Ann Acad Med Singap 2021;50:5-15

ORIGINAL ARTICLE https://doi.org/10.47102/annals-acadmedsg.2020319

Risk factors and outcomes of uterine rupture in Singapore: Emerging trends

Shu Qi Tan, 1MBBS, MRCOG, Li Houng Chen, 2MBBS, Dhilshad Bte Muhd Abdul Qadir, 1MBBS, MRCS,
Bernard SM Chern, 1MBBS, FRCOG (UK), MRANZCOG, George SH Yeo, 1MBBS, FRCOG, FAMS

ABSTRACT
Introduction: Uterine rupture is uncommon but has catastrophic implications on the pregnancy. A scarred
uterus and abnormal placentation are known contributory factors. The aim of our study was to review
the contributing factors, clinical presentation, complications and management of uterine rupture in our
population in light of the changing nature of modern obstetric practices.
Methods: A retrospective observational study was conducted at KK Women’s and Children’s Hospital
by studying proven cases of uterine rupture in the period between January 2003 and December 2014. These
cases were analysed according to their past history, clinical presentation, complications, management
and outcome.
Results: A total of 48 cases of proven uterine rupture were identified. The incidence of uterine rupture
was 1 in 3,062 deliveries. The ratio of scarred uterus rupture to unscarred uterus rupture was approximately
3:1. The most common factor was previous lower segment caesarean section for the scarred group, followed
by a history of laparoscopic myomectomy. Abdominal pain was the common clinical presentation in the
antenatal period, while abnormal cardiotocography findings were the most common presentation in
intrapartum rupture.
Conclusion: There is a notable shift in the trend of uterine rupture cases given the increasing use of
laparoscopic myomectomy and elective caesarean sections. While ruptures from these cases were few, their
presentation in the antenatal period calls for diligent monitoring with informed patient involvement in their
pregnancy care.

Ann Acad Med Singap 2021;50:5-15

Keywords: Antenatal, laparoscopic myomectomy, birth after caesarean, rupture, VBAC

INTRODUCTION METHODS
Uterine rupture is a catastrophic life-threatening A retrospective observational study of uterine rupture
complication of pregnancy with associated high case records from January 2003 to December 2014 was
maternal and neonatal morbidity and mortality. The performed at the KK Women’s and Children’s Hospital,
incidence of uterine rupture varies with geographical the largest maternity hospital in Singapore. The operating
location and obstetric practice. With the changes in theatre record books of the desired period were reviewed
obstetric practice over the years, caesarean section rates to trace the uterine rupture cases. The list of patients with
have increased in our population with undesirable the International Classification of Disease coding for
consequences. The increasing numbers of caesarean uterine ruptures was also generated from our information
sections for maternal requests, the decline of vaginal system department, and the 2 lists were compiled. Obstetric
breech deliveries, and the increasing use of laparoscopic records of these cases were traced from the Medical Records
surgeries, especially laparoscopic myomectomies Office. Only cases of proven uterine rupture were included
are contributory factors. The consequence of uterine in the study. Cases of suspected or impending rupture and
rupture can be catastrophic. It is important to review the dehiscence were excluded. This study was reviewed and
contributing factors, clinical presentation, complications granted ethical approval by the SingHealth Centralised
and management of uterine rupture. Institutional Review Board prior to its commencement.

1
Division of Obstetrics and Gynaecology, KK Women’s and Children’s Hospital, Singapore
2
Yong Loo Lin School of Medicine, National University of Singapore, Singapore
Correspondence: Dr Shu Qi Tan, Division of Obstetrics and Gynaecology, KK Women’s and Children’s Hospital, 100 Bukit Timah Road, Singapore 229899.
Email: [email protected]

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6 Uterine Rupture in Singapore—Shu Qi Tan et al.

RESULTS scarred uteri group (11.1%). There were no cases of

During this 12-year period, there were 147,003 deliveries uterine rupture in the first trimester. This could be due
and 48 cases of uterine rupture at our centre. The overall to the classification of cases as part of this retrospective
incidence of uterine rupture was 1 in 3,062 deliveries. study. Ruptures in the first trimester may have been
The overall ratio of scarred to unscarred uteri was classified as ruptured ectopic pregnancies.
approximately 3:1. Uterine rupture occurred most frequently during the
The majority of cases occurred in women less than intrapartum period (62.5%). For women with 1 previous
35 years old (72.9%) and 79.2% of these mothers were caesarean section, 84% presented in the intrapartum
multiparous. There was 1 case of twin pregnancy in our period. Among these cases with 1 previous caesarean
case series in the scarred group. All other pregnancies that ruptured in the intrapartum period, 3 cases used
were singleton pregnancies. prostaglandin in labour, and 2 cases used oxytocin.
The most common reason for a scarred uterus was In contrast, women with scarred uteri of other
1 previous caesarean section (65.8%). Laparoscopic aetiologies (including 2 or more previous caesarean
myomectomy and 2 previous caesarean sections were sections, and previous uterine rupture) presented
the next most common reasons for a scarred uterus at mainly with scar rupture in the antenatal period.
13.2% each, followed by 3 previous caesarean sections Of note, all 5 patients with a previous laparoscopic
(5.3%) and previous uterine rupture (2.6%). There was myomectomy had the scar rupture antenatally. Two
1 case of recurrence of uterine rupture in the scarred uteri of these patients’ scars ruptured in the second
group from previous right cornual interstitial pregnancy trimester, and the remaining 3 ruptured in the third
at 18 weeks. trimester. The details of uterine rupture in relation
The mean duration from the previous pregnancy was to labour are summarised in Table 1.
3.3 years. Only 1 patient had a short interpregnancy The mean duration of labour with intrapartum
interval of less than a year. All patients with previous uterine ruptures was 9.2 hours. Six cases (21.4%) of
laparoscopic myomectomies and previous uterine intrapartum ruptures had prolonged active labour of
rupture had an interval of more than 12 months between 12 hours or more.
the operation and uterine rupture episode.
The majority of the uterine ruptures occurred during Maternal presentation
the third trimester (83.3%). However, a larger proportion Abdominal pain was the most common presenting
of the unscarred uteri group experienced the rupture complaint for women with antenatal uterine rupture. For
during the second trimester (33.3%) compared to the women in labour, the most common presentation was

Table 1. Number of patients with uterine rupture from scarred and unscarred uterus with or without use of prostaglandins and/or oxytocin

Antenatal Intrapartum uterine rupture Total

uterine (n=28) (n=48)
rupture
(n=20) Use of Use of Use of both No use of
prostaglandin oxytocin only prostaglandin prostaglandin
only and ocytocin or oxytocin

Scarred 1 previous caesarean 4 3 2 0 16 25

uterus, no. section

2 previous caesarean 4 0 0 0 0 4
sections

3 previous caesarean 1 0 0 0 0 1
sections

Previous laparoscopic 5 0 0 0 0 5
myomectomy

Previous uterine injury 1 0 0 0 0 1

e.g. rupture/surgery

Unscarred uterus, no. 5 0 1 2 4 12

Total no. 20 3 3 2 20 48

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 Uterine Rupture in Singapore—Shu Qi Tan et al. 7

an abnormal cardiotocogram (89.3%). Multiple myomectomy. All cases of women with previous
presentations may be present simultaneously for laparoscopic myomectomy had ruptures at the fundus.
each case. The different maternal presentations are The most common location for the unscarred group
summarised in Table 2. was the fundus (41.7%), followed by the posterior
uterine wall (33.3%).
Operative procedures
Caesarean section with uterine repair sufficed for 89.6% Maternal mortality and morbidity
of the uterine rupture cases. However, 5 cases had severe There were no maternal deaths in this series of 48
haemorrhage, necessitating a hysterectomy to secure cases. Haemoperitoneum was noted in half of the cases
haemostasis. All of these cases were in the scarred (50%). Notably, the patients with previous laparoscopic
uteri group. One of the patients presented with myomectomy had more severe maternal bleeding and
appendicitis at 17 weeks gestation with an incidental adverse consequences from the rupture. All cases had
finding of haemoperitoneum due to uterine rupture significant haemoperitoneum, and one suffered from end
at laparotomy. organ damage secondary to hypovolaemic shock. More
than half of the cases of rupture from a previous caesarean
Location of rupture scar had no serious maternal complications (Table 3).
The most common location of the rupture was the
anterior lower uterine segment (54.2%), followed by the Fetal outcomes
fundus (22.9%). Of the 48 cases, 12 cases resulted in stillbirth and neonatal
For those with scarred uteri, 88.9% of the location death (25.0%). Six stillborns belonged to the scarred uteri
of rupture corresponded to the previous scar sites. For group. The 4 stillbirths in the unscarred group occurred
women with previous caesarean deliveries, 86.7% of before 26 weeks gestation. More newborns in the scarred
ruptures occurred at the caesarean site. For women uteri group required stay in the neonatal intensive care unit
with previous laparoscopic myomectomies, all (NICU) and resuscitation at birth compared to the unscarred
myomectomies were performed at other centres. As uteri group. The average birth weight of life baby at birth
no surgical details were available, it was not known if in the scarred and unscarred group was 2,760g and 2,803g
the rupture site corresponded to the site of the previous respectively (Table 4).

Table 2. Maternal presentation of uterine rupture

Antenatal uterine rupture (n=20)

Presentation Scarred uterus (n=15) Unscarred uterus (n=5) Total by each presentation, no. (%)

Abdominal pain 13 4 17 (85.0)

Antepartum hemorrhage 2 1 3 (15.0)

Reduced fetal movements 2 0 2 (10.0)

Maternal shock 3 1 4 (20.0)

Bloatedness 1 0 1 (5.0)

Intrapartum uterine rupture (n=28)

Presentation Scarred uterus, 1 previous Unscarred uterus (n=7) Total by each presentation, no. (%)
caesarean section (n=21)

Abnormal CTG 19 6 25 (89.3)

Signs of CPD 4 4 8 (28.6)

Loss of station 1 0 1 (3.6)

Puerperal pyrexia 1 0 1 (3.6)

Scar tenderness 1 1 (3.6)

Abdominal pain 1 1 2 (7.1)

CPD: cephalopelvic disproportion; CTG: cardiotocograph

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8 Uterine Rupture in Singapore—Shu Qi Tan et al.

Up to half of the antenatal ruptures resulted in the laparoscopic myomectomy group ruptured in the
stillbirths. There were no stillbirths in the intrapartum second trimester. All live births from the laparoscopic
group. However, there were 2 subsequent neonatal myomectomy group were admitted to the NICU.
deaths due to hypoxic ischaemic encephalopathy. NICU Table 5 compares fetal outcomes between antepartum
admission rates and the need for resuscitation are similar and intrapartum ruptures.
for both groups. Within the scarred group, there was Table 6 gives a summary of all 48 rupture cases to
a higher proportion of stillbirths in the laparoscopic illustrate the type of scar, gestation of rupture, timing
myomectomy group (40.0%) compared to the of rupture, intrapartum events and neonatal outcomes.
caesarean section group (13.3%). Both stillbirths from

Table 3. Maternal outcomes from scarred and unscarred uterine ruptures (total n=48)

Outcome Scarred (n=36) Unscarred Total by each

(n=12) outcome, no. (%)
Previous Laparoscopic Previous
caesarean section myomectomy uterine rupture
(n=30) (n=5) (n=1)

Death 0 0 0 0 0

Significant haemoperitoneum 11 5 0 8 24 (50.0)

Disseminated intravascular coagulation 1 1 0 1 3 (6.3)

Hypovolaemic shock with end organ damage 0 1 0 0 1 (2.1)

Bladder injury 1 0 0 0 1 (2.1)

Uterine atony 1 0 0 0 1 (2.1)

Table 4. Fetal outcomes from scarred and unscarred uterine ruptures (total n=48)

Outcome Scarred (n=36) Unscarred Total by each

(n=12) outcome, no. (%)
Previous caesarean Previous laparoscopic Previous uterine
section (n=30) myomectomy (n=5) rupture (n=1)

Live birth 26 3 1 8 38 (75)

Stillbirth 4 2 0 4 10 (20.8)

Subsequent neonatal death 2 0 0 0 2 (4.2)

NICU stay 11 3 1 2 17 (35.4)

Resuscitationa 11 3 1 2 17 (35.4)

Apgar score ≤6 at 1 minb 14 2 0 2 18 (37.5)

Apgar score ≤6 at 5 min 5 0 0 2 7 (14.6)

a
Resuscitative measures include: oxygen, nasal continuous positive airway pressure, positive pressure ventilation, endotracheal tube, chest compressions,
epinephrine use
b
Apgar 7–10 is excellent, 4–6 is moderately depressed, 0–3 is severely depressed

Table 5. Comparison of fetal outcomes in antenatal and intrapartum uterine ruptures (total n=48)
Outcome, no. (%) Antenatal (n=20) Intrapartum (n=28)
Live birth 10 (50.0) 28 (100.0)
Stillbirth 10 (50.0) 0
Subsequent neonatal death 0 2 (7.14)
NICU stay 8 (40.0) 9 (32.1)
Resuscitation 8 (40.0) 9 (32.1)

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 Table 6. Summary of 48 uterine rupture cases

Case Scarred Scarred Timing GA Timing of Symptoms Duration Prostaglandin Oxytocin Site of Type of Neonatal Birth NICU Resuscitation
uterus? operation of scar to rupture of labour use rupture operation outcome weight
at our rupture (g)
hospital (months)

1a 1 CS No 24m 39+6 Intrapartum Trial of 11 hours No No LUS CS Live birth 3760 Yes Yes
VBAC; NRFS

2a 1 CS Yes 14m 39+4 Intrapartum Trial of 1 hour No No LUS Crash CS Live birth 3390 Yes Yes
VBAC; NRFS

3a 1 CS Yes 12m 39+1 Intrapartum Trial of 6 hours No No LUS Crash CS Live birth 3810 Yes Yes
VBAC; NRFS

4a 1 CS Yes 11m 37+0 Intrapartum Trial of 2 hours No No LUS CS Live birth 2470 No No
VBAC; NRFS

5a 1 CS No 36m 40+1 Intrapartum Abdominal 1 hour No No LUS CS Live birth 3845 No No

pain with
NRFS

6a 1 CS No 48m 40+1 Intrapartum Trial of 11 hours Yes No LUS Crash CS Live birth 3888 Yes Yes
VBAC; NRFS

7a 1 CS Yes 23m 40+3 Intrapartum Trial of 10 hours No No LUS CS Live birth 3490 No No
VBAC; NRFS

8a 1 CS Yes 17m 37+4 Intrapartum Trial of 19 hours No Yes Left CS Live birth 2922 No No
VBAC; NRFS

9a 1 CS No 108m 40+1 Intrapartum Trial of 10 hours No No LUS CS + TH Live birth 2895 No No

VBAC; NRFS
Uterine Rupture in Singapore—Shu Qi Tan et al.

10a 1 CS No 72m 39+6 Intrapartum Trial of 7 hours No No LUS Crash CS Live birth 3160 No No
VBAC; NRFS
+ CPD

11a 1 CS Yes 13m 40+2 Intrapartum Trial of 17 hours No No LUS CS Live birth 3780 No No

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VBAC; NRFS
+ Puerperal
pyrexia

12a 1 CS Yes 22m 39+3 Intrapartum Trial of 13 hours No No Posterior CS + TH Live birth 3130 No No
VBAC; NRFS
+ CPD

13a 1 CS No 60m 40+0 Intrapartum Trial of 5 hours No No LUS Crash CS Live birth 3555 No No
VBAC; NRFS

APH: antepartum haemorrhage; CPD: cephalo-pelvic disproportion; CS: caesarean section; GA: gestational age; HIE: hypoxic ischaemic encephalopathy; LUS: lower uterine segment; NA: not applicable; NICU: neonatal intensive care unit;
NRFS: non-reassuring fetal status; TH: total hysterectomy; VBAC: vaginal birth after caesarean
a
Multiparous womenn
9
 10
Table 6. Summary of 48 uterine rupture cases (Cont’d)

Case Scarred Scarred Timing GA Timing of Symptoms Duration Prostaglandin Oxytocin Site of Type of Neonatal Birth NICU Resuscitation
uterus? operation of scar to rupture of labour use rupture operation outcome weight
at our rupture (g)
hospital (months)

14a 1 CS Yes 37m 38+1 Intrapartum Trial of 9 hours Yes No LUS CS Live birth 2359 No No
VBAC; NRFS

15a 1 CS Yes 15m 39+2 Intrapartum Trial of 5 hours Yes No LUS Crash CS Live birth 3202 Yes Yes
VBAC; NRFS NN death
from HIE

16 a 1 CS Yes 16m 39+2 Intrapartum Trial of 11 hours No No LUS Crash CS Live birth 3234 No No
VBAC; NRFS
+ CPD + loss
of station

17a 1 CS No 48m 39+1 Intrapartum Trial of 10 hours No No LUS Crash CS Live birth 3200 Yes Yes
VBAC; NRFS

18a 1 CS No 72m 40+2 Intrapartum Failed VBAC 10 hours No No Fundus CS Live birth 3090 No No

19a 1 CS No; history 48m 40+4 Intrapartum Trial of 12 hours No No Previous Crash CS Live birth 3530 Yes Yes
of classical VBAC; NRFS anterior
CS CS scar

20a 1 CS Yes 30m 40+1 Intrapartum Trial of 11 hours No No LUS Crash CS + TH Live birth 2955 Yes Yes
VBAC; NRFS NN death
from HIE

21a 1 CS Yes 46m 39+4 Intrapartum Trial of 20 hours No Yes LUS CS Live birth 2765 No No
VBAC; scar
tenderness
Uterine Rupture in Singapore—Shu Qi Tan et al.

22a 1 CS No 84m 17+4 Antenatal Abdominal NA NA NA LUS Appendicectomy + Stillbirth NA NA NA

pain CS + sub-TH

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23a 1 CS Yes 19m 37+2 Antenatal APH NA NA NA LUS CS Live birth 3365 No No
a
24 1 CS No 13m 29+5 Antenatal Abdominal NA NA NA Posterior Crash CS Live birth 1125 Yes Yes
pain with
acute
abdomen and
NRFS

APH: antepartum haemorrhage; CPD: cephalo-pelvic disproportion; CS: caesarean section; GA: gestational age; HIE: hypoxic ischaemic encephalopathy; LUS: lower uterine segment; m: months; NA: not applicable; NICU: neonatal intensive
care unit; NN: neonatal; NRFS: non-reassuring fetal status; TH: total hysterectomy; VBAC: vaginal birth after caesarean
a
Multiparous women
 Table 6. Summary of 48 uterine rupture cases (Cont’d)

Case Scarred Scarred Timing GA Timing of Symptoms Duration Prostaglandin Oxytocin Site of Type of Neonatal Birth NICU Resuscitation
uterus? operation of scar to rupture of labour use rupture operation outcome weight
at our rupture (g)
hospital (months)

25a 1 CS Yes 38m 37+1 Antenatal Reduced FM NA NA NA LUS CS Stillbirth 2324 NA NA

+ abdominal
pain +
giddiness

26a 2 CS Yes 17m 37+2 Antenatal Abdominal NA NA NA LUS Crash CS Stillbirth 3068 NA NA
pain with
NRFS

27a 2 CS No Unknown 20+6 Antenatal Abdominal NA NA NA LUS; CS + TH Stillbirth NA NA NA

pain with placenta
maternal accreta
shock

28a 2 CS No 72m 33+2 Antenatal Abdominal NA NA NA LUS Crash CS Live birth 2060 Yes Yes
pain with
acute
abdomen and
NRFS

29a 2 CS Yes 13m 35+5, Antenatal Abdominal NA NA NA LUS CS Live birth 2100; No No
DCDA pain with 2280
acute
abdomen

30a 3 CS Yes 35m 30+3 Antenatal Abdominal NA NA NA LUS Crash CS Live birth 1450 Yes Yes
pain with
Uterine Rupture in Singapore—Shu Qi Tan et al.

APH

31a Laparoscopic No 24m 28+6 Antenatal No fetal NA NA NA Fundus Peri-mortem CS Stillbirth 1225 NA NA
myomectomy movement
with maternal

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shock

32 Laparoscopic No 24m 34+4 Antenatal Abdominal NA NA NA Fundus CS Live birth 2170 Yes Yes
myomectomy pain and
NRFS

33 Laparoscopic No 30m 32+0 Antenatal Abdominal NA NA NA Fundus Crash CS Live birth 1975 Yes Yes
myomectomy pain and
NRFS

APH: antepartum haemorrhage; CPD: cephalo-pelvic disproportion; CS: caesarean section; DCDA: dichorionic diamniotic twins; FM: fetal movement; GA: gestational age; LUS: lower uterine segment; m: months; NA: not applicable;
NICU: neonatal intensive care unit; NRFS: non-reassuring fetal status; TH: total hysterectomy; VBAC: vaginal birth after caesarean
a
Multiparous women
11
 12
Table 6. Summary of 48 uterine rupture cases (Cont’d)

Case Scarred Scarred Timing GA Timing of Symptoms Duration Prostaglandin Oxytocin Site of Type of Neonatal Birth NICU Resuscitation
uterus? operation of scar to rupture of labour use rupture operation outcome weight
at our rupture (g)
hospital (months)

34 Laparoscopic No 15m 25+0 Antenatal Abdomnal NA NA NA Fundus CS Stillbirth Unknown NA NA

myomectomy pain,
bloatedness,
maternal
shock

35 Laparoscopic No 35m 26+3 Antenatal Abdominal NA NA NA Fundus Crash CS Live birth 1075 Yes Yes
myomectomy pain

36a Previous Yes 24m 34+2 Antenatal Abdominal NA NA NA Fundus Crash CS Live birth 1190 Yes Yes
uterine rupture pain
from cornual
ectopic

37a No NA NA 39+4 Intrapartum NRFS; CPD 8 hours No No Left CS Live birth 3470 Yes Yes

38 No NA NA 40+1 Intrapartum NRFS; CPD 9 hours Yes Yes Posterior CS Live birth 3840 No No
a
39 No NA NA 39+5 Intrapartum NRFS; CPD 7 hours No Yes Posterior Crash CS Live birth 3435 No No
a
40 No NA NA 39+5 Intrapartum NRFS 3 hours No No Posterior Crash CS Live birth 3180 No No

41 No NA NA 35+6 Intrapartum NRFS, APH 3 hours No No Right CS Live birth 2840 No No

42 No NA NA 35+0 Intrapartum Abdominal 5 hours No No Posterior Crash CS Live birth 2700 No No

pain + NRFS

43a No NA NA 39+2 Intrapartum CPD 22 hours Yes Yes Left CS Live birth 3320 No No

44a No NA NA 31+6 Antenatal Abdominal NA NA NA Fundus CS Live birth 1780 Yes Yes
pain + NRFS
Uterine Rupture in Singapore—Shu Qi Tan et al.

45 No NA NA 26+1 Antenatal Fall with NA NA NA Fundus CS Stillbirth 660 NA NA

secondary

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abruption

46a No NA NA 18+0 Antenatal Abdominal NA NA NA Fundus CS Stillbirth Unknown NA NA

pain

47 No NA NA 22+2 Antenatal Abdominal NA NA NA Fundus CS Stillbirth Unknown NA NA

pain

48 No NA NA 18+3 Antenatal Abdominal NA NA NA Fundus; CS Stillbirth Unknown NA NA

pain with histo:
maternal placenta
shock accreta

APH: antepartum haemorrhage; CPD: cephalo-pelvic disproportion; CS: caesarean section; GA: gestational age; LUS: lower uterine segment; m: months; NA: not applicable; NICU: neonatal intensive care unit; NRFS: non-reassuring fetal
status; TH: total hysterectomy; VBAC: vaginal birth after caesarean
a
Multiparous women
 Uterine Rupture in Singapore—Shu Qi Tan et al. 13

DISCUSSION VBAC cases quoted were 27.7% and 25.5%, respectively.

With the shift in obstetric practices towards an increasing Cautious use of these agents is essential to minimise
trend of caesarean section, the incidence of uterine risk of uterine rupture.
rupture in our case series has grown in this decade to 1 There are no guidelines to recommend duration for
in 3,062. In the previous series at our same institution trial of labour after VBAC. Up to 1 in 5 cases had
between 1972 and 1982, the incidence was 1 in 3,869.1 prolonged active labour duration of more than 12 hours
Between 1983 and 1992, the incidence was 1 in 6,331.2 in our case series. Timely review of VBAC patients to
This is comparable to rupture rates of other developed assess feasibility of success of labour by a senior
countries after year 2000, such as Saudi Arabia, Taiwan obstetrician is recommended.
and France.1-8 One of the most important risk factors in uterine
Previous uterine scars are known risk factors for rupture is a history of laparoscopic myomectomy.17 The
uterine rupture.9 A history of previous caesarean sections second most common cause of scarred uteri in our case
is the most common reason for a scarred uterus. There series is a previous history of laparoscopic myomectomy.
is a global trend moving towards caesarean sections. All cases of rupture had laparoscopic approach for their
Caesarean section incidence has been increasing, rising previous myomectomy. There were no cases of rupture
from 12% of live births in 2000 to 21% in 2015. In from a history of open myomectomy. The rupture rates
North America, Western Europe and Latin America, after laparoscopic myomectomy are variable, as high
caesarean section rates rose by around 2% a year as 10%.18-22 The technique of repair with laparoscopic
between 2000 and 2015 to 32%, 27% and 44%, suturing following myomectomy could be a contributing
respectively. In more than 15 countries, caesarean factor to the integrity of the scar subjected to a trial
section rates have surpassed 40%. 10 In Singapore, of labour.
caesarean section rates have been steadily increasing Bernadi21 suggested a few factors that increase the
from 17.8% in 1999 to 34% in 2009, and 37.4% in incidence of uterine rupture after myomectomy. This
2014.11,12 The main indication for caesarean section included short duration between myomectomy and
in 1999 was cephalopelvic disproportion but a decade conception (less than 12 months), opening of endometrial
later, history of 1 previous caesarean section became cavity, and patients with large myomas more than 4cm.
the most common indication.11 While the procedure The extensive use of electro-surgery leads to poor
can reduce mortality and morbidity in suitable cases, vascularisation and necrosis of the myometrium.18,21,23
indiscrete use can inflict unnecessary complications and This decreases scar strength and predisposes to
risk for mothers, especially in future births. uterine rupture. Appropriate use of electro-surgery and
Vaginal birth after caesarean section (VBAC) remains multilayered closure of the myometrium are essential
the most common cause for a scarred uterus rupture for the prevention of uterine rupture after a laparoscopic
in our study. The highest rate of uterine rupture in these myomectomy.24 Avoidance of entry into the endometrial
patients occur intrapartum. Ultrasound of scar thickness cavity and prevention of haematoma formation are also
has not shown to reliably predict rupture risk. Our extra precautions. The use of Morphological Uterus
institution does not offer trial of labour after 2 previous Sonographic Assessment (MUSA) classification to
sections. Mothers who are keen for trial of labour after better classify myomas and predict the risk of uterine rupture
more than 1 previous caesarean may seek a second in subsequent pregnancies is a plausible idea.25 Further
opinion at an alternative institution. Compared to studies need to be performed to validate the effectiveness
spontaneous VBAC labour, induced and/or augmented of the MUSA classification.
labour had a 2- to 3-fold increased risk of uterine In our study, the majority of ruptures in women with a
rupture and around 1.5-fold increased risk of caesarean previous laparoscopic myomectomy occurred in the third
delivery.13 Prostaglandins used for cervical ripening and trimester. A recent meta-analysis supports that up to 80%
induction of labour have been associated with increased of uterine ruptures after laparoscopy myomectomy occur
risk of rupture when used in patients with previous between 28 and 36 weeks of gestation.26 However, some
cesarean sections.14 A study by Lydon-Rochelle14 found case series have shown early preterm uterine ruptures,
that the incidence of rupture when oxytocin was used as early as 10 weeks of gestation after laparoscopic
during a VBAC was 7.7 per 1,000. In our case series, myomectomy. Makino4 suggested that uterine rupture
prostaglandin was used in 3 out of 20 cases of VBAC, occurred earliest in patients after adenomyomectomy,
while 2 cases had oxytocin use. This is much lower than followed by myomectomies in those with caesarean
that reported in other studies in the US15 and China,16 section. Obstetricians should exercise extra caution
where the rates of labour augmentation with oxytocin in antenatally with this subgroup, even in the first trimester.

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14 Uterine Rupture in Singapore—Shu Qi Tan et al.

Of note, patients with previous laparoscopic done after uterine rupture. Varying rates of hysterectomy
myomectomy presented almost exclusively antenatally. from 6.7% up to 71.5% have been reported. 1,3,5,8,30
All our patients in this subgroup ruptured antenatally in Hysterectomy, whether total or subtotal, is a common
our case series, with 1 case complicated by end organ surgical procedure in cases of uterine rupture.
damage from hypovolaemic shock. Consequently, fetal Haemoperitoneum is a common finding, and early
loss rate appears to be higher in this subgroup of women recognition is crucial to avert severe hypotension and
compared to women with scarred uteri from previous possible end organ damage.
caesarean sections. Claeys27 examined 29 cases, with The incidence of fetal loss was 25.0% in our study. This
1 case of rupture intrapartum, and 28 cases of rupture could be related to the high incidence of antenatal rupture
before the onset of labour. These women may also have in our review (41.7%). Other studies have quoted fetal
atypical presentations of pain mimicking appendicitis and loss rates varying from 12.2–84.1%.1,3,5,30 Although our
abruption, which warranted a high index of suspicion. study did not show significant differences in maternal
Careful counselling of young women of reproductive age and neonatal outcomes between the scarred and
following a laparoscopic myomectomy regarding pain in unscarred groups, severe maternal and neonatal
the third trimester appears to be useful. morbidity and mortality were more often observed
Pregnancy after laparoscopic myomectomies, however, among women with an unscarred uterine rupture, as
can be uncomplicated. A case series by Kumakiri28 of compared to uterine scar rupture in other studies. Zwart
111 patients who conceived following laparoscopic et al.8 reported significantly higher maternal intensive
myomectomy had successful term deliveries with no cases care unit admissions, hysterectomy rates, major blood
of ruptures. Of these patients, 52 had caesarean sections loss and peripartum fetal death in the unscarred uteri
and 59 underwent successful vaginal deliveries. group. As discussed, it appears that ruptures in cases with
Uterine rupture may also happen to women who have previous laparoscopic myomectomy have worse fetal
no previous uterine scars. While rare, we captured 12 outcomes than those with a history of caesarean section.
such cases in our series. One in 4 of our patients who Makino4 reviewed uterine rupture in 112 women with
experienced uterine rupture had unscarred uteri. Of these scarred uteri, and showed that neonatal death is most
12 patients, 6 were primiparous. Of these 6 primiparous prevalent in those with previous adenomyomectomy,
patients, 3 patients ruptured antenatally in their second followed by laparoscopic myomectomy, and is the least
trimester at the uterine fundus, and the histology of one in those with caesarean section. This is likely related
of these cases returned as placenta accreta. This latter to the timing of ruptures. Mothers with previous
condition is unusual. The retrospective nature of this laparoscopic myomectomy tend to present antenatally,
study limits our ability to obtain more details on these and earlier in the course of their pregnancy, when
cases. Previous literature review by Lydon-Rochelle14 fetuses are premature. They may also present with signs
found an incidence of 1 in 8,000 to 1 in 1,500. Zwart et mimicking acute abdomen or appendicitis, making
al.8 reported 25 cases of rupture in unscarred uteri, with diagnosis more difficult, and thus management can
an overall incidence of 0.7 in 10,000. Multiple factors potentially be delayed. In contrast, those with previous
are associated with rupture in the unscarred uteri. These caesarean section tend to present intrapartum, where
include: a history of instrumental abortion or postpartum they are on continuous fetal monitoring. Signs of
curettage, history of hysteroscopy, uterine anomalies, rupture are likely to be observed earlier, leading to
multiple gestations, macrosomia, oxytocin stimulation, improved fetal outcomes.
prostaglandin use, undiagnosed malpresentation, The retrospective nature of this review would mean that
forced manipulation of the birth canal such as cervical the data was dependent on the accuracy of the diagnosis
dilatation and breech extraction, and obstetric trauma.8,9,29 that was recorded. This possibly explains why there were
An interesting finding was that a high proportion of no recorded uterine rupture cases in the first trimester,
ruptures in the unscarred uteri group in our series occurred as these cases were likely classified as ruptured ectopic
in the fundus. The fundus is the most common rupture pregnancies. As the largest obstetric public institution in
site in unscarred uteri in the literature.17 It has been Singapore, our data is likely to reflect most acute cases
postulated that a history of previous termination of sent by ambulance. The numerator data could be over-
pregnancies and other uterine procedures could be represented as evidenced by the fact that all the cases
withheld from the clinician, which could be a of uterine rupture after a laparoscopic myomectomy
contributory factor to this phenomenon. were performed at other centres. In addition, the ratio of
There were no maternal deaths in our case series, and deliveries in the public versus private sectors has changed
there was an overall rate of 10.4% for hysterectomies over the past decade. This will affect the denominator

Ann Acad Med Singap Vol 50 No 1 January 2021 | annals.edu.sg

 Uterine Rupture in Singapore—Shu Qi Tan et al. 15

value as well. Therefore, our incidence of rupture could 11. Wang CCP, Tan WC, Kanagalingam D, et al. Why we do caesars: a
comparison of the trends in caesarean section delivery over a decade.
be subjected to such bias.
Ann Acad Med Singap 2013;42:408-12.
12. Chi C, Pang D, Aris IM, et al. Trends and predictors of cesarean birth
CONCLUSION in Singapore, 2005-2014: A population-based cohort study. Birth
Compared to the previous series at the same institution, 2018;45:399-408.
there is a notable change in the trend of uterine 13. RCOG Green Top Guidelines No.45, Birth after Previous Caesarean
rupture cases in Singapore given the increasing use of Birth, 1 October 2015.
laparoscopic myomectomy and elective caesarean 14. Lydon-Rochelle M, Holt VL, Easterling TR, et al. Risk of uterine
rupture during labor among women with a prior cesarean delivery.
sections. While rupture from these cases are few, their N Engl J Med 2001;345:3-8.
presentation in the antenatal period calls for diligent 15. Abraham C, Adeyekun M, Demissie S, Patterns of Oxytocin Use in
monitoring with informed patient involvement in their Those Undergoing Trial of Labor After Cesarean Delivery. Gynecol
pregnancy care. Meticulous review of previous surgical Obstet (Sunnyvale) 2017;129:S147.
documentation and photos, detailed counselling, close 16. Wu SW, Dian H, Zhang WY. Labor Onset, Oxytocin Use, and Epidural
follow-up and early identification of these at-risk patients Anesthesia for Vaginal Birth after Cesarean Section and Associated
Effects on Maternal and Neonatal Outcomes in a Tertiary Hospital in
is crucial to optimise outcomes for uterine rupture cases. China: A Retrospective Study. Chin Med J (Engl) 2018;131:933-8.
A high degree of vigilance should remain when patients 17. Okada Y, Hasegawa J, Mimura T, et al. Uterine rupture at 10 weeks
with a scarred uterus undergo a trial of vaginal birth, and of gestation after laparoscopic myomectomy. J Med Ultrason (2011)
induction of labour for this group of patients should be 2016;43:133-6.
done after careful counselling. Unscarred uteri can 18. Dubuisson JB, Fauconnier A, Deffarges JV, et al. Pregnancy outcome
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instrumentation at the booking visit could help identify
19. Malzoni M, Sizzi O, Rossetti A, et al. Laparoscopic myomectomy: a
some women at risk.
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20. Sizzi O, Rossetti A, Malzoni M, et al. Italian multicenter study on
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