What is the best course of treatment for a patient with a ruptured uterus?

Management of Uterine Rupture

The best course of treatment for a patient with a ruptured uterus is immediate surgical intervention with either hysterectomy or uterine repair, accompanied by aggressive resuscitation measures to control hemorrhage and prevent coagulopathy.

Initial Assessment and Stabilization

• Hemodynamic stabilization is paramount:

  • Establish at least two large-bore IV access lines 1
  • Initiate crystalloid fluid resuscitation targeting systolic blood pressure of 80-100 mmHg until major bleeding is controlled 1
  • Begin blood product transfusion with a target hemoglobin of 70-90 g/L 1
  • Administer tranexamic acid as soon as possible (loading dose of 1g over 10 minutes, followed by 1g over 8 hours) 1

• Rapid diagnostic workup:

  • For hemodynamically unstable patients: Bedside E-FAST (Extended Focused Assessment with Sonography for Trauma) to assess for hemoperitoneum 1
  • For stable patients: CT scan with IV contrast to evaluate extent of rupture and associated injuries 1

Surgical Management

Decision Algorithm:

1. Hysterectomy (preferred approach in most cases):

   • Indicated for:
     • Extensive uterine rupture involving the lateral wall and cervix 2
     • Longitudinal tears on lateral aspects of lower and upper segments 3
     • Presence of infection
     • Hemodynamic instability despite resuscitation
     • When fertility preservation is not a priority

2. Uterine repair (selective cases only):

   • Consider only when:
     • Simple, clean transverse tear in the lower uterine segment 3
     • No evidence of infection
     • Hemodynamically stable patient
     • Strong desire for future fertility
     • Surgeon has appropriate expertise

Intraoperative Considerations:

• Evacuate hematoma and control active bleeding sources 2
• Carefully identify and protect ureters, especially when rupture extends to the lateral wall 2
• Apply damage-control surgical principles in severely unstable patients 1
• Consider cell salvage techniques if available 1

Post-Operative Management

• Continue hemodynamic monitoring in ICU setting
• Maintain uterine tone with oxytocics (if uterus is preserved)
• Monitor for and treat coagulopathy - DIC is a common complication 4
• Antibiotic prophylaxis to prevent infection
• Serial hemoglobin measurements to guide further transfusion needs

Prevention of Complications

• Monitor for signs of multi-organ failure
• Early mobilization when stable
• Thromboprophylaxis once bleeding is controlled
• Psychological support for trauma and potential loss of fertility

Risk Factors and Prevention for Future Pregnancies

If uterine repair was performed:

• Counsel regarding high risk of recurrence in future pregnancies
• Recommend elective cesarean delivery before onset of labor in future pregnancies
• Advise against future pregnancy if extensive repair was needed

Prognosis

The mortality rate for uterine rupture with appropriate management is approximately 7%, with 90% of cases potentially manageable with prompt intervention 5. However, outcomes are highly dependent on:

• Time to diagnosis and intervention
• Extent of rupture and blood loss
• Presence of complications like DIC
• Access to appropriate surgical and critical care resources

Common Pitfalls to Avoid

• Delayed recognition of uterine rupture, especially in patients without obvious risk factors 2
• Underestimating blood loss and inadequate resuscitation
• Attempting uterine repair in inappropriate cases (extensive, irregular, or infected tears)
• Failure to protect ureters during surgery, particularly with left-sided ruptures
• Inadequate monitoring in the immediate postpartum period 2

Uterine rupture represents an obstetric emergency requiring immediate recognition and intervention to prevent maternal mortality. The surgical approach should be decisive, with hysterectomy being the safest option in most cases of extensive rupture.