• • Abnormal fetal lie or presentation

  • Haemoperitoneum

  • Absent uterine wall.

Management

• Call for help -  senior obstetricians, midwives and anaesthetists

• ABCDE approach

• Massive obstetric haemorrhage protocol if relevant 

• Delivery by caesarean section 

• Uterus repaired where possible, hysterectomy performed if not