What are the risks and management of uterine rupture during labor?

From the Guidelines

Uterine rupture during labor is a life-threatening emergency that requires immediate intervention with an emergency cesarean delivery, and women with previous cesarean deliveries should be counseled about the risk and monitored closely during labor. The risk of uterine rupture is affected by various factors, including previous cesarean delivery, especially with a classical incision, uterine surgery, trauma, excessive oxytocin use, and grand multiparity 1. Management of uterine rupture involves immediate laparotomy, delivery of the fetus, control of hemorrhage, and repair of the uterine defect if possible.

Some key points to consider in the management of uterine rupture include:

• Immediate intervention with emergency cesarean delivery without delay
• Signs of rupture include sudden severe abdominal pain, vaginal bleeding, fetal distress, loss of fetal station, or abnormal contraction pattern
• Resuscitation with crystalloid fluids and blood products is often required, with transfusion of packed red blood cells, fresh frozen plasma, and platelets as needed
• Prophylactic antibiotics, such as cefazolin 2g IV, should be administered
• The maternal mortality rate is 1-13% and fetal mortality 10-50%

According to the most recent study, the injudicious use of uterotonics to augment weak contractions during labor is a well-known risk factor for life-threatening complications, such as uterine rupture 1. Women who survive uterine rupture can have devastating consequences, such as secondary infertility due to uterine wall repair and tubal ligation, partial or total hysterectomy, or pelvic sepsis. The plan for labor and vaginal birth after cesarean delivery should be individualized to the patient based on her risk factors, including the presence of a classic uterine scar and inter-delivery interval shorter than 18 months 1.

From the Research

Uterine Rupture in Labor: Incidence and Risk Factors

• Uterine rupture is an uncommon obstetric event associated with maternal mortality, major maternal morbidity, and perinatal mortality and morbidity worldwide 2.
• The incidence of uterine rupture varies, with a reported rate of 6.8 per 10,000 deliveries in one study 3.
• Uterine rupture is more common in women with a previous cesarean section, with a reported incidence of 44.4 per 10,000 births after a single previous cesarean delivery 3.

Clinical Presentation and Diagnosis

• The most common clinical sign of uterine rupture is acute abdominal pain in labor, occurring in 51% of cases in one study 3.
• Other symptoms may include fetal bradycardia or other evidence of fetal distress 4.
• Diagnosis is often made clinically, with a high index of suspicion required, especially in women with a previous cesarean section 4.

Risk Factors

• Uterine scarring is a significant risk factor for uterine rupture, with 83% of cases in one study having a uterine scar after previous cesarean delivery 3.
• Augmentation or epidural anesthesia in patients with a uterine scar after cesarean delivery also increases the risk of uterine rupture 3.
• Other risk factors may include previous laparoscopic myomectomy or an unscarred uterus 3.

Management and Prevention

• Management of uterine rupture typically involves emergency surgical delivery and control of maternal hemorrhage 4.
• Prevention of poor outcomes depends on thorough anticipation and preparation, with physicians and delivery institutions prepared to provide emergency surgical and neonatal care in the event of uterine rupture 4.
• The use of intrauterine pressure catheter recordings may contribute to the diagnosis of uterine rupture or dehiscence 5.

Complications

• Uterine rupture can result in significant maternal and perinatal morbidity and mortality, including peripartum hysterectomy and neonatal mortality 2, 3.
• Average blood loss in cases of uterine rupture can be significant, with 11% of patients requiring blood transfusion in one study 3.