From the Guidelines
Diagnosing uterine rupture requires a high index of suspicion and immediate recognition of its classic signs and symptoms, as it is a life-threatening obstetric emergency. The diagnosis is primarily clinical, based on sudden onset of severe abdominal pain (often described as tearing or ripping), cessation of contractions, regression of fetal station, abnormal fetal heart rate patterns (typically bradycardia), vaginal bleeding, and hemodynamic instability including hypotension and tachycardia 1. On physical examination, you may note abdominal tenderness, loss of fetal station, palpable fetal parts outside the uterine cavity, or recession of the presenting part. Laboratory findings may show decreasing hemoglobin and hematocrit levels.
Diagnostic Approaches
- Ultrasound can sometimes visualize the defect or hemoperitoneum, though it's not always reliable.
- CT with intravenous (IV) contrast can be helpful in identifying surgical causes of postpartum hemorrhage, including uterine rupture, by detecting a hematoma within the cavity of an enlarged uterus or vascular complications such as bladder flap, subfascial, or perivaginal space hematoma 1.
- Definitive diagnosis often occurs during emergency laparotomy.
Risk Factors
- Previous cesarean delivery
- Uterine surgery
- Trauma
- Excessive oxytocin use
- Obstructed labor
Management
Prompt diagnosis is crucial as management requires immediate surgical intervention, fluid resuscitation, blood transfusion, and neonatal resuscitation. The mortality and morbidity risks for both mother and baby increase significantly with delayed diagnosis, making vigilance particularly important in high-risk patients 1. It is also important to consider the potential long-term consequences of uterine rupture, including secondary infertility, partial or total hysterectomy, or pelvic sepsis 1.
From the Research
Diagnosing Uterine Rupture
To diagnose uterine rupture, it is essential to maintain a high index of suspicion, especially in women with risk factors such as previous uterine surgery or cesarean delivery 2, 3, 4. The clinical presentation of uterine rupture can vary, but common signs and symptoms include:
- Abdominal pain
- Hypovolemia
- Vaginal bleeding
- Fetal compromise
Diagnostic Tools
Point-of-care ultrasound can be a useful tool in identifying uterine sacculation, which can lead to uterine rupture 3. Magnetic resonance imaging (MRI) can also be used to confirm the diagnosis of uterine rupture 3.
Risk Factors
Several risk factors can increase the likelihood of uterine rupture, including:
- Previous uterine surgery or cesarean delivery 2, 4
- Uterine sacculation 3
- Oxytocin-associated rupture of an unscarred uterus 5
- Sequential labor induction with prostaglandins and oxytocin 6
- Labor augmentation with oxytocin 6
- Antepartum fetal death 6
- Previous first-trimester miscarriages 6
- Interdelivery interval <16 months after a previous cesarean delivery 6
- Previous cesarean delivery with severe postpartum hemorrhage 6
Importance of Prompt Recognition
Prompt recognition of uterine rupture and expeditious recourse to laparotomy are critical in influencing perinatal and maternal morbidity 2. Emergency physicians should keep a high index of suspicion when evaluating pregnant patients with a history of uterine surgery 3.