Uterine Rupture

Uterine rupture is a full thickness tear of the uterine wall, including the serosa, with or without expulsion of the fetus into the abdominal cavity. It is commonest in obstructed labour in Kenya, and also occurs in labour after a caesarean scar and, rarely, in an unscarred uterus. It is a leading cause of maternal death and stillbirth because of massive haemorrhage and fetal hypoxia.

• Risk factors: previous caesarean or uterine surgery, obstructed labour, grand multiparity, oxytocin or misoprostol misuse, trauma, internal version, macrosomia, uterine anomaly.
• Fetal death is common in complete rupture with expulsion.
• Early recognition and laparotomy within minutes save lives.

Women have sudden severe abdominal pain, sometimes with a feeling of something tearing, followed by relief from contractions and then shock. Fetal heart rate falls or disappears, the presenting part recedes, and fetal parts are felt easily under the abdominal wall.

• Constant scar pain and tenderness, vaginal bleeding, haematuria.
• Signs of shock out of proportion to the visible blood loss.
• Differential diagnosis: placental abruption, uterine inversion, scar dehiscence, obstructed labour with impending rupture, ruptured ectopic in abdominal pregnancy, ruptured liver in preeclampsia, pulmonary embolism, amniotic fluid embolism.
• Complications: haemorrhagic shock, fetal death, hysterectomy, bladder and ureteric injury, disseminated intravascular coagulation, sepsis, infertility, maternal death.

The diagnosis is clinical and rapid, and confirmed at laparotomy.

• Pulse, blood pressure, abdominal tenderness, loss of presenting part station, fetal parts palpable, absent fetal heart on Doppler or ultrasound.
• Bedside ultrasound: free fluid in the abdomen, fetus outside the uterus, empty uterus, absent fetal heart.
• Haemoglobin, platelets, fibrinogen, clotting screen, group and cross-match 4 to 6 units, creatinine, urine for blood.
• Do not delay surgery for tests.

The principle is immediate resuscitation and emergency laparotomy with repair or hysterectomy.

• Supportive: call for senior obstetric, anaesthetic and surgical help; two large-bore cannulae; Ringer's lactate 1 to 2 litres rapidly; oxygen 10 to 15 L/minute; blood transfusion early (use O negative if cross-match is not ready), with fresh frozen plasma 15 mL/kg and cryoprecipitate 10 units for fibrinogen below 2 g/L; urinary catheter with hourly output; warm the patient.
• Pharmacological: cefazolin 2 g IV plus metronidazole 500 mg IV before incision, then ampicillin 2 g IV 6-hourly plus gentamicin 5 mg/kg IV once daily plus metronidazole 500 mg IV 8-hourly for 5 to 7 days; tranexamic acid 1 g IV over 10 minutes, repeated once after 30 minutes if bleeding continues; oxytocin 10 IU IM after delivery of the baby; calcium gluconate 1 g IV after every 4 units of blood; paracetamol 1 g IV 6-hourly (maximum 4 g in 24 hours); morphine 2.5 to 5 mg IV titrated for pain; newborn resuscitation with bag and mask; enoxaparin 40 mg subcutaneous daily from 12 to 24 hours after surgery for at least 10 days.
• Procedures: emergency laparotomy; repair of the tear in layers when it is clean, accessible and the woman wants more children; subtotal or total hysterectomy for ragged, extensive, infected or bleeding tears and when the woman is unstable; inspection and repair of the bladder, ureters and broad ligament; bilateral internal iliac artery ligation or compression sutures for refractory bleeding; bladder catheter for 7 to 14 days.
• Special groups: rupture in a scarred uterus allows repair when the tear is clean and the woman is stable, and later births are by planned caesarean section at 36 to 37 weeks; rupture with obstructed labour has high infection risk and needs prolonged antibiotics; RhD negative women give anti-D immunoglobulin 500 IU IM within 72 hours if the baby is RhD positive.
• Red flags: shock, absent fetal heart, abdominal rigidity, bleeding from the vagina or abdomen, haematuria, oliguria below 30 mL per hour, fibrinogen below 2 g/L.
• Follow-up: high dependency care for 24 to 48 hours; haemoglobin and clotting 6-hourly until stable; ferrous sulphate 200 mg oral 8-hourly for 3 months; contraception and counselling; planned caesarean section at 36 to 37 weeks in any future pregnancy, with an interval of at least 12 to 18 months.