II. Epidemiology
- Overall risk: Up to 0.03 to 0.08% of all deliveries
- Uterine scar risk: Up to 0.3 to 1.7% of all deliveries with prior cesarean
- Low transverse scar (VBAC, Vaginal Birth after Cesarean): 0.8% Incidence
- Trauma in Pregnancy risk: 0.06%
III. Causes
- Rupture of uterine scar
- Cesarean Section scar (most common cause)
- Prior uterine curettage or perforation
- Abdominal Trauma
-
Trauma in Pregnancy
- High velocity collision
- More often in third trimester
- Associated with Pelvic Fractures and Bladder injury
- Typically affects uterine fundus or uterine scar
- Obstructed labor due to Cephalopelvic Disproportion
- Uterine hyperstimulation with Labor Induction
- Oxytocin Induction and augmentation
- Cervical Ripening (Misoprostol or Dinoprostone)
- Maternal Cocaine Abuse
- Other factors
- Uterine distention
- Amnioinfusion
- Gestational Trophoblastic Neoplasia
- Difficult manual removal of placenta
- Findings not related to Uterine Rupture
- Oxytocin at high infusion rates
- Five or more contractions in 10 minutes
- Tetanic contractions lasting >90 seconds
- Phelan (1998) Obstet Gynecol 92:394-7 [PubMed]
IV. Types
- Rupture of Classical Cesarean Scar (Vertical)
- Occurs in late pregnancy or early labor
- Presents as Acute Abdominal Pain and shock
- Risk of rupture in labor as high as 9%
- Rupture of Lower Uterine segment scar
- Often occult presentation
- Occurs with Trial of Labor after Cesarean (TOLAC)
- Absolute risk of rupture
- One prior Cesarean Section: 0.6% of TOLACs
- Two prior Cesarean Sections: 3.9% of TOLACs
- Absolute risk of neonatal death: 0.02% of TOLACs
- Lydon-Rochelle (2001) N Engl J Med 345:3-8 [PubMed]
- Absolute risk of rupture
- Spontaneous Uterine Rupture
- Risk of rupture in labor is less than 0.0125%
- Multiparous woman with labor obstruction
- Strong contractions result in rupture
- Presents as Acute Abdominal Pain and bleeding
V. Signs
- Classic Signs (unreliable)
- Sudden tearing uterine pain (13% of cases)
- Vaginal Bleeding (11%)
- Decreased uterine contractions
-
Fetal Distress
- Sudden deterioration in Fetal Heart Rate pattern
- Most frequent finding
- Prolonged Late Decelerations and Fetal Bradycardia
- Most reliable sign of Uterine Rupture
- Sudden deterioration in Fetal Heart Rate pattern
- Maternal distress
- Abdominal findings
- Severe Abdominal Pain/tenderness and distention
- Fetal parts may be palpable through abdominal wall
VI. Differential Diagnosis
VII. Imaging
VIII. Diagnosis
- Intrauterine pressure catheter (unreliable sign)
- Readings may show no loss of tone despite rupture
IX. Management
-
General Resuscitation measures
- See Fetal Distress
- Intravenous FluidResuscitation
- Type and cross match for Blood Products
- Stop Oxytocin
- Maternal position change
- Subcutaneous Terbutaline to stop any contractions
- Emergent delivery (usually by Cesarean Section)
- Indication: Sudden and persistent Fetal Bradycardia
- Consider Hysterectomy after infant delivered
- Best outcomes if delivery in <17 minutes of diagnosis
- Uterine Rupture noted after delivery
- Emergent Surgery
- Repair of Uterine Rupture
- Consider Hysterectomy
- Close observation indications
- Small, asymptomatic rupture
- Rupture often occurs in lower uterine segment
- Emergent Surgery
X. Complications
- Severe maternal Hemorrhage and Anemia
- Blood loss approaches 2 liters in 50% of cases
- Average Blood Transfusion requires 5 units pRBC
- Hysterectomy (Up to 23% of Uterine Rupture cases)
- Bladder rupture (0.05%)
- Maternal mortality
- Neonatal mortality
- Rupture occurred at tertiary center: 2.6%
- Rupture occurred pre-hospital: 6%
- Trauma-related Uterine Rupture is associated with 12-20% (up to 100%) fetal mortality
XI. Prevention
- Select VBAC patients very carefully
XII. References
- Krywko and Jennings (2018) Crit Dec Emerg Med 32(4): 3-11
- Evensen (2017) Am Fam Physician 95(7): 442-9 [PubMed]
- Leung (1993) Am J Obstet Gynecol 169:945-50 [PubMed]
- Toppenberg (2002) Am Fam Physician 66(5):823-8 [PubMed]
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Related Studies
Definition (MSH) | A complete separation or tear in the wall of the UTERUS with or without expulsion of the FETUS. It may be due to injuries, multiple pregnancies, large fetus, previous scarring, or obstruction. |
Concepts | Pathologic Function (T046) |
MSH | D014597 |
SnomedCT | 156231001, 34430009 |
LNC | LA20046-1, LA18987-0 |
English | Rupture, Uterine, Ruptures, Uterine, Uterine Rupture, Uterine Ruptures, UTERINE RUPTURE, Ruptured uterus, rupture of uterus (diagnosis), rupture of uterus, Rupture uterus, Uterus rupture, Uterus ruptured, Uterine Rupture [Disease/Finding], uterine rupture, rupture uterus, uterus rupture, rupture uterine, uterus ruptured, ruptured uterus, Ruptured uterus (disorder), Uterus--Rupture, Uterine rupture, Rupture of uterus (disorder), Rupture of uterus, rupture; uterus, uterus; rupture, Rupture of uterus, NOS, Uterine rupture, NOS |
French | RUPTURE UTERINE, Utérus rompu, Rupture utérine, Rupture de l'utérus |
German | UTERUSRUPTUR, Ruptur des Uterus, Uterus rupturiert, rupturierter Uterus, Uterusriss, Gebärmutterriss, Uterusriß, Gebärmutterriß, Uterusruptur, Gebärmutterruptur |
Dutch | geruptureerde uterus, ruptuur van uterus, uterus ruptuur, ruptuur; uterus, uterus; ruptuur, baarmoederruptuur, Ruptuur, uterus-, Uterusruptuur |
Portuguese | Útero com ruptura, RUTURA UTERINA, Ruptura do útero, Ruptura Uterina |
Spanish | Útero roto, UTERO RUPTURA, Rotura de útero, Rotura uterina, ruptura del útero (trastorno), ruptura del útero, ruptura uterina, Rotura Uterina |
Japanese | 子宮破裂, シキュウハレツ |
Swedish | Livmoderbristning |
Finnish | Kohdun repeämä |
Russian | MATKI RAZRYV, МАТКИ РАЗРЫВ |
Czech | Ruptura dělohy, ruptura dělohy, děložní ruptura, děloha - ruptura, ruptura děložní, ruptura uteri, uterus - ruptura |
Polish | Pęknięcie macicy |
Hungarian | Ruptura uteri |
Norwegian | Uterusruptur, Livmorruptur, Brist i livmoren |
Italian | Rottura dell'utero |
Ontology: Rupture of gravid uterus (C0269885)
Concepts | Injury or Poisoning (T037) |
SnomedCT | 15504009 |
English | Rupture of gravid uterus (diagnosis), uterine rupture gravid, Obstetrical rupture of uterus, Rupture of gravid uterus (disorder), Rupture of gravid uterus, Obstetrical rupture of uterus, NOS |
Spanish | ruptura obstétrica del útero (trastorno), ruptura obstétrica del útero, ruptura uterina obstétrica |
Ontology: Rupture of uterus during labor (C3812903)
Concepts | Pathologic Function (T046) |
SnomedCT | 23431000119106 |
English | Rupture of uterus during labour, Rupture of uterus during labor (disorder), Rupture of uterus during labor |