RUPTURE UTERUS

By THOMAS RUTTO
 Introduction

 Incidence
 About 1:4000, 95% of cases occur in
multipara particularly grand multipara.
 Causes
 During pregnancy
 Spontaneous:
 Rupture of a uterine scar: e.g. previous C.S. especially upper
segment, myomectomy, metroplasty or perforation.
 Abruptio placenta with severe concealed hemorrhage.
 Anterior sacculation in incarcerated retroverted gravid uterus &
posterior sacculation in ventrofixation of the uterus.
 Rupture of rudimentary horn at the 4th - 5th month.
 Perforating vesicular mole.

 Traumatic:
 Perforation during vaginal evacuation.
 External trauma.
 Causes

 During labour:
 Spontaneous:
 Obstructed labour.
 Rupture of a uterine scar.
 3Grand multipara: due to degeneration and over thinning of
uterine muscles.
 Traumatic:
 Internal version: particularly after drainage of liquor.
 Manual separation of the placenta.
 Destructive operations.
 Extending cervical tear due to forceps or vacuum.
 applications before full cervical dilatation.
 Improper use of oxytocins.
 Causes
 Weak uterine scar may be a result of:
 Imperfect suture with improper coaptation of edges.
 Bad hemostasis results in blood clot formation
which prevents good coaptation and predisposes to
wound infection.
 Wound infection.
 Subsequent implantation of the placenta over it.
 Subsequent overdistension of the uterus by
polyhydramnios or multiple pregnancy.
 Upper segment caesarean section scar is weaker
than lower segment scar.
 Repeated vaginal deliveries after a previous C.S
 Types and Sites
 Types:
 Complete : involving the whole uterine wall including the
 peritoneum.
 Incomplete: not involving the peritoneal coat.

 Sites: It depends upon the cause of rupture:

 In obstructed labour:
 It is usually in lower uterine segment, more on the left side due
to dextrorotation of the uterus and left occipito-positions are
more common It may extend laterally to uterine vessels and
broad ligament producing hematoma or involve ureter or
bladder.
 In rupture scar:
 At the site of the scar; upper or lower segment scar.
 Clinical Picture

 Impending rupture :
 before actual rupture the following
manifestations may be detected:
 Lower abdominal pain.
 Tender uterine scar.
 Vaginal spotting (minimal bleeding).
 Clinical picture contd
 Actual rupture:
 Symptoms:
 Sudden severe abdominal pain : It is differentiated
from labor pain being continuous.
 If the patient was in labor, there is cessation of
uterine contractions.
 Shoulder pain on lying down due to irritation of the
phrenic nerve by accumulating blood under the
diaphragm.
 Note : Silent rupture: minimal symptoms may
occur in rupture lower segment scar due to
presence of fibrosis and minimal internal
hemorrhage.
 Clinical Picture (cont.)

 Signs
 General examination:
 Variable degrees of collapse is present according to
amount of blood loss.

 Abdominal examination:
 Scar of previous operation.
 Fetal parts are prominent and felt easy.
 The presenting part recedes upwards.
 Abnormal fetal attitude and lie.
 FHS usually not heard.
 The uterus is felt separated from the fetus .
 Clinical Picture (cont.)
 Vaginal examination:
 The presenting part recedes
upwards.
 Vaginal bleeding may be present.
 Contracted pelvis may be detected.
 A cervical tear may be found
extending to the lower
 uterine segment and a broad
ligament hematoma may be
present.
 Differential Diagnosis


Abruptio placentae.
 Disturbed advanced
extrauterine pregnancy.
 Other causes of acute
abdomen.
 Management

 Prophylactic:
 Early detection of causes of obstructed
labour as contracted pelvis and
malpresentations.
 Proper use of oxytocin.
 Version is not done if liquor amnii is drained.
 Forceps application and breech extraction
should not be done before full cervical
dilatation.
 Elective caesarean section for susceptible
scars for rupture as upper segment C.S.
 Management (cont.)

 Curative:
 Fix Iv Line, Start on IV fluids, GXM; Blood transfusion
 Immediate laparotomy.
 Deliver the fetus and placenta.
 Explore the rupture site:
 If it is amenable for repair and the patient did not
complete her family: repair is done.
 If it is not amenable for repair: Subtotal hysterectomy
 Exploration of the other viscera mainly the bladder.
 Internal iliac artery ligation in case of broad ligament
hematoma.
 Vaginal repair: may be amenable if there is slight
extension of a cervical tear with accessible apex.
 Complications

 Maternal:
 Shock.
 Hemorrhage.
 Paralytic ileus.
 Bladder, ureter or visceral injuries.
 Infection.
 Death
 Fetal :
 Death due to asphyxia from detachement of the
placenta.