Risk factors and perinatal outcome of uterine rupture in a low-resource setting

Background:

Uterine rupture has continued to be a catastrophic feature of obstetric practice especially in the low-resource settings. This study determined the incidence, predisposing factors, treatment options and feto-maternal outcome of ruptured uterus.

Materials and Methods:

A 10-year retrolective study of all cases of uterine ruptures that were managed in Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria between 1st January, 2001 and 31st December, 2010 was undertaken. The proforma was initially used for data collection, which was transferred to a data sheet before entering them into the Epi-info software. Analysis was done using Epi info 2008 (version 3.5.1).

Results:

Out of 5,585 deliveries over the study period, 47 had uterine rupture, giving an incidence of 0.84% or 1 in 119 deliveries. All the patients were multiparous and majority (63.8%) was unbooked. Traumatic (iatrogenic) rupture predominated (72.1%). Uterine repair with (55.8%) or without (34.9%) bilateral tubal ligation was the commonest surgery performed. Case fatality rate was 16.3%, while the perinatal mortality rate was 88.4%. Average duration of hospitalization following uterine rupture was 10.3 days.

Conclusion:

Uterine rupture constituted a major obstetric emergency in the study hospital and its environs. The incidence, maternal and perinatal mortalities were high. The traumatic/iatrogenic ruptures constituted the majority of cases, hence, majority of the cases are preventable. There is therefore a dire need for education of our women on health-related issues, utilization of available health facilities, adequate supervision of labour and provision of facilities for emergency obstetric care.     

急症子宫切除在孕产妇子宫出血中应用时机及价值的探讨

目的:探讨急症子宫切除术在孕产妇异常子宫出血中的应用时机、价值以及降低产科子宫切除的可能预防措施。方法:对因子宫异常出血致急症子宫切除30例孕产妇子宫切除时机及相关因素进行回顾性分析。结果:30例子宫切除患者29例治愈,1例死亡。孕期、产时子宫切除原因主要为胎盘因素,而产后主要为感染因素。结论:孕产妇急症子宫切除对不能控制的子宫出血是行之有效的措施,但应把握手术时机。     

A five year appraisal of caesarean section in a northern Nigeria university teaching hospital

A retrospective analysis of cases of caesarean section performed in Jos University Teaching Hospital between January 1994 and December 1998 was undertaken to determine the incidence, indications, perinatal and maternal outcome. There were 11,571 deliveries with 2083 caesarean sections done giving an incidence of 18%. 62.2% of the patients who had caesarean section were booked for antenatal care and delivered in the hospital, while 37.8% were unbooked seen as emergency. 90% of the operations were done as an emergency while only 10% was electively performed. There was a high caesarean section rate in all the age groups as well as the various parity distributions. The main indications for the elective section were repeat caesarean section, placenta praevia, precious baby, severe pregnancy induced hypertension and bad obstetric history while those for emergency section were cephalo-pelvic disproportion foetal distress, repeat caesarean section, antepartum haemorrhage, severe pregnancy induced hypertension/eclampsia, obstructed labour and breech presentation. The maternal mortality rate was 624.1/100,000 due mainly to haemorrhage, eclampsia and sepsis and there was one anaesthetic death amongst the booked patients. The perinatal mortality rate was 81.6/1000. The clinical causes of deaths were birth asphyxia, ante-partum haemorrhage, obstructed labour and prematurity.     

围产期紧急子宫切除术的应用

目的：总结围产期紧急子宫切除术的病因、时机及指征,以期降低围产期紧急子宫切除术的发生。方法回顾性分析本院2006年1月-2011年12月本院分娩总数31104例次中围产期行子宫切除术的53例病例。结果围产期子宫切除率为1.7‰（53/31104）,53例中有1例因羊水栓塞并发肝功能衰竭死亡,其余均治愈。53例围产期紧急子宫切除术手术指征：胎盘异常（包括植入胎盘、前置胎盘）20例,羊水栓塞12例,急性脂肪肝5例,子宫破裂5例,宫缩乏力2例,胎盘早剥2例,宫颈癌2例,其他2例。结论围产期紧急子宫切除术仍是治疗难治性产后出血的最后手段,胎盘植入是最主要的手术指征,剖宫产更易引起胎盘植入而导致子宫切除。     

Grandmultiparity in Lagos, Nigeria

The case-notes and records of grandmultiparous patients delivered at the Lagos University Teaching Hospital between 1st January, 1994 and 31st December, 1996 were analysed. The incidence of grandmultiparity was 4.11%. There were no cases of extreme grandmultiparity. The mean age +/- SD was 33.26 +/- 1.8 years, and the mean parity +/- SD 5.57 +/- 0.38. No patient was under 20 years and none had a parity greater than 9. Fifty-seven (42.22%) were booked patients and 78(57.78%) were unbooked. Anaemia and malpresentation were commonest in the antenatal period, whilst hypertension and disproportion were commonest intrapartum. Fifty per cent of the patients had a spontaneous vaginal delivery. The Caesarean section rate was 30.37%. The incidence of intrapartum complications, cephalopelvic disproportion, obstructed labour and Caesarean section, were found to be higher in the unbooked patients. There was an increased incidence of twin pregnancy and placenta praevia. The maternal mortality ratio was 44.4/1000 amongst the grandmultipara which was not statistically more significant than in the general obstetric population. The perinatal mortality rate was 169/1000 deliveries.     

急症产科子宫切除术19例分析

19例急症产科子宫切除术中,18例指征为子宫出血,其中15例为剖宫产,3例阴道产,说明剖宫产是急症子宫切除的高危因素。但阴道产子宫切除失血量多于剖宫产者,且易引起死亡。子宫出血的首位原因是各种胎盘异常,其发生与多次流产有关;1例指征为羊水栓塞症,因手术过晚,产妇死亡。指出在失血代偿期经连续、迅速、系统的治疗后,子宫出血仍得不到控制者,应立即果断地切除子宫。     

疤痕子宫合并胎盘植入44例临床分析

目的:探讨疤痕子宫合并胎盘植入的高危因素,早期诊断的可能性和有效的治疗措施。方法:回顾性分析2010年1月～2011年10月广州医学院第三附属医院44例疤痕子宫合并胎盘植入的年龄、孕周、合并前置胎盘率、胎盘位于前壁率、B超及MRI诊断率、临床诊治和围生期结局进行分析。结果:疤痕子宫合并胎盘植入的发生率为0.5%,80%为30岁以上孕妇,合并前置胎盘率79.5%,其中为前壁中央型前置胎盘占75%。植入性胎盘占31.8%,穿透性胎盘占40.9%。产前诊断率52.3%,其中B超和MRI的敏感性分别为43.6%、48%。发生产后出血率84.1%,早产率47.7%,新生儿不足2 500 g占36.4%,子宫切除率34.1%。结论:疤痕子宫是胎盘植入的主要高危因素,易形成凶险型前置胎盘,而产前难以诊断,母婴危害极大。及时采取了防治措施及适时实施子宫切除术,尤其对凶险型胎盘植入采用经后路子宫切除术,有效减少了产后出血量,避免了产妇死亡。     

产科急症子宫切除术19例临床分析

[目的 ]探讨 10年间产科急症子宫切除术的指征 ,旨在降低其发生率 .[方法 ]采用回顾性分析方法对产科急症子宫切除术 19例临床资料进行了分析 .[结果 ]19例产科急症子宫切除术指征均为子宫出血 .子宫出血的原因中胎盘因素居第 1位 ,共 8例 ,其中胎盘植入 5例 ,胎盘粘连 3例 ;产后弥漫性血管内凝血居第 2位 ,共 6例 ,其中死胎滞留 3例 ,重症肝炎、重度妊娠高血压综合征及羊水栓塞各 1例 ;产后宫缩乏力居第 3位 ,共 5例 ,其中双胎 2例 .本组产妇死亡 1例 .[结论 ]胎盘植入和难以控制的子宫出血是产科急症子宫切除术的主要指征 ,要降低产科急症子宫切除术的发生率 ,应做好围产期保健工作 ,加强孕期检查 ,及时诊治弥漫性血管内凝血的诱发病     

Ruptured uterus at Sagamu,Nigeria

Ruptured uterus, the largest contributor to maternal deaths in our center was reviewed to find ways of reducing it and improve the outcome. Sixty cases treated at Ogun State University Teaching Hospital, Sagamu between January 1988 and December 1997 were scrutinised. During the 10 year period, total deliveries were 5,214 giving an incidence of 11.5 per 1,000. 76.7% of cases occurred in patients aged 30 years and more; and 58.6% in para 4 and more. 88.3% were unbooked. The ruptures were spontaneous in 76.7% and lower uterine segment was the most common (80%). Uterine repair with sterilisation was carried out in 46.7%, sub total hysterectomy in 26.7% and repair only in 11.7%. Most of the aetiological factors were preventable by good antenatal care and the outcome improved by early referral and efficient blood transfusion system.     

Ruptured uterus in pregnancy: a Canadian hospital's experience.

Between 1966 and 1985, 15 cases of complete rupture of the uterus in pregnancy were identified among 52,854 deliveries at Foothills Provincial General Hospital, Calgary, for an incidence rate of 0.3 per 1000 deliveries. Previous cesarean section (in seven patients) was not the only predisposing factor: a history of dilatation and curettage (in two patients) or laparoscopy (in one) were also implicated. Long, obstructed labour did not appear to be a factor. Rupture also occurred in patients at low risk. The most frequent immediate complication was hypotension, in five patients. The rupture site was repaired in 11 of the patients; the other 4 underwent hysterectomy. Close surveillance and prompt intervention are the keys to good fetal and maternal outcome.     

Rupture of the gravid uterus in a tertiary health facility in the Niger delta region of Nigeria: A 5-year review

Background:

Ruptured uterus is a major life-threatening condition encountered mostly in developing countries and is an index of failure of obstetric care at a point in time in a woman''s reproductive career. With worsening economic condition, increasing caesarean section rates, and patients’ aversion for operative delivery this condition would still remain a major obstetric matter for discussion.

Objective:

To identify the incidence, sociodemographic variables, clinical characteristics, causes, and outcome of ruptured uterus at the University of Port Harcourt Teaching Hospital.

Materials and Methods:

A 5-year retrospective study of cases of ruptured uterus at the University of Port Harcourt Teaching Hospital was carried out. The case notes of 40 patients with uterine rupture during the period 2003-2007 were analyzed. Data collected included sociodemographic characteristics, etiologic factors, clinical presentation, and outcome. Data were analyzed using Microsoft Excel version 2007 and SPSS 14.0 computer software.

Results:

The incidence of rupture of the gravid uterus was 1:258 deliveries. In patients with rupture of the gravid uterus, 65% (26) of patients were unbooked; 37.5% (15) were aged between 25 and 29 years. A total of 42.5% (17) of patients had secondary education and 21 (52.5%) were housewives. Rupture of a previous scar was the commonest etiologic factor accounting for 32.5% (11). The commonest presentation was abdominal pain in 92.5% of cases. Perinatal mortality and maternal mortality were 80% and 17.5% respectively.

Conclusion:

Rupture of the gravid uterus still remains a major cause of maternal mortality. Injudicious use of oxytocics should be discouraged in peripheral health facilities and reinforcement of the need for hospital based deliveries in patients with previous caesarean sections should also be intensified to improve outcome.     

Mycobacterial species causing pulmonary tuberculosis at the korle bu teaching hospital, accra, ghana

Summary OBJECTIVE: Characterize mycobacterial species causing pulmonary tuberculosis (PTB) at the Korle-Bu Teaching Hospital in Ghana. DESIGN: Sputum smear positive samples, two (2) from 70 patients diagnosed as having tuberculosis, after they had consented, were collected from the Korle-Bu Teaching Hospital Chest Clinic between January and July 2003. SETTING: Korle-Bu Teaching Hospital Chest Clinic, Accra. RESULTS: Sixty-four mycobacterial isolates were obtained and confirmed as members of Mycobacterium tuberculosis complex by colonial morphology and conventional biochemical assays. Forty-seven (73%) were M. tuberculosis, the human strain, 2 (3%) M. bovis, the bovine strain, 13 (20%) M. africanum I (West Africa type), and 2 (3%) M. africanum II (East Africa type). CONCLUSION: The results indicate that, there are various strains causing PTB at the Korle-Bu Teaching Hospital and of great concern is M. bovis, which mostly causes extra-PTB in humans but found to cause PTB in this study. This calls for the need to conduct a nationwide survey using both conventional and molecular techniques to characterize various mycobacterial species causing TB in Ghana. This will result in better understanding of the various strains circulating in the country and inform individual TB treatment regimen especially the inclusion or exclusion of pyrazinamide.     

产科急症子宫切除术29例分析

目的分析产科急症子宫切除术的原因、手术时机和手术方式，探讨子宫切除术在产科急症中的应用价值。方法对29例产科急症子宫切除术进行回顾性分析。结果产科急症子宫切除主要原因为：胎盘因素、子宫收缩乏力、妊娠合并症、产科DIC等。手术方式以子宫次全切除为主。结论子宫切除术是抢救产科急、重症出血，降低孕产妇死亡的重要措施。     

剖宫产子宫次全切术25例分析

目的分析子宫次全切术在剖宫产术(CS)中的应用。方法回顾分析10年间25例CS中行子宫次全切术病例的临床资料。结果10年间4618例CS患者中,有25例实施了子宫次全切术。产后出血、宫缩乏力和胎盘因素是子宫次全切术的主要手术指征。25例中围产儿病死率为1.2%。结论子宫次全切除术是抢救CS术中急诊危重出血患者生命的一项重要措施。     

Maternal and perinatal mortality

A brief analysis of data from the records of the Government Hospital for Women and Children in Madras for a 36-year period (1929-1964) is presented. India with a population of over 550 million has only 1 doctor for each 6000 population. For the 80% of the population which is rural, the doctor ratio is only 88/1 million. There is also a shortage of paramedical personnel. During the earlier years of this study period, abortions, puerperal infections; hemorrhage, and toxemia accounted for nearly 75% of all meternal deaths, while in later years deaths from these causes were 40%. Among associated factors in maternal mortality, anemia was the most frequent, it still accounts for 20% and is a contributory factor in another 20%. The mortality from postpartum hemorrhage was 9.3% but has now decreased to 2.8%. Eclampsia is a preventable disease and a marked reduction in maternal and perinatal mortality from this cause has been achieved. Maternal deaths from puerperal infections have dropped from 25% of all maternal deaths to 7%. Uterine rupture has been reduced from 75% to 9.3% due to modern facilities. Operative deliveries still have an incidence of 2.1% and a mortality rate of 1.4% of all deliveries. These rates would be further reduced by more efficient antenatal and intranatal care. Reported perinatal mortality of infants has been reduced from 182/1000 births to an average of 78/1000 in all areas, but is 60.6/1000 in the city of Madras. Socioeconomic standards play an important role in perinatal mortality, 70% of such deaths occurring in the lowest economic groups. Improvement has been noted in the past 25 years but in rural areas little progress has been made. Prematurity and low birth weights are still larger factors in India than in other countries, with acute infectious diseases, anemia, and general malnutrition among mothers the frequent causes. Problems requiring further efforts to reduce maternal and infant mortality are correct vital statistics, improved socioeconomic standards, better obstetric and pediatric services, education of the public to use such services, and treatment of diseases complicating pregnancy and research. The clinical and practical aspects of obstetric care are the most important areas in training undergraduates. For existing facilities to yield maximum benefits, hospital deliveries should be restricted to high risk patients. To accomplish this, closer integration of the hospital and domiciliary services is necessary.     

Clinical analysis of 40 cases of uterine rupture at Durgapur Subdivisional Hospital: an observational study

Forty cases of uterine rupture that occurred at Durgapur Subdivisional Hospital during 5 years period from January, 1995 to December, 1999 were analysed for clinical observations. The incidence was 1:273; 77.5% were spontaneous, 15% were traumatic, and 7.5% had scar rupture. It was complete in 92.5% cases. Disproportion was responsible in 40% cases and malpresentation in 27.5% cases. Total hysterectomy was done in 30% cases, subtotal in 27.5% cases and rent repair in 42.5% of cases. Overall maternal mortality was 30% of which highest (41.2%) found in rent repair and lowest (16.6%) in total hysterectomy.     

剖宫产术后瘢痕子宫并发前置胎盘87例临床分析

目的探讨剖宫产术后瘢痕子宫再次妊娠时并发前置胎盘对孕产妇和围产儿的影响,为临床提供参考。方法将我院87例因剖宫产术致瘢痕子宫并发前置胎盘患者作为研究组,随机选取同期因多次妊娠、多次人工流产、多次刮宫操作所致前置胎盘患者70例作为对照组,并将研究组按照此次与上次分娩间隔时间分为研究1组（≤2年）和研究2组（〉2年）。对比对照组与研究组,及研究1组与研究2组孕产妇和围产儿的临床表现。结果研究组剖宫产率明显高于对照组,差异具有统计学意义（P〈0．05）;研究组孕产妇胎盘植入发生率、产后出血量和子宫破裂发生率均明显高于对照组（P〈0．05）;研究1组孕产妇子宫破裂发生率较研究2组更高（P〈O．05）;在围产儿早产率、胎儿窘迫率和围产儿死亡率方面,研究组高于对照组（P〈0．05）,研究1组与研究2组未见明显差异（P〉0．05）。结论剖宫产术后瘢痕子宫并发前置胎盘可增加孕产妇和围产儿的并发症与风险的发生率,两次分娩间隔时间短者更易发生子宫破裂,临床应严格把握剖宫产指征,并指导剖宫产术后再次妊娠的合理间隔时间。     

Shoulder dystocia-a review at the Department of Obstetrics and Gynaecology, Alexandra Hospital, Singapore

Shoulder dystocia is associated with a high incidence of perinatal morbidity, mortality and maternal morbidity. The present study was undertaken to review all the cases of shoulder dystocia at the Department of Obstetrics and Gynaecology, Alexandra Hospital during a 11-year period from January 1978 until December 1988. The incidence of shoulder dystocia in this series was 1:1739 deliveries or 0.05%. The constant awareness of the possibility of rapid development of shoulder dystocia with its potentially dangerous consequences should always be kept in mind. Shoulder dystocia drills should be held regularly in the resident training programme.     

Triplet pregnancy as seen in the Jos University Teaching Hospital

BACKGROUND: Triplet pregnancies are high-risk pregnancies and fortunately the prevalence is low. They are associated with high perinatal morbidity and mortality. DESIGN: All the records of the 16 triplet pregnancies managed in Jos University Teaching Hospital, North Central Nigeria, were retrieved and analysed. RESULTS: There were a total of 41,159 deliveries and 16 triplet pregnancies giving a prevalence of 1 triplet pregnancy in 2,572 deliveries. Over 60% of the mothers were above the age of 24 years, and about 94% were multipara. The female to male sex ratio was 1:0.85, that is, 1 female in 0.85 males. The pre-term delivery rate was 68.7% of the total triplet pregnancies. Booked patients had better foetal and maternal outcome compared with unbooked patients. Most (81.3%) of the women were allowed vaginal delivery. There was no significant difference between the average Apgar scores of babies delivered by caesarean section and vaginal delivery. All the patients had postpartum haemorrhage (a blood loss of 500 ml and above), but none of them required blood transfusion. CONCLUSION: Triplet pregnancies are not managed often in Jos University Teaching Hospital probably because they do not occur commonly on the Jos Plateau, Nigeria.     

Risk of adverse maternal outcome following macrosomic birth in Nigeria

Objective: To determine the risk of adverse maternal outcome associated with obstetric intervention in labour.Methods:All cases of macrosomic births conducted at the University of Calabar Teaching Hospital,Calabar,between January 1st 1994 and December 31st 2000 were reviewed.Measure of treatment/intervention effect was calculated as relative risk for adverse maternal outcome,using spontaneous vaginal births as control.Results:Frequency of mode of delivery was as follow: vaginal births,139(60.7%);instrumental vaginal deliveries,16(7%);and abdominal deliveries,74(32.3%).Obstetric intervention occurred in 90(39.3%) cases.Sixty-four(28%) cases did not book for antenatal care,with 42 cases(18.3%) requiring obstetric intervention.About one in every two parturients(1: 2.1) in this study,requiring obstetric intervention at delivery had been interfered with at unorthodox health facilities.Relative risks for postpartum haemorrhage,wound sepsis and paralytic ileus were significantly high in parturients with abdominal delivery;while in parturients with instrumental vaginal delivery relative risks were significantly high for puerperal sepsis,paralytic ileus and obstetric palsy.There were no maternal deaths.Conclusion:Obstetric intervention in parturients with macrosomic births was high due to labour complications;and was associated with significant risk for adverse maternal outcome,especially in parturients with unskilled interference.