How is a ruptured uterus managed during delivery?

Management of Ruptured Uterus During Delivery

Immediate laparotomy with either hysterectomy or surgical repair of the uterine defect is the definitive management for uterine rupture during delivery, with the choice depending on hemodynamic stability, extent of rupture, and the patient's desire for future fertility. 1, 2

Immediate Recognition and Stabilization

The diagnosis of uterine rupture requires a high index of suspicion, as there are no reliable predictors or unequivocal clinical manifestations. 3 Key warning signs include:

• Fetal bradycardia or other evidence of fetal distress is the most common presenting sign 3
• Maternal hypovolemic shock with complete rupture and fetal extrusion into the peritoneal cavity 1
• Sudden cessation of contractions or change in labor pattern 4
• Abdominal pain that may be sudden or progressive 5, 4

Rapid replacement of maternal blood volume must begin immediately while preparing for emergency surgery. 1 This includes:

• Large-bore intravenous access with aggressive crystalloid resuscitation 1
• Type and crossmatch for packed red blood cells 1
• Replacement of coagulation factors if disseminated intravascular coagulation (DIC) develops 1
• ICU-level monitoring for hemodynamically unstable patients 2

Surgical Management Options

Primary Surgical Approach: Laparotomy

Emergency laparotomy remains the standard approach for uterine rupture, particularly when:

• The patient is hemodynamically unstable 2
• Complete rupture with fetal extrusion has occurred 1
• The diagnosis is made intrapartum 1, 3

The operative time for laparotomy averages 78 minutes (IQR 58-114 minutes). 2 However, laparotomy is associated with higher morbidity, including:

• 40% ICU admission rate 2
• 60% blood transfusion requirement 2
• Median hospital stay of 5 days 2

Fertility-Preserving Laparoscopic Repair

Laparoscopic repair is a viable fertility-preserving alternative for hemodynamically stable patients with early, minor ruptures discovered after spontaneous delivery. 2 The "CHEESE" method (closure of hemodynamically stable, early uterine rupture, via endoscopic surgery after spontaneous delivery) offers significant advantages:

• Comparable operative time of 80 minutes (IQR 60-114 minutes) 2
• Dramatically reduced ICU admissions (14.2% vs. 40%) 2
• Lower transfusion requirements (14.2% vs. 60%) 2
• Shorter hospital stays (median 3 days vs. 5 days) 2

Hysterectomy vs. Uterine Repair Decision Algorithm

The choice between hysterectomy and repair depends on:

1. Extent of uterine damage: Massive rupture with extensive tissue destruction necessitates hysterectomy 1
2. Hemodynamic stability: Unstable patients may require hysterectomy for rapid hemorrhage control 1
3. Fertility desires: Selected stable patients desiring future fertility may undergo repair 1, 2
4. Surgeon expertise: Laparoscopic repair requires advanced minimally invasive surgical skills 2

Suturing Technique Considerations

Single-layer closure is sufficient for maintaining uterine integrity in appropriately selected cases, though this remains somewhat controversial. 2 Key technical points include:

• Barbed sutures significantly reduce closure time (224 ± 46 seconds vs. 343 ± 75 seconds for traditional sutures) 2
• Double-layer closure has historically been preferred to reduce future rupture risk, though evidence supporting superiority over single-layer is limited 2
• The American College of Obstetricians and Gynecologists notes that classical hysterotomy (vertical incision into muscular uterus) is associated with increased future rupture risk compared to low transverse incisions 6

Critical Postoperative Monitoring

Meticulous postoperative surveillance is mandatory, particularly for:

• Signs of ongoing hemorrhage or DIC: Serial hemoglobin, coagulation studies 1
• Infection: Fever, uterine tenderness, elevated white blood cell count requiring broad-spectrum antibiotics 7
• Future pregnancy counseling: Recurrence rates range from 4.8% to 19.4% in subsequent pregnancies 2

Future Pregnancy Management

Women with prior uterine rupture require specialized management in subsequent pregnancies:

• Mandatory cesarean delivery in future pregnancies due to substantially increased rupture risk 6
• Earlier delivery timing (typically 36-37 weeks) to avoid labor 6
• Delivery at tertiary care centers with level III-IV maternal and neonatal capabilities 6

Common Pitfalls to Avoid

• Do not delay surgical intervention while attempting conservative management in unstable patients 1, 3
• Do not underestimate blood loss: Uterine rupture can cause rapid, massive hemorrhage requiring aggressive transfusion 1, 2
• Do not overlook DIC: Monitor coagulation parameters and replace factors as needed 1
• Do not assume laparoscopic repair is appropriate for all cases: Reserve for hemodynamically stable patients with minor ruptures 2