From the Guidelines
A uterine artery rupture during cesarean section can be identified by sudden, profuse bleeding that doesn't respond to typical hemostatic measures, often accompanied by hemodynamic instability and signs of hypovolemic shock. The bleeding will typically occur laterally at the lower uterine segment where the uterine arteries run, as noted in the context of postpartum hemorrhage management 1. Other signs include a rapidly expanding broad ligament hematoma, visible arterial pulsatile bleeding, and laboratory findings showing decreasing hemoglobin and hematocrit levels.
Key Signs and Symptoms
- Sudden, profuse bleeding not responsive to typical hemostatic measures
- Hemodynamic instability with dropping blood pressure and rising heart rate
- Visible arterial pulsatile bleeding
- Rapidly expanding broad ligament hematoma
- Signs of hypovolemic shock, including pallor, dizziness, and decreased urine output
- Decreasing hemoglobin and hematocrit levels
Immediate Management
If a uterine artery rupture is suspected, immediate action is required, including:
- Direct pressure on the bleeding site
- Calling for additional surgical assistance
- Mobilizing blood products
- Potentially performing arterial ligation or hysterectomy if bleeding cannot be controlled, as surgical procedures like these may be utilized in the setting of cesarean section to control intraoperative and immediate hemorrhage 1.
Given the potential for significant blood loss and the critical nature of uterine artery rupture, prompt recognition and intervention are crucial to prevent maternal morbidity and mortality, emphasizing the importance of clinical vigilance and readiness to manage such complications during cesarean sections.
From the Research
Signs and Symptoms of Uterine Artery Rupture
- Acute-onset abdominal pain and maternal hypovolemic collapse due to hemoperitoneum are presenting symptoms of spontaneous rupture of uterine vessels during pregnancy 2
- A 2-step process of presentation may occur, with initial sharp abdominal pain radiating to the right flank, followed by paroxysmal, diffuse abdominal pain associated with acute fetal distress 2
- Fetal bradycardia or other evidence of fetal distress may be indicative of uterine rupture 3
Diagnosis and Management
- Uterine artery pseudoaneurysm rupture is a rare, yet life-threatening event that can occur after vascular trauma during invasive procedures such as cesarean section 4
- Selective transarterial embolization can be performed to obliterate the pseudoaneurysm sac 4
- Emergency cesarean section and selective suture of the ruptured uterine artery may be necessary to treat the rupture 2
- Management of uterine rupture involves surgery for prompt delivery of the infant and control of maternal hemorrhage 3
Risk Factors and Prevention
- Uterine rupture is more common in women with a previous Caesarean section, especially after a trial of labour 5
- Rupture of an unscarred uterus is rare, usually traumatic, and its incidence decreases with improvement in obstetric practice 5
- Prevention of poor outcomes depends on thorough anticipation and preparation, with physicians and delivery institutions being prepared to provide emergency surgical and neonatal care in the event of uterine rupture 3