Rupture of the uterus

1. RUPTURE OF THE UTERUS FAHAD ZAKWAN

2. INTRODUCTION Uterine rupture is a grave obstetric complication. Associated with high Maternal mortality Perinatal mortality It may occur Labour Delivery Pregnancy – lesser extent Every second of time is vital for survival

3. Incidence of uterus rupture 0.05% for all pregnancies 0.8% after previous lower segment caesarean section(LSCS) >5% after classical caesarean section Scar dehiscence has an incidence of 0.6% in pregnancies with previous C/S and has a more favourable outcome for both mother and fetus than does uterine rupture.

4. Definition Separation of the muscular wall of the uterus U sually occurs during labor Occasionally happen during the later weeks of pregnancy

5. Uterine rupture Total disruption of the wall of the pregnant uterus with or without extrusion of its contents Uterine scar dehiscence Herniation of intact amniotic membrane into an existing uterine scar Uterine scar rupture Separation of the scar along its entire length often with involvement of the amniotic membranes

6. Uterine dehiscence involves myometrial separation at a site of uterine scar from previous surgery, and the uterine serosa remains intact. Uterine rupture , on the other hand, involves the entire thickness of the uterine wall, resulting in communication between the uterus and peritoneal cavities.

7. Uterine rupture : separation of an old uterine incision with rupture of the fetal membranes so that the uterine cavity and the peritoneal cavity communicate directly. Dehiscence of a scar does not involve rupture of the fetal membranes. Rupture is more acute while dehiscence is more gradual.

8. CAUSES During pregnancy weak scar after previous operations on the uterus History of cesarean section (VBAC - vaginal birth after c- section) myomectomy excision of a uterine septum previous perforation of uterus(D&C, hysteroscopy, forceps delivery

9. During labor : uterine hyper-stimulation(oxytocin with pitocin induction or augmentation of labor) obstructed labor(macrosomia, feopelvic dispropotion) intrauterine manipulation(internal version, manual removal of an adherent placenta) forcible dilatation(cervical tear) a weak scar(C-section or other operations)

10. TYPES Incomplete rupture complete rupture depending on whether the peritoneal coat is torn through or not

11. Traditional classification Complete The visceral peritoneum overlying the uterus is disrupted Incomplete Overlying peritoneum is intact Not clinical relevant

12. Etiological classification Spontaneous rupture Scar rupture Traumatic rupture

13. Spontaneous rupture Feto-pelvic disproportion Congenital uterine anomalies Soft tissue obstruction Scar rupture Previous uterine surgery Previous uterine perforation PREDISPOSING FACTORS

14. Traumatic/ iatrogenic rupture Surgical intervention Internal version Forceps delivery Manual removal of placenta Destructive operations Medical intervention Uterine stimulation

15. Symptoms and signs Abdominal pain and tenderness Shock Vaginal bleeding Undetectable fetal heart beat Palpable fetal body parts Cessation of contractions Signs of intraperitoneal bleeding The most common sign is the sudden appearance of fetal distress during labor

16. The signs and symptoms of uterine rupture in patients with a previous scarred uterus differ from patients without a uterine scar. The most common sign in woman with previous uterine scar is lower abdominal tenderness . In women without a scar, shock is the most common sign, followed by uterine bleeding, severe abdominal pain, and easily palpable fetal parts.

17. Ultrasonography is probably the safest and most useful imaging technique during pregnancy. sonographic findings associated with uterine rupture includes: Extra peritoneal hematoma intrauterine blood free peritoneal blood empty uterus gestational sac above the uterus large uterus mass with gas bubbles DIAGNOSIS

18. TREATMENT Principles for the treatment of uterine rupture includes: Intensive resuscitation Emergency laparotomy Broad spectrum antibiotics Adequate post operative care

19. Intensive resuscitation Correct hypovolaemia from…. Haemorrhage Sepsis Dehydration Intravenous broad spectrum antibiotics Cephalosporin + Metronidazole combination Monitor to ensure adequate fluid and blood replacement Blood volume expansion may worsen the bleeding from damaged vessel and so the laparotomy should not be delay, once patient condition has improved

20. Surgical options Hysterectomy Treatment of choice except any other compelling reasons to preserve the uterus Total Sub-total Rupture repair Occasionally one may be forced to repair Repair with sterilization Not an attractive option May be useful especially in unskilled hands

21. Outcome Death from uterine rupture is not uncommon. Mortality appears to be higher in women who have an unscarred uterus and when the rupture occurs outside the hospital. Overall mortality: 15.9% Perinatal morbidity rate associated with uterine rupture ranges from 8-56%

22. Preventive measures Antenatal care High risk cases Oxytocics Previous caesarean section Augmentation of labour

23. NOTE!!! During trial of scar watch out for……. Fetal heart abnormalities Maternal tachycardia Vague abdominal pain in between contractions Suprapubic tenderness Vaginal bleeding Bladder tenesmus

24. DIAGNOSTIC CRITERIA FOR UTRINE RUPTURE

25. Thank you for your attention