Uterine rupture | |
---|---|
Specialty | Obstetrics |
Symptoms | Increased pain, vaginal bleeding, change in contractions [1] [2] |
Usual onset | During labor [3] |
Risk factors | Vaginal birth after cesarean section, other uterine scars, obstructed labor, induction of labor, trauma, cocaine use [1] [4] |
Diagnostic method | Supported by a rapid drop in the baby's heart rate [1] |
Treatment | Surgery [1] |
Prognosis | 0.1%-10% risk of maternal death, [5] 6% risk of infant death [1] |
Frequency | 1 in 12,000 vaginal deliveries with a normal uterus [1] 1 in 280 with vaginal birth after cesarean section [1] |
Uterine rupture is when the muscular wall of the uterus tears during pregnancy or childbirth. [3] Symptoms, while classically including increased pain, vaginal bleeding, or a change in contractions, are not always present. [1] [2] Disability or death of the mother or baby may result. [1] [3]
Risk factors include vaginal birth after cesarean section (VBAC), other uterine scars, obstructed labor, induction of labor, trauma, and cocaine use. [1] [4] While typically rupture occurs during labor it may occasionally happen earlier in pregnancy. [3] [1] Diagnosis may be suspected based on a rapid drop in the baby's heart rate during labor. [1] [4] Uterine dehiscence is a less severe condition in which there is only incomplete separation of the old scar. [1]
Treatment involves rapid surgery to control bleeding and delivery of the baby. [1] A hysterectomy may be required to control the bleeding. [1] Blood transfusions may be given to replace blood loss. [1] Women who have had a prior rupture are generally recommended to have C-sections in subsequent pregnancies. [6]
Rates of uterine rupture during vaginal birth following one previous C-section, done by the typical technique, are estimated at 0.9%. [1] Rates are greater among those who have had multiple prior C-sections or an atypical type of C-section. [1] In those who do have uterine scarring, the risk during a vaginal birth is about 1 per 12,000. [1] Risk of death of the baby is about 6%. [1] Those in the developing world appear to be affected more often and have worse outcomes. [7] [3]
Symptoms of a rupture may be initially quite subtle. An old cesarean scar may undergo dehiscence; with further labor the woman may experience abdominal pain and vaginal bleeding, though these signs are difficult to distinguish from normal labor. Often a deterioration of the fetal heart rate is a leading sign, but the cardinal sign of uterine rupture is loss of fetal station on manual vaginal exam. Intra-abdominal bleeding can lead to hypovolemic shock and death. Although the associated maternal mortality is now less than one percent, the fetal mortality rate is between two and six percent when rupture occurs in the hospital.
In pregnancy uterine rupture may cause a viable abdominal pregnancy. This is what accounts for most abdominal pregnancy births.
A uterine scar from a previous cesarean section is the most common risk factor. (In one review, 52% had previous cesarean scars.) [8] 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. [9]
Uterine rupture during pregnancy without a prior cesarean section is one of the major diagnostic criterion for vascular Ehlers-Danlos syndrome (vEDS). [10]
In an incomplete rupture the peritoneum is still intact. With a complete rupture the contents of the uterus spill into the peritoneal cavity or the broad ligament.
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.
Caesarean section, also known as C-section or caesarean delivery, is the surgical procedure by which one or more babies are delivered through an incision in the mother's abdomen. It is often performed because vaginal delivery would put the mother or fetus at risk. Reasons for the operation include obstructed labor, twin pregnancy, high blood pressure in the mother, breech birth, shoulder presentation, and problems with the placenta or umbilical cord. A caesarean delivery may be performed based upon the shape of the mother's pelvis or history of a previous C-section. A trial of vaginal birth after C-section may be possible. The World Health Organization recommends that caesarean section be performed only when medically necessary.
Ectopic pregnancy is a complication of pregnancy in which the embryo attaches outside the uterus. Signs and symptoms classically include abdominal pain and vaginal bleeding, but fewer than 50 percent of affected women have both of these symptoms. The pain may be described as sharp, dull, or crampy. Pain may also spread to the shoulder if bleeding into the abdomen has occurred. Severe bleeding may result in a fast heart rate, fainting, or shock. With very rare exceptions, the fetus is unable to survive.
Placenta praevia is when the placenta attaches inside the uterus but in a position near or over the cervical opening. Symptoms include vaginal bleeding in the second half of pregnancy. The bleeding is bright red and tends not to be associated with pain. Complications may include placenta accreta, dangerously low blood pressure, or bleeding after delivery. Complications for the baby may include fetal growth restriction.
Umbilical cord prolapse is when the umbilical cord comes out of the uterus with or before the presenting part of the baby. The concern with cord prolapse is that pressure on the cord from the baby will compromise blood flow to the baby. It usually occurs during labor but can occur anytime after the rupture of membranes.
A hysterotomy is an incision made in the uterus. This surgical incision is used in several medical procedures, including during termination of pregnancy in the second trimester and delivering the fetus during caesarean section. It is also used to gain access and perform surgery on a fetus during pregnancy to correct birth defects, and it is an option to achieve resuscitation if cardiac arrest occurs during pregnancy and it is necessary to remove the fetus from the uterus.
Placental abruption is when the placenta separates early from the uterus, in other words separates before childbirth. It occurs most commonly around 25 weeks of pregnancy. Symptoms may include vaginal bleeding, lower abdominal pain, and dangerously low blood pressure. Complications for the mother can include disseminated intravascular coagulopathy and kidney failure. Complications for the baby can include fetal distress, low birthweight, preterm delivery, and stillbirth.
Antepartum bleeding, also known as antepartum haemorrhage (APH) or prepartum hemorrhage, is genital bleeding during pregnancy after the 28th week of pregnancy up to delivery.
Cervical dilation is the opening of the cervix, the entrance to the uterus, during childbirth, miscarriage, induced abortion, or gynecological surgery. Cervical dilation may occur naturally, or may be induced surgically or medically.
Bloody show or show is the passage of a small amount of blood or blood-tinged mucus through the vagina near the end of pregnancy. It is caused by thinning and dilation of the cervix, leading to detachment of the cervical mucus plug that seals the cervix during pregnancy and tearing of small cervical blood vessels, and is one of the signs that labor may be imminent. The bloody show may be expelled from the vagina in pieces or altogether and often appears as a jelly-like piece of mucus stained with blood. Although the bloody show may be alarming at first, it is not a concern of patient health after 37 weeks gestation.
Myomectomy, sometimes also called fibroidectomy, refers to the surgical removal of uterine leiomyomas, also known as fibroids. In contrast to a hysterectomy, the uterus remains preserved and the woman retains her reproductive potential. It still may impact hormonal regulation and the menstrual cycle.
Prelabor rupture of membranes (PROM), previously known as premature rupture of membranes, is breakage of the amniotic sac before the onset of labor. Women usually experience a painless gush or a steady leakage of fluid from the vagina. Complications in the baby may include premature birth, cord compression, and infection. Complications in the mother may include placental abruption and postpartum endometritis.
Complications of pregnancy are health problems that are related to, or arise during pregnancy. Complications that occur primarily during childbirth are termed obstetric labor complications, and problems that occur primarily after childbirth are termed puerperal disorders. While some complications improve or are fully resolved after pregnancy, some may lead to lasting effects, morbidity, or in the most severe cases, maternal or fetal mortality.
Placenta accreta occurs when all or part of the placenta attaches abnormally to the myometrium. Three grades of abnormal placental attachment are defined according to the depth of attachment and invasion into the muscular layers of the uterus:
Uterine atony is the failure of the uterus to contract adequately following delivery. Contraction of the uterine muscles during labor compresses the blood vessels and slows flow, which helps prevent hemorrhage and facilitates coagulation. Therefore, a lack of uterine muscle contraction can lead to an acute hemorrhage, as the vasculature is not being sufficiently compressed. Uterine atony is the most common cause of postpartum hemorrhage, which is an emergency and potential cause of fatality. Across the globe, postpartum hemorrhage is among the top five causes of maternal death. Recognition of the warning signs of uterine atony in the setting of extensive postpartum bleeding should initiate interventions aimed at regaining stable uterine contraction.
In case of a previous caesarean section a subsequent pregnancy can be planned beforehand to be delivered by either of the following two main methods:
A vaginal delivery is the birth of offspring in mammals through the vagina. It is the most common method of childbirth worldwide. It is considered the preferred method of delivery, with lower morbidity and mortality than caesarean sections (C-sections).
An asynclitic birth or asynclitism are terms used in obstetrics to refer to childbirth in which there is malposition of the head of the fetus in the uterus, relative to the birth canal. Asynclitic presentation is different from a shoulder presentation, in which the shoulder is presenting first. Many babies enter the pelvis in an asynclitic presentation, and most asynclitism corrects spontaneously as part of the normal birthing process.
An obstetric labor complication is a difficulty or abnormality that arises during the process of labor or delivery.
An interstitial pregnancy is a uterine but ectopic pregnancy; the pregnancy is located outside the uterine cavity in that part of the fallopian tube that penetrates the muscular layer of the uterus. The term cornual pregnancy is sometimes used as a synonym, but remains ambiguous as it is also applied to indicate the presence of a pregnancy located within the cavity in one of the two upper "horns" of a bicornuate uterus. Interstitial pregnancies have a higher mortality than ectopics in general.
Early pregnancy bleeding refers to vaginal bleeding before 14 weeks of gestational age. If the bleeding is significant, hemorrhagic shock may occur. Concern for shock is increased in those who have loss of consciousness, chest pain, shortness of breath, or shoulder pain.