What is the management of a rupture of an intrauterine pregnancy (IUP)?

From the Guidelines

Management of a ruptured intrauterine pregnancy requires immediate surgical intervention with an emergency laparotomy or laparoscopy to control bleeding and remove the ruptured pregnancy tissue. This approach is crucial to prevent morbidity and mortality associated with ruptured intrauterine pregnancy, as it can lead to severe hemorrhage and hypovolemic shock if not promptly addressed 1.

Initial Stabilization

Initial stabilization includes:

• Establishing two large-bore IV lines for fluid resuscitation with crystalloids and blood products as needed
• Type and cross-matching for potential transfusion
• Continuous monitoring of vital signs
• Oxygen supplementation as needed Laboratory tests, including complete blood count, coagulation profile, and type and cross-match, should be obtained promptly to guide further management.

Surgical Intervention

During surgery, the ruptured tissue is removed, bleeding vessels are ligated, and the uterus is repaired if possible. In cases of extensive damage or uncontrollable hemorrhage, hysterectomy may be necessary. The use of misoprostol in women with previous cesarean delivery should be avoided due to the risk of uterine rupture, as highlighted by the American College of Obstetricians and Gynecologists (ACOG) 1.

Postoperative Care

Postoperatively, patients require close monitoring for signs of continued bleeding, infection, or hemodynamic instability. Rh-negative women should receive Rh immunoglobulin (RhoGAM) 300 mcg IM within 72 hours to prevent isoimmunization. Pain management with opioid analgesics such as morphine 2-4 mg IV or fentanyl 50-100 mcg IV is appropriate for postoperative pain control.

Key Considerations

• The risk of uterine rupture associated with misoprostol use in the third trimester, as reported in studies 1
• The importance of continuous monitoring of fetal heart rate and uterine activity during labor induction, as recommended by ACOG 1
• The potential for significant cost differences between misoprostol and dinoprostone for induction of labor, as noted by the ACOG committee 1

From the FDA Drug Label

Carboprost tromethamine injection is indicated for ... Inadvertent or spontaneous rupture of membranes in the presence of a previable fetus and absence of adequate activity for expulsion The management of a rupture of an intrauterine pregnancy (IUP) may involve the use of carboprost tromethamine injection in certain conditions, such as:

• Inadvertent or spontaneous rupture of membranes in the presence of a previable fetus
• Absence of adequate activity for expulsion 2

From the Research

Management of Rupture of Intrauterine Pregnancy (IUP)

• The management of a rupture of an intrauterine pregnancy (IUP) is a critical obstetric emergency that requires immediate attention 3.
• Uterine rupture is a potentially fatal event that may occur in pregnancy, and identification of known risk factors allows the obstetric team to prepare for rapid diagnosis and intervention 3.
• A study on uterine rupture during medical termination of pregnancy or intrauterine death found that knowledge of surgical history is involved in the prevention of uterine rupture, and the signs of detection are pain, ascending presentation, and bleeding 4.
• The management of uterine rupture typically involves laparotomy, and in some cases, transfusion, vascular ligation, or hysterectomy may be required 4.
• The speed of management and good teamwork are crucial in reducing maternal complications in cases of uterine rupture 4.

Prevention and Treatment of Uterine Atony

• Uterine atony is a common cause of primary postpartum hemorrhage, and oxytocin is the first-line agent for prevention and treatment 5, 6.
• Second-line uterotonic agents, such as methylergonovine, carboprost, and misoprostol, may be used in combination with oxytocin to prevent postpartum hemorrhage 6, 7.
• Combined therapy rather than oxytocin alone is recommended for preventing postpartum hemorrhage, as it has an additive or synergistic effect and a greater risk reduction for postpartum hemorrhage prevention 7.
• Tranexamic acid has been found to be effective and safe for decreasing maternal mortality in women with postpartum hemorrhage, and prophylactic use of tranexamic acid may decrease the need for packed red blood cell transfusions and/or uterotonics 7.