Analysis of uterine rupture in a tertiary center in Eastern Nepal: lessons for obstetric care

AIM: To determine the etiologic factors, clinical presentation, management and fetomaternal outcome in cases of rupture of the gravid uterus and propose preventive measures. METHODS: A retrospective analysis of cases of uterine rupture was carried out at B.P. Koirala Institute of Health Sciences, Nepal, between February 1999 and January 2004. RESULTS: There were 126 cases of uterine rupture with incidence of one in 112 deliveries. Twenty-five patients (19.8%) had a cesarean scar. Obstructed labor was the common antecedent factor in the unscarred group (46.5%) and use of oxytocics accounted for maximum ruptures (44%) in the scarred category. Patients with an unscarred uterus presented with hypotension and intrauterine death (89.1%), while abdominal tenderness (76%) and fetal distress (64%) were common modes of presentation in the scarred category. Complete rupture was seen in 84.9% of patients. Lateral wall ruptures (71.3%) necessitating hysterectomy (75.2%) were seen in the unscarred group. Anterior ruptures (92%) and repair (84%) were common in the scarred category. Maternal mortality was 13.5% and perinatal mortality 83.3%; these were both higher in the unscarred uterus. CONCLUSION: The incidence of uterine rupture is high in Eastern Nepal and rupture of the unscarred uterus carries graver risks. Regular antenatal care, hospital deliveries and vigilance during labor with quick referral to a well-equipped center will reduce the incidence of this condition.     

Using audits to reduce the incidence of uterine rupture in a Malawian district hospital

Objectives

To improve obstetric care and reduce the incidence of uterine rupture through the use of audits.

Methods

Data were collected from medical records and from questioning women who sustained uterine rupture over a 12-month period in Thyolo District Hospital, Malawi. Audit sessions were performed every 2-3 weeks for the first 3 months with relevant members of the hospital staff, after which an extended audit was held with input from two external expert obstetricians. Cases were also audited by the principal investigator for delays in referral, diagnosis, and treatment.

Results

Thirty-five cases of uterine rupture were diagnosed at the facility during the study period. Sixteen ruptures were diagnosed during the first 3 months, an incidence of 19.2 per 1000 deliveries. Following audit and implementation of recommendations, the incidence of uterine rupture decreased by 68% (OR 0.32; 95% CI, 0.16-0.63) to 6.1 per 1000 deliveries over the next 9 months. The overall case fatality rate was 11.4%, and the perinatal mortality rate was 829 per 1000 live births.

Conclusions

Audit is an inexpensive, appropriate, and effective intervention to improve the quality of facility-based maternal care and decrease the incidence of uterine rupture in low-resource settings. Ensuring constructive self-criticism, continuous professional learning, and good participation by district health managers in audit sessions may be important requirements for their success.     

Uterine rupture: risk factors and pregnancy outcome

OBJECTIVES: This study aimed at determining risk factors and pregnancy outcome in women with uterine rupture. STUDY DESIGN: We conducted a population-based study, comparing all singleton deliveries with and without uterine rupture between 1988 and 1999. RESULTS: Uterus rupture occurred in 0.035% (n=42) of all deliveries included in the study (n=117,685). Independent risk factors for uterine rupture in a multivariable analysis were as follows: previous cesarean section (odds ratio [OR]=6.0, 95% CI 3.2-11.4), malpresentation (OR=5.4, 95% CI 2.7-10.5), and dystocia during the second stage of labor (OR=13.7, 95% CI 6.4-29.3). Women with uterine rupture had more episodes of postpartum hemorrhage (50.0% vs 0.4%, P<.01), received more packed cell transfusions (54.8% vs 1.5%, P<.01), and required more hysterectomies (26.2% vs 0.04%, P<.01). Newborn infants delivered after uterine rupture were more frequently graded Apgar scores lower than 5 at 5 minutes and had higher rates of perinatal mortality when compared with those without rupture (10.3% vs 0.3%, P<.01; 19.0% vs 1.4%, P<.01, respectively). CONCLUSION: Uterine rupture, associated with previous cesarean section, malpresentation, and second-stage dystocia, is a major risk factor for maternal morbidity and neonatal mortality. Thus, a repeated cesarean delivery should be considered among parturients with a previous uterine scar, whose labor failed to progress.     

Maternal and neonatal outcomes after uterine rupture in labor

OBJECTIVE: There is significant controversy about the risks related to attempted vaginal birth after cesarean and the implications for informed consent of the patient. Recent data suggest that women who deliver in hospitals with high attempted vaginal birth after cesarean rates are more likely to experience successful vaginal birth after cesarean, as well as uterine ruptures. We conducted a study to evaluate maternal and neonatal morbidity and mortality after uterine rupture at a tertiary care center. STUDY DESIGN: We performed a retrospective chart review of cases of uterine rupture from 1976 to 1998. All women who had a history of uterine rupture were identified with International Classification of Diseases, Ninth Revision, identifiers with hospital discharge data cross-referenced with a separate obstetric database. We abstracted demographic information, fetal heart rate patterns, maternal pain and bleeding patterns, umbilical cord gas values, and Apgar scores from the medical record. Outcome variables were uterine rupture events and major and minor maternal and neonatal complications. RESULTS: During the study period there were 38,027 deliveries. The attempted vaginal birth after cesarean rate was 61.3%, of which 65.3% were successful. We identified 21 cases of uterine rupture or scar dehiscence. Seventeen women had prior cesarean deliveries (10 with primary low transverse cesarean delivery, 3 with unknown scars, 1 with classic cesarean delivery, 2 with two prior cesarean deliveries, and 1 with four prior cesarean deliveries). Of the 4 women who had no history of previous uterine surgery, one had a bicornuate uterus whereas the others had no factors increasing the risk for uterine rupture. We confirmed uterine rupture and scar dehiscence in 19 women. Specific details were not available for 2 patients. Uterine rupture or scar dehiscence was clinically suspected in 16 women with 3 cases identified at delivery or after delivery. Sixteen women had symptoms of increased abdominal pain, vaginal bleeding, or altered hemodynamic status. There were 2 patients who required hysterectomies and 3 women who received blood transfusions; there were no maternal deaths related to uterine rupture. The fetal heart rate pattern in 13 cases showed bradycardia and repetitive variable or late decelerations. Thirteen neonates had umbilical artery pH >7.0. Two cases of fetal or neonatal death occurred, one in a 23-week-old fetus whose mother had presented to an outlying hospital and the second in a 25-week-old fetus with Potter's syndrome. All live-born infants were without evidence of neurologic abnormalities at the time of discharge. CONCLUSION: Our data confirm the relatively small risk of uterine rupture during vaginal birth after cesarean that has been demonstrated in previous studies. In an institution that has in-house obstetric, anesthesia, and surgical staff in which close monitoring of fetal and maternal well-being is available, uterine rupture does not result in major maternal morbidity and mortality or in neonatal mortality.     

Uterine rupture: differences between a scarred and an unscarred uterus

OBJECTIVES: This study aimed to compare risk factors, site of rupture, and outcome of uterine rupture among patients with a scarred versus an unscarred uterus.Study design We conducted a comparison between all cases of uterine rupture (n=53) in women with a scarred versus an unscarred uterus, occurring between January 1988 and July 2002. RESULTS: During the study period, there were ruptures among 26 patients with a scarred uterus and 27 patients without a uterine scar. No significant differences were noted between the scarred and unscarred groups while comparing risk factors such as birth order, birth weight, hydramnios, oxytocin induction, diabetes, and malpresentation. The main site of involvement in both groups was the lower uterine segment representing 92.6% of the ruptures in the unscarred group and 92.3% of the ruptures in the scarred uterus group. Cervical involvement was significantly more common among patients without a previous uterine scar (33.3% vs 7.7%; odds ratio [OR]=6.0, 95% CI, 1.16-31.23, P=.04). Conversely, uterus corpus involvement did not differ between the groups. Perinatal mortality did not differ between the groups. In addition, no significant differences were noted regarding maternal morbidity such as the need for hysterectomy, blood transfusion, or length of hospitalization. CONCLUSION: Although cervical involvement was significantly more prevalent in the rupture of an unscarred uterus, no significant differences in maternal or perinatal morbidity were noted between rupture of a scarred versus an unscarred uterus.     

Uterine rupture: A twelve-year clinical analysis

Objective. To review the experience of uterine rupture at a tertiary obstetric unit in Eastern Turkey and to propose preventive measures.

Methods. All uterine rupture cases managed from November 1995 to March 2007 at the Department of Obstetrics and Gynecology of the Medical School of Yuzuncu Y?l University, Van, Turkey, were analyzed retrospectively.

Results. There were 33 cases of uterine rupture with an incidence of 1/287 deliveries. Of these, 72.72% had complete and 27.27% had incomplete uterine rupture. Of the patients, 39.39% had a scarred uterus, 90.90% received no antenatal care, 60.60% were referred after various interventions had been attempted, and 42.42% required subtotal or total hysterectomy. The maternal mortality rate was 15.15% and the perinatal mortality rate was 42.42%.

Conclusions. Improvements in antenatal care, reduction in cesarean rates, the place where the birth occurs, and skilled attendants are important factors in reducing uterine rupture.     

Maternal mortality in an urban tertiary care hospital of north India

Objectives

The aims of the study were to help generate information and knowledge regarding the causes and complications leading to maternal deaths (MDs) in an urban tertiary care hospital, to find if any of them are potentially preventable, and to use information thus generated to save lives.

Methods

The medical records of all MDs occurring over a period of 4 years between January 2003 and December 2006 were reviewed and correlated with maternal age, antenatal registration, mode of delivery, parity, admission death interval, and causes of death.

Results

The maternal mortality rate (MMR) ranged between 926 and 377/100,000 births in the study period. The causes of deaths were sepsis 23.84%, eclampsia /pregnancy-induced hypertension 17.69%, hemorrhage 13.84%, hepatitis 13.84%, anemia 13.07%, respiratory infections 8.46%, other indirect obstetrical causes 6.15%, and unrelated causes 4.61%. Maximum deaths (71.53%) occurred in women between 21 and 30 years of age while multigravida had MMR of 51.53%. Mortality was highest in postnatal mothers 63.06%.Unbooked cases constituted 92.31% of MDs and included 25% referred cases.

Conclusion

Overall maternal mortality was 690/100,000. MDs due to direct obstetric causes were 55.38%, indirect obstetric deaths 40%, and unrelated deaths 4.61%. The causes of potentially preventable deaths include deaths due to anemia, sepsis, hemorrhage, DIC, and anesthesia complication, and accounted for 25.38% of all deaths.     

Unsafe abortion: a neglected tragedy. Review from a tertiary care hospital in India

AIM: With 16% of the world's population, India accounts for over 20% of the world's maternal deaths. The maternal mortality ratio, defined as the number of maternal deaths per 100 000 live births is incredibly high at 408 per 100 000 live births for the country. Abortion has been legalized in India for the past three decades. However, the share of unsafe abortion as a cause of maternal mortality continues to be alarming. The objective of the present study is to identify the magnitude of problem of unsafe abortion in India. METHODS: Emergency gynecologic admissions to a tertiary care center in North India over a 15-year period (1988-2002) were reviewed to evaluate the demographic and clinical profile of patients admitted as a result of unsafe abortion. The records were analyzed with regard to the age group, parity and marital status of the abortion seekers, the indication of abortion, the methods used, qualification of abortion providers, complications and fatality rate. RESULTS: The majority of women who were admitted with diagnosis of unsafe abortion were in the third decade of their lives. They were married, multiparous women living with their spouses. Sixty percent of the women had approached unqualified abortion providers who used primitive methods of pregnancy termination. All the women were admitted with serious complications of unsafe abortions and one-fourth of them succumbed to the complications. CONCLUSION: Unsafe abortion constitutes a major threat to the health and lives of women. This study highlights the need to focus more directly on the needs and preferences of women who seek abortion as well as on the accessibility of contraceptives and skills of the providers of abortion services, in order to improve the quality of abortion care.     

Primary postpartum haemorrhage in an Australian tertiary hospital: a case-control study

The present study aimed to determine the incidence of primary postpartum haemorrhage (PPH) after vaginal birth at an Australian tertiary hospital, and to investigate risk factors for primary PPH at this hospital. A case-control study of women delivering vaginally at a tertiary hospital from February to June 2003 was performed. Demographic, antenatal, intrapartum, treatment and outcome data were abstracted from patient records. The study population comprised 125 cases and 125 controls, with a primary PPH rate of 12.1 per 100 vaginal births. Risk factors on multivariate analysis were past history of PPH, second stage labour > 60 min, forceps delivery, and incomplete placenta/ragged membranes.     

Maternal morbidity and mortality associated with elective Caesarean delivery at a university hospital in Nigeria

BACKGROUND: Data about maternal outcomes of elective Caesarean section in low-income countries are limited. AIMS: To estimate the maternal morbidity and mortality associated with elective Caesarean delivery at a Nigerian University hospital. METHODS: Retrospective analysis of all elective Caesarean deliveries at the Olabisi Onabanjo University Teaching Hospital, Sagamu, Nigeria (1990-2005). For each case of elective Caesarean delivery, four parturients who achieved non-operative vaginal delivery following spontaneous onset of labour were selected to serve as a referent group. Morbidity outcomes and mortality among women who had elective Caesarean delivery were compared with those of the referent group to estimate their comparative risks. Level of significance was put at P<0.05. RESULTS: A total of 164 elective Caesarean sections were performed out of 6882 deliveries (2.4%). All morbidities were more frequent among women who had elective Caesarean section compared to those who had vaginal delivery but only peripartum blood transfusion (11.6 vs 5.6%), puerperal febrile morbidity (11.0 vs 4.7%), unplanned readmission (4.3 vs 1.4%), mean fall in haemoglobin concentration (1.5 +/- 0.6 vs 0.5 +/- 0.7 g/dL) and mean hospital stay (13.3 +/- 8.8 vs 6.2 +/- 5.4 days) showed statistically significant differences. There was one maternal death among the elective Caesarean section group, giving a maternal mortality ratio of 6.1:1000 deliveries, which was not significantly different from 3.0:1000 deliveries in the referent group. CONCLUSION: Elective Caesarean delivery in this hospital is certainly accompanied by considerable maternal risks and should be offered to pregnant women with extreme caution. Efforts should be made to improve its safety by investigating and rectifying the factors responsible for the associated severe maternal complications.     

Gunshot uterine rupture: A case report

A case report of gunshot uterine rupture from which the mother and fetus survived is presented for the first time. Management was guided by pre-operative ultrasound diagnosis of traumatic anhydramnios.     

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.     

Uterine rupture: the road ahead?

The worldwide increase in caesarean sections, as well as that in laparoscopic and hysteroscopic surgery, augments the risk for women to suffer a uterine rupture. Also the use of misoprostol for the termination of pregnancy and induction of labour, particularly in developing countries, contributes to the greater incidence of uterine rupture. In developing countries, again, neglected obstructed labour remains a very frequent cause of uterine rupture. Diagnosis of uterine rupture may be difficult and, if made too late, serious and even devastating complications may follow, culminating in infant and/or maternal death. A high index of suspicion is indicated when dealing with women at risk. Options in terms of managing uterine rupture include simple repair of the tear, subtotal, and total hysterectomy. Counselling women before and after surgical interventions on the genital tract, especially caesarean section on request, should include information concerning the subsequent risk of uterine rupture.     

Suspected versus non-suspected small-for-gestational age fetuses at term: perinatal outcomes

Objective: To compare perinatal outcomes of suspected versus non-suspected small-for-gestational age fetuses (SGA) at term. Methods: Retrospective cohort study among all term singleton neonates with a birth weight <10th percentile born in the Parkstad region between 1 January 2006 and 3 March 2008. The subjects were assigned to a prenatally suspected or non-suspected SGA group. Primary outcome was adverse neonatal outcome at birth, defined as a composite of intrauterine fetal death, Apgar <7 at 5?min, or pH umbilical artery <7.05. Secondary outcome included neonatal medium care unit (NMCU) admission ≥7 days. Results: 430 subjects were included in the study; 36.7% was suspected of SGA. In the suspected SGA group mean gestational age at birth and birth weight were significantly lower, whereas maternal morbidity was significantly higher. The incidence of labor induction and elective cesarean section were also significantly higher in the suspected SGA group. Total perinatal mortality was 2.1%. Identification of SGA and subsequent management led to a significant decrease of adverse neonatal outcome at birth, but did not lead to a significant decrease in NMCU admission ≥7 days. Conclusions: Suspicion of SGA was associated with a more active management of labor and delivery, resulting in a better neonatal outcome at birth.