Uterine Rupture Weeks After Cesarean Section

Yes, uterine rupture can occur weeks after cesarean section delivery, though it is rare compared to ruptures during labor. 1, 2

Incidence and Timing of Uterine Rupture

The overall prevalence of complete uterine rupture after cesarean section is approximately 22 per 10,000 births (0.22%) in women with previous cesarean section, with significant variation between countries (ranging from 8 to 68 per 10,000 births) 1, 3
While most uterine ruptures occur during labor, particularly in women attempting vaginal birth after cesarean (VBAC), documented cases show rupture can occur weeks after delivery 2, 4
A WHO multicountry survey analysis reported the incidence of uterine rupture in women with previous cesarean section was 45 per 10,000 births (0.45%), ranging from 0.1% to 2.5% 1

Previous cesarean section is the primary risk factor for uterine rupture, with risk increasing with each additional cesarean section 1, 3
Physical strain, including sexual intercourse, has been documented as a potential trigger for delayed uterine rupture in the postpartum period 2
Cesarean section scar defects are common, with prevalence ranging between 24% and 88% on ultrasonography, creating potential weak points for future rupture 1
Incomplete healing of the cesarean incision, tissue necrosis, and suture granuloma at the surgical wound can contribute to delayed rupture 2

Delayed uterine rupture may present without obvious abdominal pain or infection signs, making diagnosis challenging 2
Clinical manifestations can include:
- Vaginal bleeding (which may be brisk) 2
- Hemodynamic instability or shock 5
- Shoulder pain (referred pain from blood irritating the diaphragm) 4
- Free fluid in the peritoneal cavity detected on imaging 4
The most common manifestation of uterine scar separation during labor is fetal heart rate abnormalities (70.3%), while pain and bleeding are less common (7.6% and 3.4%, respectively) 6

Prompt recognition is crucial, as delayed uterine rupture is a life-threatening emergency 5, 2
Imaging modalities for diagnosis include:
- Ultrasound: May show complex adnexal mass, hematoma, or free fluid 4
- MRI: Superior for detecting myometrial defects with intact serosal layer due to better soft-tissue contrast 1
- CT: May show gas in the myometrial defect extending from the endometrium to parametrial tissue along with hemoperitoneum, suggestive of uterine rupture 1
Management typically requires emergency surgery:
- Hysterectomy or uterine repair depending on the extent of damage and desire for future fertility 5, 2
- Rapid replacement of blood volume and correction of coagulopathy if present 5

Women who have undergone cesarean delivery should be advised to avoid strenuous physical activity and sexual intercourse for at least 4-6 weeks postpartum 2
Healthcare providers should maintain a high index of suspicion for uterine rupture in women with previous cesarean section who present with concerning symptoms, even weeks after delivery 7, 4
There are no reliable predictors of uterine rupture, emphasizing the importance of thorough anticipation and preparation 7

Maternal complications include hemorrhage, hypovolemic shock, and disseminated intravascular coagulation 5
Long-term complications following cesarean section include chronic wound pain (15.4% at 3-6 months) and secondary infertility (43%) 3
Increased risk for complications in future pregnancies, including placenta accreta, with risk increasing with each additional cesarean section 1, 3