Rupture of The Uterus: Associate Professor Iolanda Blidaru, MD, PHD

RUPTURE OF THE
UTERUS
Associate Professor
Iolanda Blidaru, MD, PhD
RUPTURE OF THE UTERUS
 a potential obstetric catastrophe
 a major cause of maternal death.
 The incidence of uterine rupture is approximately

1/ 1500 deliveries.
ETIOLOGY
A.Before current pregnancy
1. surgery involving the myometrium
* cesarean section or hysterotomy
* previously repaired uterine rupture
* myomectomy, cornual resection, metroplasty
2. uterine trauma
* abortion with instrumentation
* sharp or blunt trauma (accidents, bullets, knives)
* silent rupture in previous pregnancy
3. congenital anomaly
* pregnancy in undeveloped uterine horn
B. During current pregnancy
1.Before delivery
 external trauma
 labor stimulations (oxytocin or PG)
 external version
 uterine overdistention (multiple pregnancy,

hydramnios)
 Utero-placental pathology (sacculation of
entrapped retroverted uterus, cornual
pregnancy, adenomyosis)
B. During current pregnancy
2. During delivery
 fetal anomaly distending lower segment

(hydrocephalus)
 internal version, breech extraction
 difficult forceps delivery
 difficult manual removal of placenta
 abnormal presentations
 contracted pelvis
 tumors of the birth canal
 multiparity
 placenta increta or percreta
 gestational trophoblastic neoplasia
The most common

cause of uterine
rupture is separation
of a previous
cesarean section
scar.
CLASIFICATION
Incomplete rupture → a laceration separated
by the visceral peritoneum.
“Occult” (“incomplete rupture”) → dehiscence of
an uterine incision from previous surgery.
Complete rupture traumatic

spontaneous
→ during the course of labor

 Vertical uterine incision through the uterine

body - probability of rupture is several times
greater than that of a lower segment scar.
 The corporeal scar ruptures before labor (1/3).
 Dehiscence of a lower segment cesarean

section scar is more frequent than actual
rupture.
Pathological anatomy
Incomplete ruptures frequently

extend into the broad ligament.
Hemorrhage tends to be less severe

than in complete rupture and the
blood acumulates between the
leaves of the broad ligament.
Ruptured vertical
cesarean section
scar (arrow)
identified at time
of repeat
cesarean delivery
early in labor.
Spontaneously
ruptured
uterus at left
lateral edge
of lower
uterine
segment.
Pathological anatomy
 Rupture of the previously intact uterus

at the time of labor → the lower uterine
segment ( left margin)
 After complete rupture, the uterine
contents escape into peritoneal cavity,
unless the presenting part is firmly
engaged, when only a portion of the
fetus may be extruded from the uterus.
CLINICAL FINDINGS. DIAGNOSIS
Impending uterine rupture → the sudden

appearance of gross hematuria is suggestive.
 Prior to the onset of labor, a beginning

rupture may produce local pain and
tenderness associated with increased uterine
irritability and, in some cases, a small amount
of vaginal bleeding.
 If the fetus is partly or totally extrauterine,

abdominal palpation or vaginal examination →
the presenting part has moved away from the
pelvic inlet (loss of station).
The classic SIGN & SYMPTOMS of
spontaneous rupture during labor
 cessation of uterine contractions
 suprapubic pain and tenderness
 disappearance of fetal heart tones
 recession of the presenting part
 vaginal hemorrhage → signs and
symptoms of hypovolemic shock and
hemoperitoneum.
RUPTURE OF A CESAREAN SCAR
 complicates about 1 in 200 trials of labor.
 in most cases = a dehiscence of little
consequence.
Criteria for vaginal delivery following previous
cesarean section
 only one previous cesarean section;
 low transverse uterine incision;
 original indication for cesarean not necessarily
recurring in subsequent pregnancies;
 benign postoperative course;
 non-complicated current pregnancy (macrosomia,
malposition, multiple gestation).
PREVENTION
 good prenatal care
 correct trial of labor
 correct supervised administration of oxytocin

during labor.
 correct closure of a cesarean section incision
 correct estimation of fetal weight

TREATMENT
Whenever uterine rupture is diagnosed –
EMERGENCY SURGERY
 two effective, large-bore intravenous infusion
 type-specific whole blood in large quantities is rapidly

infused;
 a surgical team, including anesthesia personnel;
 pediatric personnel skilled in neonatal resuscitation.

 Immediate laparotomy
 Suture or Total hysterectomy
 If a large hematoma in the broad
ligament, identification and ligation of
the internal iliac arteries (reduces the
hemorrhage appreciably).
 Prompt diagnosis, immediate operation,

the availability of large amounts of blood
and antimicrobial therapy have greatly
improved the maternal prognosis.
PROGNOSIS
Maternal Prognosis
 the maternal mortality rate is 10
to 40%.
 if the patient survives: pituitary
failure (Sheehan syndrome),
infertility/sterility
 vesico-vaginal fistula.
FETAL PROGNOSIS
 If the fetus is alive at the time of the

rupture, the only chance of continued
survival is afforded by immediate
delivery, most often by laparotomy.
Otherwise, hypoxia and death from
both, placental separation and
maternal hypovolemia, is inevitable.

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RUPTURE OF THE

 a potential obstetric catastrophe

 a major cause of maternal death.

 The incidence of uterine rupture is approximately

 labor stimulations (oxytocin or PG)

 uterine overdistention (multiple pregnancy,

 fetal anomaly distending lower segment

The most common

Complete rupture traumatic

→ during the course of labor

 Vertical uterine incision through the uterine

 The corporeal scar ruptures before labor (1/3).

 Dehiscence of a lower segment cesarean

Incomplete ruptures frequently

Hemorrhage tends to be less severe

 Rupture of the previously intact uterus

Impending uterine rupture → the sudden

 Prior to the onset of labor, a beginning

 If the fetus is partly or totally extrauterine,

 good prenatal care

 correct trial of labor

 correct supervised administration of oxytocin

 correct closure of a cesarean section incision

 correct estimation of fetal weight

 type-specific whole blood in large quantities is rapidly

 a surgical team, including anesthesia personnel;

 pediatric personnel skilled in neonatal resuscitation.

 Prompt diagnosis, immediate operation,

 If the fetus is alive at the time of the

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