What is the management approach for a suspected cesarean (c-) scar rupture?

Management of Suspected Cesarean Scar Rupture

Immediate emergency laparotomy is the definitive management for suspected cesarean scar rupture, with aggressive fluid resuscitation and blood product transfusion initiated simultaneously. 1, 2

Immediate Recognition and Resuscitation

Clinical Presentation

• Acute severe abdominal pain with hemodynamic instability (hypotension, tachycardia) is the hallmark presentation of cesarean scar rupture 1, 2
• Patients may present with a history of prior vaginal bleeding episodes that were initially managed conservatively 1
• Perform immediate paracentesis if diagnosis is uncertain - fresh non-coagulating blood confirms hemoperitoneum 1

Emergency Stabilization

• Initiate aggressive crystalloid fluid resuscitation immediately - large volumes may be necessary 3
• Activate massive transfusion protocol and ensure blood products are readily available 4
• Obtain large-bore intravenous access (two sites minimum) 3
• Alert anesthesia team and critical care personnel immediately 3

Surgical Management

Operative Approach

• Proceed directly to emergency laparotomy - do not delay for additional imaging or stabilization attempts 1, 2
• Midline vertical incision provides optimal access and visualization for managing hemorrhage and assessing extent of rupture 3, 1
• Mobilize the most experienced pelvic surgeons available, as extensive vascular engorgement and challenging anatomy are expected 3

Intraoperative Decision-Making

• Careful resection of placental tissue and repair of the ruptured isthmic region should be attempted if the patient is hemodynamically stable and the defect is repairable 1, 5
• Hysterectomy is required if hemorrhage cannot be controlled with conservative repair or if tissue destruction is extensive 2
• Consider uterine artery ligation or bilateral utero-ombilical trunk clamping to control bleeding before attempting repair 5
• Avoid forced placental removal as this results in profuse hemorrhage 3

Postoperative Management

Immediate Complications Monitoring

• Maintain vigilance for ongoing bleeding with a low threshold for reoperation 3
• Monitor for renal failure, liver failure, infection, unrecognized ureteral/bladder/bowel injury, pulmonary edema, and disseminated intravascular coagulation 3
• Consider Sheehan syndrome (postpartum pituitary necrosis) given the potential for hypoperfusion 3

Adjunctive Interventions

• Pelvic vessel interventional radiologic strategies (uterine artery embolization) may be useful for persistent bleeding, but not all cases are amenable and should be considered case-by-case 3, 6
• Cell salvage technologies should be utilized if available 3
• Tranexamic acid infusion and packing the abdomen are temporizing measures if transfer to higher-level facility is needed 3

Critical Pitfalls to Avoid

• Do not delay surgical intervention for additional diagnostic workup once clinical suspicion is high - cesarean scar rupture is a surgical emergency 1, 2
• Do not attempt conservative management in the setting of hemodynamic instability or confirmed rupture 2
• Do not underestimate blood loss - these patients can rapidly decompensate and require massive transfusion 1, 2
• Inadequate preparation and failure to have a multidisciplinary team with appropriate equipment readily available leads to poor outcomes 3

Future Pregnancy Counseling

• Counsel patients about significantly increased risks in future pregnancies, including recurrent cesarean scar pregnancy, placenta accreta spectrum, and repeat uterine rupture 4
• Detailed ultrasound evaluation should be performed in early pregnancy to confirm proper implantation in any future conception 4