子宫破裂的诊断及处理

子宫破裂是产科严重并发症。各种子宫手术所致的瘢痕子宫、子宫畸形等是常见的危险因素。腹痛、电子胎心监护异常是子宫破裂的主要临床表现。治疗的关键是尽可能缩短从诊断到开始手术治疗的时间。     

妊娠期子宫破裂高危因素的研究进展

子宫破裂是一种产科严重并发症，其发生率较低，但对产妇及围生儿结局影响较大。子宫破裂由多种因素共同导致，其中最常见的高危因素是由剖宫产及子宫相关手术导致的瘢痕子宫。随着我国二胎政策的放开，原瘢痕子宫再次妊娠，子宫破裂潜在风险增加。此外，非瘢痕子宫破裂的危险因素包括子宫畸形、难产、孕妇年龄、孕次、产次以及药物等，因其受孕妇个人、家庭支持及社会背景等因素影响，故不容忽视。相比分娩期的子宫破裂，妊娠期子宫破裂并发症更为严重，需医务工作者高度重视。现综述妊娠期子宫破裂的影响因素，并对妊娠期子宫破裂的筛查评估提出建议，旨在预防妊娠期子宫破裂，为早发现、早诊断并及时采取措施，避免对母胎造成更严重的伤害提供依据。     

妊娠子宫破裂的超声诊断

目的：探讨子宫破裂的超声图像特点及其发生的危险因素.方法：回顾性分析5例子宫破裂患者的超声图像特点与相关的病史资料,并与手术结果相对照.结果：5例均为子宫完全破裂,超声检查应注意：首先找到增大的子宫;胎儿及其附属物可完全被挤入腹腔内,也可部分被挤入腹腔内,部分滞留于宫腔内;盆腹腔有积血.结论：子宫破裂超声图像复杂,结合病史,超声检查可对子宫破裂做出诊断.     

晚孕子宫破裂和子宫破裂性损伤的预防和处理(附8例分析)

<正>子宫破裂系指晚孕子宫的体部或子宫下段发生破裂,子宫破裂性损伤系指产褥期子宫因产科手术所导致的破裂。一旦发生子宫破裂和子宫破裂性损伤即病情危急,严重威胁产妇的生命。为降低孕产妇     

妊娠子宫破裂的超声诊断

目的：探讨子宫破裂的超声图像特点及其发生的危险因素。方法：回顾性分析5例子宫破裂患者的超声图像特点与相关的病史资料,并与手术结果相对照。结果：5例均为子宫完全破裂,超声检查应注意：首先找到增大的子宫;胎儿及其附属物可完全被挤入腹腔内,也可部分被挤入腹腔内,部分滞留于宫腔内;盆腹腔有积血。结论：子宫破裂超声图像复杂,结合病史,超声检查可对子宫破裂做出诊断。     

子宫破裂的常见原因及预防

子宫破裂是一种严重威胁母儿生命安全的围产期并发症。随着生育政策的开放,国内孕产妇子宫破裂的发生率有上升趋势,主要原因是瘢痕子宫。瘢痕子宫的成因除剖宫产外,还有非产科因素的子宫手术史,后者也是最容易被忽视的病因。瘢痕子宫的子宫破裂多在阴道分娩过程中发生,但胎盘植入可导致妊娠中晚期的自发子宫破裂,值得临床关注。腹痛、阴道流血和胎心下降是子宫破裂常见的临床表现,妊娠中晚期隐匿性的子宫破裂则常以腹痛和休克症状为临床表现。因此,子宫破裂的早期识别和及时手术治疗与母儿结局息息相关。文章着重阐述了子宫破裂的常见原因及临床表现,以期提高临床医生的警惕性,改善此类孕产妇的母儿结局。     

妊娠期子宫破裂64例分析

本文回顾分析了我院1975年1月至1990年2月,15年来收治的子宫破裂64例,其中32例为非疤痕破裂.64例中子宫完全破裂30例,占46.87%,不完全破裂34例,占53.13%,经手术治疗无孕产妇死亡.围产儿(双胎1例)存活28例,占43.08%,死亡37例,其中3例<28周,2例畸形儿.校正围产儿死亡率为492.3‰。我院子宫破裂的发生率以1975～1979年较高(1:819),1980～1984年有所下降(1:2523),而1985～1990年又有回升(1:1259),其发生的因素中非疤瘦子宫破裂以产程处理不当为主,占81.25%(26/32);疤痕子宫破裂以前次剖宫产子宫纵切口发病率高,占65.63%(21/32),本文还提出了预防措施。     

妊娠期子宫破裂的识别与急救

子宫体部或下段于妊娠期或分娩期发生不同程度的裂伤称为子宫破裂（rupture of uterus）。国内报道发生率为1.4%。国外报道为0.08‰。妊娠期子宫破裂一般较少见,国外文献统计共121例,国内文献报道不足20例,国外文献报道破裂最早为孕4个半月,国内文献报道的最早为孕167周。     

妊娠期自发性非瘢痕子宫破裂4例临床资料分析

目的:探讨自发性非瘢痕子宫破裂的危险因素、临床表现及治疗措施。方法:回顾分析安徽省立医院妇产科收治的4例妊娠期自发性非瘢痕子宫破裂患者的病史、临床体征、辅助检查及治疗过程。结果:4例患者均无剖宫产史,既往多次人工流产史或多次自然分娩史,入院时均主诉"突发下腹痛"。术前体征显示,患者心率增加、血红蛋白下降,B超检查发现子宫破裂或腹腔积液。剖腹探查明确子宫破裂,且破裂部位均位于宫角处。行子宫破裂修补术并联合紧急剖宫产术及相应对症治疗后,患者症状明显改善。结论:自发性非疤痕子宫破裂早期的临床体征不具备特异性,易出现漏诊、误诊,应根据患者是否有高危因素及相应的临床体征并结合B超检查,及时行剖腹探查术明确诊断并进行子宫破裂修补。     

妊娠期子宫破裂的早期识别

妊娠期子宫破裂是罕见的产科并发症,其临床表现多样、缺乏特异性,常造成漏诊或误诊为其他妊娠急腹症而导致母儿灾难性后果。早期识别、及时诊治对改善妊娠结局起到关键作用。文章围绕妊娠期子宫破裂的发病率、高危因素、临床征象等,结合笔者临床经验进行探讨,旨在为妊娠期子宫破裂的早期识别及诊断提供参考。     

Single- versus double-layer uterine incision closure and uterine rupture

Objective. To evaluate whether closure of the uterine incision with one or two layers changes uterine rupture or vaginal birth after cesarean section (VBAC) success rates.

Methods. Subjects with one previous cesarean section by documented transverse uterine incision that attempted VBAC were identified. Exclusion criteria included lack of documentation of the type of closure of the previous uterine incision, multiple gestation, more than one previous cesarean section, and previous scar other than low transverse.

Uterine rupture and VBAC success rates were compared between those with single-layer and double-layer uterine closure. Time interval between deliveries, birth weight, body mass index (BMI), and history of previous VBAC were evaluated as possible confounders.

Results. Of 948 subjects identified, 913 had double-layer closure and 35 had single-layer closure. The uterine rupture rate was significantly higher in the single-layer closure group (8.6% vs. 1.3%, p = 0.015). This finding persisted when controlling for previous VBAC, induction, birth weight >4000 g, delivery interval >19 months, and BMI >29 (OR 8.01, 95% CI 1.96–32.79). There was no difference in VBAC success rate (74.3% vs. 77%, p = 0.685).

Conclusion. Single-layer uterine closure may be more likely to result in uterine rupture.     

Maternal and fetal signs and symptoms associated with uterine rupture in women with prior cesarean delivery

Objective: To describe the association between maternal and fetal physical signs and symptoms (signs/symptoms) and childbirth outcomes in women with prior cesarean delivery (CD).

Methods: Cases of uterine rupture at a single institution were reviewed to examine risk factors for experiencing signs/symptoms and poor childbirth outcomes.

Results: Among 21?014 deliveries, 3252 (15.5%) had prior CD, and 75 (2.3%) had uterine rupture. Of these, 66 (88.0%) labored. Among those who labored, 51 (77.3%) demonstrated signs/symptoms prior to delivery. Signs/symptoms included vaginal bleeding, abdominal pain, fetal bradycardia and decreased fetal heart rate (FHR) variability. Laboring patients with signs/symptoms were seven times more likely than those without them to have poor maternal/neonatal outcome (27/51 [52.9%] versus 2/15 [13.3%], OR?=?7.31 [95% CI 1.34–52.43], p?=?0.0155). In multivariate analysis, risk factors for poor fetal outcome were cervical ripening (OR 4.99 [95% CI 0.86–28.99, p?=?0.0735) and prolonged FHR deceleration/bradycardia (OR 2.78 [95% CI 0.86–9.10], p?=?0.0905). Fetal tachycardia was a risk factor for poor maternal outcome (OR 8.10 [95% CI 1.40–46.84], p?=?0.0195).

Conclusions: Among laboring women with uterine rupture, 77% demonstrated maternal or fetal signs/symptoms before delivery. The presence of at least one sign/symptom identified nearly all laboring patients (27/29 [93.1%]) with poor outcomes.     

Collagen content and growth factor immunoexpression in uterine lower segment of type IA osteogenesis imperfecta: Relationship with recurrent uterine rupture in pregnancy

OBJECTIVE: The purpose of this study was to evaluate collagen content and platelet-derived growth factor, vascular endothelial growth factor, and connective tissue growth factor expression in the myometrium of the uterine lower segment from a patient with type IA osteogenesis imperfecta with recurrent uterine rupture and to evaluate the existence of a relationship between the rare recurrent uterine rupture and the tissue disorders of type IA osteogenesis imperfecta. STUDY DESIGN: Collagen content and platelet-derived growth factor, vascular endothelial growth factor, and connective tissue growth factor expression in the uterine lower segment were assessed in the patient with type IA osteogenesis imperfecta and in eight otherwise healthy ("control") patients. RESULTS: Type IA osteogenesis imperfecta contained less total collagen amount, with no difference in type III collagen expression and showed increased levels of platelet-derived growth factor and vascular endothelial growth factor in myometrial smooth muscle cells. No difference was observed in connective tissue growth factor expression. CONCLUSION: These findings confirm the diminished collagen amount in myometrium from osteogenesis imperfecta and show the presence of additional pathogenetic mechanisms. A relationship is hypothesized between the underlying myometrial biochemical modifications and the recurrent uterine rupture.     

Silent uterine rupture, an unusual cause of anhydramnios

Anhydramnios is a rather common ultrasound finding, usually caused by ruptured membranes, placental dysfunction, or impaired fetal renal function. We present a case of anhydramnios, resulting from the perforation of a fetal leg through the uterine wall. Neonatal death occurred caused by severe lung hypoplasia. The absence of clinical symptoms strongly suggests a preexisting weak spot in the uterine wall, presumably resulting from an unrecognized perforation at a previous curettage procedure.     

Ventral hernia with uterine rupture after vaginal delivery

ObjectiveVentral hernia is uncommon during pregnancy and is extremely rare in postpartum women. It leads to a life-threatening emergency.Case reportA 33-year-old woman, gravida 2 para 1, was admitted to our institute with severe abdominal pain and overdistended abdomen immediately after a full-term vaginal delivery. She had a normal prenatal course and denied having any medical and surgical history. The primipara woman with no history of abdominal surgery was diagnosed with a ventral hernia with uterine rupture after vaginal delivery. We performed an emergency laparotomy and primary repair of the uterine rupture and abdominal wall defect. An abdominal binder was provided for the postoperative period. The patient's postoperative period was uncomplicated. She was discharged from the hospital after 12 days.ConclusionIf a patient has hernia-related symptoms or complications, the diagnosis and management of the hernia should be performed as soon as possible, regardless of the onset, to decrease maternal and fetal mortality.     

Risk factors for peripartum hysterectomy following uterine rupture

Abstract

Objective: To investigate risk factors for hysterectomy following uterine rupture.

Methods: A population-based study comparing all uterine ruptures with and without hysterectomy between 1988 and 2011 was conducted. Stratified analysis was performed using a multiple logistic regression analysis.

Results: Peripartum hysterectomy complicated 20.7% (n?=?34) of uterine ruptures during the study period (n?=?164). Independent risk factors for hysterectomy following uterine rupture, from a multivariable logistic regression model, were relaparotomy (OR?=?32.2, 95% CI?=?2.5–421.9), extended tears involving the uterine cervix (OR?=?6.1, 95% CI?=?1.5–24.7), severe bleeding requiring packed cells transfusions (OR?=?13.7, 95% CI?=?3.2–58.5) and grand multiparity (≥5 deliveries, OR?=?11.4 95% CI?=?2.7–47.1).

Conclusion: Hysterectomy is not common following uterine rupture. Independent risk factors for hysterectomy include relaparotomy, extended tears involving the uterine cervix, severe bleeding requiring packed cells transfusions and grand multiparity. Trained obstetricians should be involved in cases of uterine rupture and the possibility for conducting hysterectomy should be emphasized.