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This paper reviews the literature since 1967 on rupture of the pregnant uterus and presents findings from a series of 47 uterine ruptures (35 of which were complete) managed by the authors. Uterine rupture accounts for 5% of maternal mortality in the US and there is some evidence that its incidence is increasing. The incidence of uterine rupture is 1:1000-1:1500 deliveries in the US but far lower if only cases of spontaneous rupture of the intact uterus are included. In the author's series, spontaneous ruptures accounted for about 25% of the total and only 17% of these occurred before the onset of labor. A uterine scar, particularly one from a previous cesarean section, is the most common predisposing factor. Age and parity are alos related to the incidence of uterine rupture in most series. Ruptures occuring during labor generally involve the lower segment whereas those prior to labor are usually corporal. Symptoms are estremely variable, ranging from none to complete collapse. The amount of intraperitoneal spill, degree of fetal and placental extrusion, condition of the patient, and degree of retraction of the uterine musculature and important factors in symptamatology. The classical clinical picture includes abdominal pain and tenderness, cessation of labor, shock, and vaginal bleeding. Immediate surgical intervention, with institution of appropriate supportive measures to combat shock and hemorrhage, is the cornerstone of treatment of uterine rupture. The choice of surgical procedure depends on the type, extent, and location of the rupture as well as the patient's condition and desire to preserve her childbearing capacity. Hysterectomy is the procedure of choice in cases of spontaneous or traumatic rupture with no uterine scar. It is doubtful that the incidence of spontaneous rupture of the unscarred uterus can be reduced until more is known about its etiology. Traumatic and spontaneous ruptures are most dangerous, with maternal mortality rates of 20% and 8%, respectively. Knowledge of uterine rupture would be significantly enhanced by a collaborative type study collecting data from several institutions over a given time period.
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PMID:Rupture of the pregnant uterus: a review. 34 49

Uterine rupture during induced midtrimester abortion is infrequent. Often the diagnosis is established only after manual exploration of the uterus, exploratory laparotomy, or even autopsy. It is crucial to establish, the diagnosis rapidly and to offer efficient treatment immediately to prevent further complications. 14 cases revealed by a Medline search and 2 additional personal cases were reviewed. The most common complaint accompanying the rupture was abdominal pain; secondary complaints were signs of blood loss, such as vaginal bleeding, decreased hematocrit level, and decreased blood pressure. 72% of women with uterine rupture (10 of 14) did not abort within 24 hours after intra-amniotic injection, and 85% (11 of 13) had large quantities of oxytocin administered for more than 12 hours. The rupture occurred predominantly in the lower segment and there was no preference either for the right or left side of the uterus. It was shown that uterine rupture during midtrimester induced abortion is not unique to women of high parity or old age. The major complications occurring in induced midtrimester abortions are similar to those seen in patients who deliver in the 3rd trimester.
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PMID:Uterine rupture during induced mid-trimester abortion. 399 23

Uterine rupture was diagnosed in 2 postpartum mares with hemorrhagic vaginal discharge. Both mares had abdominal pain, as evidenced by pawing, kicking at the abdomen, or attempting to roll. Peritoneal fluid analysis was useful in establishing a diagnosis. One mare had many RBC in the peritoneal fluid and was anemic; this mare was managed medically with oxytocin, antibiotics, and blood transfusion. The mare was able to raise her foal to weaning age. The second mare had many RBC, degenerate neutrophils, and intracellular and extracellular bacteria in peritoneal fluid. Surgical repair of the uterus was performed, and the mare was treated for peritonitis. The mare later became pregnant.
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PMID:Uterine rupture as a postpartum complication in two mares. 408 60

Uterine rupture is an uncommon complication of midtrimester abortion, occurring more frequently in the older multiparous patient and with the use of high doses of oxytocic agents. The clinical presentation may vary from an unexplained drop in the hematocrit or persistent abdominal pain to profound shock and maternal death. There is often considerable delay in diagnosis and subsequent treatment. The clinical presentation of a patient who sustained uterine rupture during midtrimester abortion is described and the possible etiology, clinical presentation, and management of this condition are described. It is recommended that older multiparous patients receiving oxytocic agents be monitored closely to prevent uterine hyperstimulation and that prompt laparotomy be performed when the diagnosis of uterine rupture is made.
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PMID:Uterine rupture occurring during midtrimester abortion. 708 30

At the Glasgow Royal Infirmary in Scotland, a 26-year-old woman requested termination of her 18-week pregnancy. She had no history of cervical or uterine surgery. She was administered under supervision 200 mg oral mifepristone followed 48 hours later by 600 mcg vaginal misoprostol, which was repeated 6 hours later. Four hours later painful uterine contractions developed. She was administered slow intravenous (IV) diamorphine (total 10 mg) for analgesia. She had vaginal bleeding (about 100 ml). 30 minutes later, the fetus was delivered but not the placenta. Severe abdominal pain ensued, requiring 10 mg more IV diamorphine. She then blanched and peripherally shut down. Physicians had to perform emergency manual removal of the placenta under general anesthesia. They then checked the uterine cavity digitally and discovered a large defect in the uterine wall and a palpable ovary (right) within the uterine cavity. A laparotomy revealed an 8 cm right uterine side wall rupture with considerable hemorrhage into the broad ligament and abdominal cavity. The surgeons performed a hysterectomy and right salpingo-oophorectomy to control the bleeding. The patient lost about 4000 ml of blood. She required 7 units of packed red cells, 1500 ml gelofusine, and 2 l crystalloid and 2 units of fresh frozen plasma. She received 1.2 g augmentin and 120 mg gentamicin perioperatively. She recovered uneventfully. Pathological analysis confirmed the 8 cm rupture. It also revealed normal endometrial decidualization and myometrial hypertrophy and no underlying weakness. This case is the first recorded of uterine rupture after administration of oral mifepristone and vaginal misoprostol. Uterine rupture occurs rarely in second trimester medical terminations of pregnancy. Many cases had risk factors associated with uterine rupture. As a result of this 26-year-old case, the physicians have amended their regimen for drug-induced abortion in cases of second trimester termination of pregnancy.
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PMID:Uterine rupture during second trimester termination of pregnancy using mifepristone and a prostaglandin. 873 Jun 20

Uterine rupture complicates approximately 1% of trials of labor after cesarean. Classic signs and symptoms include loss of station, cessation of labor, vaginal bleeding, fetal distress, and abdominal pain. Other signs are also possible. We report a case of uterine rupture at VBAC trial that includes an unusual clinical sign of uterine rupture: vernix caseosa observed in the urine of the parturient. During labor, a bladder catheter was inserted to evaluate oliguria. Vernix caseosa and blood were found in the tubing. Prompt cesarean delivery followed. A tear extending from the original transverse scar into the bladder dome was found. Vernixuria is an additional sign of uterine rupture.
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PMID:Vernixuria: another sign of uterine rupture. 1277 48

Uterine rupture during near-term pregnancy is a life-threatening condition. A 31-year-old pregnant woman with a breech presentation at the gestation age of 35(+2) weeks had complained of a dull abdominal pain for days. She was treated 2 years ago with bilateral uterine artery ligation and hysterotomy for removal of the retained placenta. An aggravation of abdominal pain occurred suddenly 4 h after hospitalization. The cardiotocogram showed a fetal heart beat with loss of variability, but increasing deceleration. An urgent cesarean section was performed because of suspected placenta abruption. After successful delivery of the fetus, a protruding placental tissue was found on the fundal uterine wall. We performed wedge resection of the ruptured uterine wall with the aid of an intrauterine muscle injection of 20 IU oxytocin, a local injection of diluted vasopressin (1:60) into the myometrium around and into the rupture site, an intramuscular injection of 0.2 mg methylergonovine, and primary repair of the defect, but in vain. Cesarean hysterectomy was used to control the intractable bleeding. The accumulated blood loss was more than 10,000 mL. The final pathology confirmed placenta percreta with uterine rupture. Luckily, both mother and fetus recovered well and were discharged 7 days later. We concluded that women with retained placenta and/or postpartum hemorrhage managed by previous hysterotomy and uterine artery ligation still need careful prenatal care, since the possibility of re-occurrence of the placenta percreta is easily overlooked and may result in a further life-threatening situation, such as the uterine rupture in this case.
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PMID:Uterine rupture secondary to placenta percreta in a near-term pregnant woman with a history of hysterotomy. 2153 13

Uterine rupture is the primary concern when a patient chooses a trial of labor after a cesarean section. Bladder rupture accompanied by uterine rupture should be taken into consideration if gross hematuria occurs. We report the case of a patient with uterine rupture during a trial of labor after cesarean delivery. She had a normal course of labor and no classic signs of uterine rupture. However, gross hematuria was noted after repair of the episiotomy. The patient began to complain of progressive abdominal pain, gross hematuria and oliguria. Cystoscopy revealed a direct communication between the bladder and the uterus. When opening the bladder peritoneum, rupture sites over the anterior uterus and posterior wall of the bladder were noted. Following primary repair of both wounds, a Foley catheter was left in place for 12 days. The patient had achieved a full recovery by the 2-year follow-up examination. Bladder injury and uterine rupture can occur at any time during labor. Gross hematuria immediately after delivery is the most common presentation. Cystoscopy is a good tool to identify the severity of bladder injury.
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PMID:Simultaneous uterine and urinary bladder rupture in an otherwise successful vaginal birth after cesarean delivery. 2114 16

Spontaneous uterine rupture is lethal in pregnant women. Placenta percreta-induced spontaneous uterine rupture in the first trimester is extremely rare and difficult to diagnose. A 35-year-old pregnant woman, with a history of 2 vaginal deliveries and 2 spontaneous abortions treated by dilatation and curettage, was admitted to the emergency department because of sudden severe abdominal pain; the gestational age as calculated by sonography was 14 weeks. Diagnostic laparoscopy was considered for surgical abdomen and fluid collection that was noted in sonography. During laparoscopy, uterine rupture with massive bleeding was detected; therefore, total abdominal hysterectomy was performed. The patient was discharged without any complications. Pathological analysis of the uterine specimen revealed placenta percreta to be the cause of the rupture. Uterine rupture should be considered in the differential diagnosis in all pregnant women who present with acute abdomen, show fluid collection in the peritoneal cavity. In addition, we recommend laparoscopy for the investigation of acute abdomen with unclear diagnosis in the first trimester of pregnancy.
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PMID:Placenta percreta-induced uterine rupture diagnosed by laparoscopy in the first trimester. 2181 75

Cornual pregnancy is a diagnostic and therapeutic challenge with potential severe consequences if uterine rupture occurs with following massive intraabdominal bleeding. We report a case of a misdiagnosed ruptured cornual pregnancy occurring at 21 weeks of gestation. Ultrasound examination and computer tomography revealed no sign of abnormal pregnancy. The correct diagnosis was first made at emergency laparotomy. Uterine rupture should be considered in pregnant women presenting with abdominal pain and haemodynamic instability.
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PMID:Misdiagnosed uterine rupture of an advanced cornual pregnancy. 2260 65


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