Spontaneous uterine rupture during pregnancy
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University Clinical Center of Serbia, Clinic for Gynecology and Obstetrics, Belgrade, Serbia
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University of Belgrade, Faculty of Medicine, Belgrade, Serbia
ABSTRACT
Uterine rupture is a life-threatening complication of pregnancy which is associated with high incidence rates of maternal and neonatal morbidity and mortality. The aim of this paper is to present the risk factors, clinical picture, and diagnostic and therapeutic options for the management of uterine rupture. The paper presents the data from the papers selected by searching the PubMed database using the combination of the following keywords: uterine rupture, pregnancy, delivery, risk factors, diagnosis, treatment.
In developed countries, uterine rupture is most often a complication of a previous caesarean section, and less frequently of other uterine procedures. It occurs more frequently in developing countries, and it is usually the consequence of obstructed labor or inadequate use of labor-inducing medication. A typical clinical picture of uterine rupture includes abdominal pain and hemorrhagic shock in the mother and abnormal fetal heart rate. Non-specific symptoms and signs of uterine rupture make timely diagnosis difficult. The treatment of uterine rupture depends on the extent of the rupture, age, parity, and the patient’s general condition. The primary goal is to stop hemorrhage and make the patient hemodinamically stable, which is done by hysterectomy or suturing of the uterus.
Due to the increasing caesarean section rate and the fact that nowadays it is the most common risk factor for uterine rupture during pregnancy and childbirth, uterine rupture is still an important complication of pregnancy. Uterine rupture should be considered in pregnant women with risk factors, especially in case of non-specific abdominal pain and cardiotocographic changes. In such situations, timely diagnosis and immediate treatment can significantly contribute to a favorable maternal and neonatal outcome.
INTRODUCTION
Uterine rupture is a life-threatening complication of pregnancy which is associated with a high incidence of maternal and neonatal morbidity and mortality [1]. In developed countries it occurs rarely and is most commonly a complication of a previous caesarean section, or less frequently of other uterine procedures, such as myomectomy and metroplasty [2],[3],[4],[5]. In developing countries, it occurrs more often and is commonly the consequence of obstructed labor or inadequate use of labor-inducing medication [1],[2],[6].
Rupture of the pregnant uterus may occur during pregnancy, during the onset of labor, or during prolonged labor, most commonly in full term pregnancy or in the third trimester. Extremely rarely, uterine rupture may occur during the first trimester or early second trimester [7],[8].
The aim of this narrative review is to present the risk factors, clinical picture, and diagnostic and therapeutic options for the management of uterine rupture.
MATERIAL AND METHODS
The paper presents the data from the articles selected by searching the PubMed database using the combination of the following keywords: uterine rupture, pregnancy, delivery, risk factors, diagnosis, treatment. The data collected from the articles, which had been previously selected by means of consensus reached by the authors, are used and presented in this paper.
CLASIFICATION
In relation to the layers of the uterine wall, uterine rupture can be complete or incomplete [6]. In case of incomplete uterine rupture, perimetrium remains intact, whereas complete rupture involves all three layers of the uterine wall, including the perimetrium. This results in a direct connection between the peritoneal cavity and the uterine cavity, with or without protrusion or expulsion of the fetus and/or placenta into the peritoneal cavity [8].
Incomplete uterine rupture is most frequently caused by uterine scar dehiscence from a previous caesarean section and/or another uterine procedure and it is frequently asymptomatic, so the diagnosis is made during the cesarean section or during manual exploration of the uterus after vaginal delivery in a patient who has previously undergone a uterine procedure [7],[9].
Uterine rupture can be primary or secondary depending on whether it occurs in a patient whose uterus has a surgical scar at the time of the rupture [10]. Primary uterine rupture is uterine rupture without a scar, whereas secondary uterine rupture is the rupture of the uterus which has a scar from a previous surgery, or uterine rupture resulting from trauma or an anomaly of the uterus [4],[5],[10].
EPIDEMIOLOGY
Uterine rupture is a very rare obstetric complication. According to literature, the incidence of complete uterine rupture during labor is 0.4 to 0.6/10000 in an intact uterus and 21.1 to 22.0/10000 in a scarred uterus [8]. In developed countries, the average incidence of uterine rupture is 0.09% [11].
On a sample of 1441712 labors in Norway between 1967 and 2008, Al-Zirqi et al. [10] documented 359 uterine ruptures with the incidence of 2.5/10000 labors [12]. The incidence of uterine rupture in this study was significantly higher in women who had previously had a uterine incision, with an upward trend from 14.2/10000 in the period between 1978 and 1988 to 66.8/10000 in the period between 2000 and 2008. This increase in incidence is explained by a more significant influence of risk factors for the occurrence of uterine rupture in the second examined period, such as: maternal age above 35 years, a prior uterine scar, and prostaglandins and Syntocinon for inducing labor.
In a study conducted by Chang [13] in a tertiary institution in New Zealand during the period of 11 years (from 2008 to 2018), on a sample of 38182 births there were 32 complete uterine ruptures (8.4/10000). In 29 out of 32 cases, the rupture occurred during labor whereas in three cases it occurred before the onset of labor. There was no fatal outcome and it was necessary to perform hysterectomy in three patients.
In an international multicenter study by Vandenberghe et al. [14], it was determined that the increase in the incidence of complete uterine rupture may be explained, among other things, by an increase in the incidence of attempts of vaginal delivery after a previous caesarian section (Trial of Labor After Caesarean Section –TOLAC). The study included nine countries (Austria, Belgium, Denmark, Finland, France, Germany, the Netherlands, Sweden and the United Kingdom of Great Britain and Northern Ireland) in the period between 2004 and 2014.
Motomura et al. [15] examined the incidence of uterine rupture in patients who had a scar from a previous caesarian section in 29 countries in Africa, Asia, South America and in the Middle East. On a sample of 37366 pregnant women, they determined the incidence of uterine rupture was 0.3% in the category of most developed countries. In highly developed countries, the incidence was 0.2%, in moderately developed countries it was 0.4%, and in underdeveloped countries it was 1.0%.
RISK FACTORS
According to literature, there are numerous factors that can contribute to the occurrence of uterine rupture in pregnancy and during labor [13],[14],[16]. It is stated that the most significant among them is a uterine scar, usually from a previous caesarean section, but also from other surgeries (myomectomy, suture of the uterine wall after perforation and /or curettage, metroplasty), the scar from a previous caesarean section being the most important factor in developed countries [2],[13],[14],[16],[17]. Pregnancies after myomectomy are also complicated by an increased risk of uterine rupture and the frequency of such pregnancies is on the rise [18].
Other risk factors for uterine rupture are: uncritical induction of labor, maternal age (≥40), multiparity, gestational age over 40 weeks, fetal macrosomia, a short interval between two pregnancies, prolonged second stage of labor, a placental abnormality, gestational trophoblastic disease, the application of Kristeller maneuver, as well as the presence of myomas and congenital uterine anomalies [3],[11]. Another significant risk factor for uterine rupture is a previous pregnancy complicated by uterine rupture either during pregnancy or in labor [3],[19].
According to Tinelli et al. [5], the data on risk factors for spontaneous uterine rupture in the second and early third trimester are very limited. Uterine rupture occurs rarely in women who have not previously had a cesarean section and the listed risk factors include multiparity, a placental abnormality, and uterine anomalies.
According to Al-Zirqi et al. [16], the most significant risk factor for complete uterine rupture in labor is combined induction by prostaglandins and Syntocinon, both in women who have previously had a cesarean section and in those whose uterus is intact. Among other risk factors, breech delivery, induction of labor by Syntocinon, antepartum fetal death, first trimester termination of pregnancy by curettage of the uterine cavity, maternal age over 35 years, macrosomia, gestational age ≥41 and amniotomy were singled out.
Sturzenegger et al. [11] examined risk factors for uterine rupture on a sample of 22152 births. The results of a multivariate analysis showed that only the existence of a scar on the uterus from a previous caesarean section represented a significant risk factor for uterine rupture.
The research conducted by Gambacorti-Passerini et al. [20] included 23 studies and 2367 pregnancies following myomectomy. The analysis of the results showed the incidence of uterine rupture of 0.47% in women in whom trial of vaginal labor was attempted following myomectomy. The significance of previous myomectomy as a risk factor for the occurrence of uterine rupture was also pointed out by Tinelli et al. [7]. Apart from this, myomectomy, as well as a previous caesarean section, can directly or indirectly cause the formation of abnormally invasive placenta which additionally increases the risk of uterine rupture [7],[21].
A multicenter study by Tinelli et al. [3] on a sample of 270 patients diagnosed with uterine rupture showed that 224 patients (82.9%) had had a surgery prior to uterine rupture. This research showed that the most common operation on the uterus that preceded uterine rupture in pregnancy was caesarian section – in 113 (65.69%) patients.
The most common risk factors for the occurrence of uterine rupture are significantly different in underdeveloped countries in comparison with developed countries [6],[22]. Berhe et al. [6] state that the most common causes of uterine rupture in underdeveloped countries are: obstructed labor due to fetopelvic disproportion or fetal malpresentation, uncritical and inadequate use of medication to stimulate uterine contractions, Kristeller maneuver, multiparity, embryotomy, internal rotation and lack of adequate medical assistance during childbirth. Similar risk factors are listed in a research conducted in Nigeria [23].
THE CLINICAL PICTURE OF UTERINE RUPTURE
Uterine rupture may occur before labor, during labor or upon labor [2]. A rupture may occur on the back wall of the uterus, on the front wall of the uterus, laterally, in the fundus or in the lower uterine segment (the isthmic-cervical segment) [7].
Rupture of the scarred uterus most commonly occurs in the third trimester, although uterine rupture after hysteroscopic myomectomy or a classical caesarian section more frequently occurs before the onset of labor and at a younger gestational age compared to uterine rupture which occurs after lower-segment transverse caesarian section [2],[3].
A typical clinical picture of uterine rupture includes acute abdominal pain and signs of hemorrhagic shock in the pregnant woman with a history of previous uterine procedure [2].
The most common symptom of uterine rupture in patients who have previously had a uterine procedure is abdominal pain (especially suprapubic pain) [2]. Other symptoms of uterine rupture include hypotension, shock, hematuria and shoulder pain [17]. There are no pathognomonic symptoms of uterine rupture and in case of a slow dehiscence of the uterine scar symptoms may be completely absent until the occurrence of complete rupture when changes in the fetal heart rate are often registered (variable decelerations, late decelerations, bradycardia) [2],[3],[24].
Abdominal examination may or may not register the presence of tenderness on palpation.
During labor, one of the most common symptoms is a change in fetal heart rate which is usually manifested by fetal bradycardia in cardiotocography [2],[9],[13],[17],[24],[25]. According to Chang’s study [13], the occurrence of a pathological cardiotocographic finding is registered in 45% of patients with scarred uterus. Other symptoms of intrapartum uterine rupture include cessation of uterine contractions, a change in the shape of the uterus, maternal hypotension, hematuria, and tenderness at the site of the previous scar, the combination of fetal heart failure and maternal abdominal pain being the most common of all [2],[9],[17].
Uterine rupture that occurs after labor is manifested by abdominal pain which may be followed by postpartum hemorrhage [2]. If the rupture affects the urinary bladder as well, hematuria may also occur [2].
The rupture of intact uterus is followed by clinical symptoms of massive hemorrhage and a rapid development of shock in the mother in comparison with the rupture of scarred uterus where scar dehiscence may develop gradually and bleeding is usually less intense [7]. The rupture of intact uterus is usually followed by a strong abdominal pain in the mother and fetal bradycardia or the absence of fetal heartbeat, and it may be accompanied by cessation of uterine contractions, vaginal bleeding, and maternal collapse [7]. A typical clinical picture of the rupture of intact uterus includes the occurrence of acute abdominal pain, maternal tachycardia and hypotension, vaginal bleeding and the state of shock, and parts of the fetal body are palpated over the front abdominal wall of the mother.
DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS
Since the symptoms of uterine rupture are non-specific and can occur in many other conditions, establishing a diagnosis is difficult and often delayed [26]. On a sample of 174189 births in Israel between 2005 and 2008, Rottenstreich et al. [27] identified 143 cases of uterine rupture of which in 20% of cases there was a delay in making a diagnosis. The following factors significantly contributed to establishing a diagnosis in this study: the absence of a uterine scar, the application of epidural analgesia during labor, and multiparity.
Bearing in mind that fetal heart failure during labor is one of the significant symptoms that indicate the possibility of uterine rupture, it should be considered an early warning sign in order to arrive at a diagnosis as soon as possible [7].
The following changes in uterine contractility during labor are also one of the clinical signs of uterine rupture: hypertonia and hypotonia, as well as an increase or a decrease in the number of uterine contractions [3].
On ultrasound, uterine rupture is usually manifested as an empty uterus and the presence of amniotic fluid and/or parts of the fetus outside the uterus, while signs of bleeding in the uterus and/or peritoneal cavity can also be seen [7].
Imaging methods such as computerized tomography (CT) and magnetic resonance imaging have limited use in the diagnosis of uterine rupture since they require more time, and CT is also associated with radiation [7],[26].
When it comes to differential diagnosis, in cases of uterine rupture, the following may be taken into consideration: ectopic pregnancy, placental abruption, placenta previa, uterine inversion, soft birth canal lacerations, coagulopathy, uterine atony, and rupture of uterine blood vessels [7],[17]. Three most common causes of massive hemorrhage in obstetrics are placental abruption, placenta previa, and uterine rupture [28]. Other, less frequent, conditions that should be taken into consideration in differential diagnosis are subcapsular hematoma of the liver with or without hepatic rupture, rupture of broad ligament, spleen rupture, uterine torsion, as well as rupture of uterine blood vessels [29].
MANAGEMENT OF UTERINE RUPTURE
Timely diagnosis and adequate resuscitation are of great significance in the management of uterine rupture [7]. The most important factors that influence the reduction in maternal and fetal morbidity and mortality rates are timely diagnosis, adequate replacement of blood loss, urgent surgical intervention, and the availability of modern neonatal intensive care. When it comes to blood loss, it is important to keep in mind that in pregnant women the loss of up to two liters of blood can occur without any noticeable changes in hemodynamics, while the patient’s general condition can significantly worsen if there is a loss of more than two and a half liters [7].
There are cases in literature in which the occurrence of uterine rupture was diagnosed by ultrasound examination in the second and third trimester and then successfully treated by suturing the uterus, so the pregnancy continued until fetal maturation [7]. In case of complete uterine rupture, a favorable maternal and neonatal outcome is ensured by immediate delivery [25]. According to literature, if surgical intervention is performed within 10 to 37 minutes upon the onset of uterine rupture, the risks of permanent fetal morbidity can be avoided [3].
After extracting the fetus and the placenta from the patient’s abdominal cavity, the priority is to stop maternal bleeding [2]. If the rupture occurs on the back wall of the uterus, it is difficult to diagnose it, and it is also possible that it occurs in an old incision site, which also affects the choice of surgical approach [2].
The treatment of uterine rupture depends on the size of rupture, age, parity, and the patient’s general condition, as well as the experience of the surgeon who needs to assess whether suturing of the rupture is an option or if hysterectomy is necessary [2],[7]. According to this, the choice of the surgical intervention comes down to four options: complete (total) hysterectomy, supracervical (subtotal) hysterectomy, suturing of the rupture, or suturing of the rupture combined with bilateral tubal ligation. The primary aim of the surgical intervention is to stop bleeding, resuscitate the patient, and make her hemodynamically stable as quickly as possible [7]. The most common reasons for hysterectomy are extensive uterine rupture which does not allow an adequate surgical reconstruction of the defect, and profuse bleeding [27]. Al-Zirqi et al. [30] researched maternal outcomes of complete uterine rupture in Norway on a sample of 2209506 pregnant women and they registered 247 cases of complete uterine rupture. The cited authors found that postpartum hysterectomy in this research was significantly associated with the rupture of intact uterus, age, multiparity, and uterine rupture after vaginal delivery. In underdeveloped countries the incidence of maternal and perinatal morbidity and mortality is significantly higher [31].
Al-Zirqi et al. [32] researched neonatal outcomes of complete uterine rupture on a sample of 244 newborns. The cited authors concluded that ruptures of intact uterus were more often associated with fetal or neonatal death. When it comes to the time that passed from the moment uterine rupture was suspected to the moment of delivery, the median was 20 minutes, and the number of fatal fetal outcomes was the lowest if this period was shorter than 20 minutes.
PREGNANCY AFTER UTERINE RUPTURE
Recently published data from a multicenter URIDA study indicate that pregnancy after uterine rupture may be relatively safe [3]. In a sample of 174 deliveries after uterine rupture, the largest number of pregnancies ended by caesarean section, and one patient underwent postpartum hysterectomy.
CONCLUSION
Uterine rupture is a rare and life-threatening obstetric complication. As a consequence of increasing frequency of caesarean births, which nowadays represents the most common risk factor for the occurrence of uterine rupture during pregnancy and in labor, uterine rupture remains a very significant pregnancy complication in modern obstetrics. Timely diagnosis is a special challenge in practice, as the symptoms and signs of uterine rupture are non-specific and are often similar to the symptoms of many other complications that may occur during pregnancy and labor. Due to this, uterine rupture should be considered in all pregnant women who have risk factors, especially in case of non-specific abdominal pain and pathological changes in cardiotocography. In such situation, timely diagnosis and prompt treatment can contribute to a favorable maternal and neonatal outcome.
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Cite this article:
Radmila Sparić
Clinic for Gynecology and Obstetrics, University Clinical Center of Serbia
26 Dr Koste Todorovića Street, 11000 Belgrade, Serbia
E-mail:
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