Uterine rupture and subsequent pregnancy outcome – how safe is it? A 25-year study

Objectives.?(a) To review the cases of ruptured uterus over the last 25 years and analyze the causative factors with a view to its prevention (b) To analyze subsequent pregnancy outcome with a view to its safety.

Method.?The case notes were reviewed for all patients with ruptured uterus over a period of 25 years from January 1982 to January 2007. Relevant dates relating to the characteristics of labor, delivery, maternal, perinatal, and subsequent pregnancy outcomes were assessed.

Results.?The incidence of ruptured uteri was calculated to be 0.03%. Total deliveries included in the study were 152,426. There were 46 cases of ruptured uteri and 44 were available for study. Twenty-two (52%) ruptured uteri occurred in patients with previous caesarean scars, of which 10 occurred in women with previous four or more caesarean sections. In 12 cases (27%), uterine rupture occurred due to oxytocin; PGE2 and oxytocin were used in 3 of these 12 cases. Two (4.5%) ruptures occurred due to non-removal of cervical cerclage during labor. Two (4.5%) primigravidae ruptured their uterus following road traffic accident, resulting in maternal and fetal deaths. Malpresentation in labor resulted in eight (18%) ruptures. Rupture occurred at the fundus in 10 cases and in the lower segment in the remaining 34. Fetal heart abnormalities were observed in all cases in which the uterus ruptured during labor. Abdominal hysterectomy was performed in 20 cases (45%) of which 13 were subtotal and 7 (10%) were total. Of the remaining 24 (55%) patients, 10 had suture repair and in addition 14 patients underwent hypogastric artery ligation. Later, 22/24 (92%) women became pregnant. Twenty (91%) were delivered by planned caesarean section. There were no maternal or fetal complications. The remaining two women had previous classical scar, undetected malpresentation, and sparse antenatal care. Their uteri ruptured spontaneously at 32 and 35 weeks at home. They died intra-operatively due to intractable hemorrhage along with their fetus.

Conclusion.?In the previous caesarean section, the indiscriminate use of oxytocin and malpresentation are the risk factors for uterine rupture. Child birth after uterine rupture is not to be recommended routinely. Most women with a previous uterine rupture with meticulous tertiary level antenatal care had a favorable outcome in subsequent pregnancies.     

Uterine rupture and labour after a previous low transverse caesarean section

This study reviewed all cases of complete uterine rupture (UR) in pregnancy during the decade 1993-2002. In 69,412 deliveries, 5,320 women had a single prior caesarean section. Of these, 4,021 had a trial of labour and 3,129 (77.8%) delivered vaginally. In nine (0.22%) cases, the previous transverse scar ruptured during labour. None of these nine ruptures resulted in maternal or fetal death, peripartum hysterectomy or fetal morbidity. In our practice, a trial of labour in women with a previous low transverse caesarean is associated with a high rate of vaginal delivery and a low rate of UR.     

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.     

Delivery in the scarred uterus. Apropos of 606 cases in 62,193 deliveries

Scarred uterus represent 1 p. cent of the deliveries in our department (n = 606). Delivery is performed vaginally in 61 p. cent of the cases and by caesarean section in 39 p. cent of the cases. During two 4-year periods (1981-1984 and 1985-1988), the rate of repeated caesarean sections increases from 36 to 41 p. cent with decrease of the number of uterine ruptures which however, persists (almost 5 p. cent of scarred uteruses). The type of scarring is the major risk factor with: segmental scarring (1.5 p. cent of ruptures), gynecological (5 p. cent), segmento-corporeal (26 p. cent) and corporeal (33 p. cent). Strict obstetrical monitoring permits to control this risk (25 p. cent of ruptures occur at home). It is the uterine rupture that determines the maternal risk (3 death scarred uteruses represent almost 40 p. cent of uterine ruptures 11) and result in 3 p. cent of the maternal mortality in the department. The perinatal mortality is 63.6 for 1,000. A dynamic test of the uterus requires an obstetrical decision taking into consideration the scar, essentially segmental transverse, the head delivery with favorable cephalo-pelvic comparison and a well-trained team. This choice is dictated by the maternal risk of caesarean section, 2 for 1,000 in Europe (14) and for 1,000 in the department and a persistent high mortality in children (97 for 1,000 in Gabon).     

Midtrimester abortion in patients with a previous uterine scar

OBJECTIVE: To investigate whether extraamniotic prostaglandin E2 (PGE2) for midtrimester pregnancy interruption in women with a scarred uterus has any adverse effects compared to those without an uterine scar. STUDY DESIGN: Two hundred and sixty-two women who underwent second trimester (16-27 gestational weeks) termination of pregnancy were enrolled in this study. Thirty-one women with a uterine scar were compared with 231 patients without a scarred uterus. Extraamniotic PGE2 was applied in serial doses of 200 mcg every 2 h up to 20 doses. Intravenous infusion of oxytocin was added in cases when the fetus was not expelled. Curettage was performed in the majority of the patients. RESULTS: The two groups were similar for indications for pregnancy termination, maternal age and gestational age. Gravidity and parity were significantly higher in the group with an uterine scar. The mean induction to abortion time and the complication rate were similar in both groups. No uterine rupture was observed. CONCLUSION: Extraamniotic PGE2 for midtrimester termination of pregnancy is a safe procedure with a low complication rate, even in patients with an uterine scar.     

Oxytocin augmentation in dysfunctional labour after previous caesarean section

Summary. Uterine activity was quantified in women with a previous caesarean scar and a slow progress of labour who needed oxytocin augmentation. Of the 63 women 49 (78%) progressed well (mean cervical dilatation rate of 1·5 cm/h) and were delivered vaginally. Fourteen women had slow progress of labour (0·3 cm/h) and were delivered by caesarean section despite adequate and similar augmented uterine activity to that in the women who were delivered vaginally. Those who were delivered by caesarean section had a significantly higher mean maximum dose of oxytocin and a longer period of augmentation. All caesarean sections were for cephalopelvic disproportion and the mean birthweight of babies born by caesarean section (3598 g) was significantly higher than that of babies born vaginally (3230g). Satisfactory rate of cervical dilatation in the presence of optimal uterine activity is predictive of favourable outcome when oxytocin is used for dysfunctional labour after previous caesarean section.     

Oxytocin augmentation in dysfunctional labour after previous caesarean section

Uterine activity was quantified in women with a previous caesarean scar and a slow progress of labour who needed oxytocin augmentation. Of the 63 women 49 (78%) progressed well (mean cervical dilatation rate of 1.5 cm/h) and were delivered vaginally. Fourteen women had slow progress of labour (0.3 cm/h) and were delivered by caesarean section despite adequate and similar augmented uterine activity to that in the women who were delivered vaginally. Those who were delivered by caesarean section had a significantly higher mean maximum dose of oxytocin and a longer period of augmentation. All caesarean sections were for cephalopelvic disproportion and the mean birthweight of babies born by caesarean section (3598 g) was significantly higher than that of babies born vaginally (3230 g). Satisfactory rate of cervical dilatation in the presence of optimal uterine activity is predictive of favourable outcome when oxytocin is used for dysfunctional labour after previous caesarean section.     

Uterine rupture in the Netherlands: a nationwide population-based cohort study

Objective  To assess incidence of uterine rupture in scarred and unscarred uteri and its maternal and fetal complications in a nationwide design.
Design  Population-based cohort study.
Setting  All 98 maternity units in the Netherlands.
Population  All women delivering in the Netherlands between August 2004 and August 2006 ( n  = 371 021).
Methods  Women with uterine rupture were prospectively collected using a web-based notification system. Data from all pregnant women in the Netherlands during the study period were obtained from Dutch population-based registers. Results were stratified by uterine scar.
Main outcome measures  Population-based incidences, severe maternal and neonatal morbidity and mortality, relative and absolute risk estimates.
Results  There were 210 cases of uterine rupture (5.9 per 10 000 pregnancies). Of these women, 183 (87.1%) had a uterine scar, incidences being 5.1 and 0.8 per 10 000 in women with and without uterine scar. No maternal deaths and 18 cases of perinatal death (8.7%) occurred. The overall absolute risk of uterine rupture was 1 in 1709. In univariate analysis, women with a prior caesarean, epidural anaesthesia, induction of labour (irrespective of agents used), pre- or post-term pregnancy, overweight, non-Western ethnic background and advanced age had an elevated risk of uterine rupture. The overall relative risk of induction of labour was 3.6 (95% confidence interval 2.7–4.8).
Conclusion  The population-based incidence of uterine rupture in the Netherlands is comparable with other Western countries. Although much attention is paid to scar rupture associated with uterotonic agents, 13% of ruptures occurred in unscarred uteri and 72% occurred during spontaneous labour.     

An audit of trial of labour after previous caesarean section.

The first aim of the study was to assess the success rate of vaginal delivery after a trial of labour in women with history of caesarean delivery. The second, was to analyse the management used and suggest recommendations that might improve the outcome. The caesarean section rate in Tameside hospital, in the period of 1995 and 1996, was (11%), 20% of which were repeat caesarean sections Fifty-one per cent of those with a history of previous caesarean section were allowed a trial of labour. The success rate of vaginal delivery in cases allowed trial of labour was 70%. But, if we include the 49% of cases who had elective repeat caesarean section in the calculation, the success rate for vaginal delivery would drop to 36%. More than one previous caesarean section was the main indication for elective repeat caesarean section. The second most common indication was cephalopelvic disproportion based on X-ray pelvimetry. Other indications included pregnancy-induced hypertension, breech presentation and maternal request. The main indication for repeat emergency caesarean section was fetal distress. Other causes included failure to progress, cephalo-pelvic disproportion, tender scar, ante-partum haemorhage and one case of ruptured uterus.     

An audit about labour induction, using prostaglandin, in women with a scarred uterus

Objectives

Induction of labour after a previous caesarean section is still controversial. We aim to analyse, in a population of women who have a uterine scar, the maternal, foetal and neonatal complications in relation to the mode of labour and delivery.

Study design

Retrospective analysis of collected data from all the singleton deliveries of patients with a scarred uterus (N?=?798), admitted to the hospital between August 2006 and March 2009. Outcomes: maternal and perinatal complications.

Results

Among 798 singleton deliveries, 36.1?% had a spontaneous labour, 12.6?% a prostaglandin-induced labour and 2.9?% an ocytocin-induced labour, and 48.4?% had an elective caesarean section. The chance of delivering vaginally was respectively 84.4?% for those who had a spontaneous labour, 75.2?% for those who were induced using prostaglandin, 82.6?% after induction using ocytocin. There were eight uterine ruptures, four after spontaneous labour (1.4?%), two after prostaglandin induction (2?%) and two at the time of an iterative caesarean section (0.5?%). There were no differences between groups, except the risk of haemorrhage (17.4?% after spontaneously induced labour, 34.8?% after ocytocin, 17.8?% after prostaglandin and 44.6?% after iterative caesarean section; p?<?0.005) and the neonatal admissions when analysed by intention to treat only (8.3?% after spontaneously induced labour, 9.1?% after ocytocin, 12?% after prostaglandin and 16.8?% after iterative caesarean section; p?<?0.009).

Conclusion

Although no increase in maternal or perinatal outcome was observed in relation to prostaglandin-induced labour after caesarean section, this study is too underpowered to exclude an increased risk.     

Vaginal birth after one previous caesarean section in a tertiary institution in Nigeria.

Vaginal birth after one previous lower segment caesarean section represents one of the most significant and challenging issues in obstetric practice. A 5-year retrospective study was carried out at the University of Benin Teaching Hospital between January 1999 and December 2003, to determine the incidence, the maternal and fetal outcome following vaginal delivery after one previous caesarean section with a view to evaluating its safety and efficacy. There were 5234 deliveries, with 395 cases of one previous caesarean section, giving an incidence of 7.5%. The incidences of emergency caesarean section, elective caesarean section and spontaneous vaginal delivery following trial of vaginal delivery were 34.7%, 9.4% and 48.1%, respectively. During the study period there were 1317 cases of caesarean section, giving an incidence of 25.2% caesarean section rate. The incidence of one previous section among all caesarean section births was 30%. The major morbidity following vaginal delivery was uterine rupture with an incidence of 1.5% and hysterectomy of 0.8%. Three of the uterine ruptures occurred before admission because the patients laboured at home. One maternal death occurred as a result of uterine rupture and postpartum haemorrhage, giving a maternal mortality ratio of 19/100,000 and a case fatality rate of 0.3%. The corrected perinatal mortality rate was 15.2/1000, mainly from obstructed labour, abruptio placenta and fetal distress. Both maternal and fetal mortalities from vaginal birth after one previous section were significantly less than the respective overall maternal and fetal mortality from the institution. The 1-minute apgar score of babies delivered by elective section was significantly (P < 0.001) higher than the apgar score of babies delivered by emergency section and vaginally. There was only one patient with wound dehiscence at elective section without associated perinatal death. Vaginal delivery following caesarean section is relatively safe. However, women in developing countries will continue to require counselling to counter the myths of aversion to operative delivery even at the expense of losing their lives. Our hospitals should have adequate monitoring equipment for high-risk pregnancies so that patients and their babies can be assured of survival.     

Rupture of the gravid uterus

Seventeen cases of uterine rupture in late pregnancy managed over an eight-year period in one hospital in Hong Kong were analysed. Labour was associated with rupture in 16 cases, including ten with one or more previous caesarean section scars. Rupture occurring in an unscarred uterus was associated with high fetal losses and all required hysterectomy. All of these patients had at least one previous vaginal delivery, in contrast to the patients with a scarred uterus. Labour should be closely monitored in multiparous patients with or without a uterine scar, and oxytocics should be used carefully. Patients with previous sections who are scheduled for repeat elective sections should be delivered before 39 weeks.     

Fertility of females with abnormalities of the uterus

In 209 females examined with hysterosalpingography indications for examination were fertility disturbances in 131 cases, inspection of operation scar after caesarean section in 42 cases, repeated failure of intrauterine device in 9 cases and other causes in 27 cases. Development malformations of the uterus were observed in 54 females (25.8%), which comprised 40 cases with fertility malfunctions and 14 cases who had been delivered of before. The high percentage of women, who, in spite of malformations of the uterus, were delivered either spontaneously or by means of the caesarean section of live children leads to the following conclusions: 1. The occurrence of uterine malformations is more frequent than the incidence in women examined because of fertility malfunctions would indicate. 2. Uterine malformations in women who had been delivered were not always diagnosed. 3. The occurrence of repeated failure of intrauterine device coincides conspicuously with the occurrence of uterine malformations. The diagnosis of developmental malformations of the uterus cannot be always the cause of infertility.     

Eight years' experience of uterine rupture cases.

Ruptured uterus is a serious obstetric emergency with a high maternal and perinatal mortality. It is a preventable and common obstetric problem in developing countries. The objective of this study was to review the incidence, methods of diagnosis and maternal and perinatal morbidity and mortality associated with uterine rupture. Case notes were reviewed for all patients with a ruptured uterus at Yüzüncü Yil University Medical Faculty Department of Obstetrics and Gynaecology from January 1995 to August 2003. Relevant data relating to the clinical characteristics of labour, operative procedures, maternal and perinatal outcome were assessed. There were 20 cases of ruptured uteri. The incidence was 0.40%. When patients referred from other hospitals were excluded, the revised ratio was 0.12%. There were 13 (65%) complete and seven (35%) incomplete ruptures. Nine (45%) cases occurred in patients with scarred uteri. Ten (50%) cases were grand multiparous. Subtotal abdominal hysterectomy was performed in five (25%) cases, total abdominal hysterectomy was performed in two (10%) cases and the remaining 13 (65%) cases had uterine rupture repair. There were two (10%) maternal deaths. Both of them were referred from other hospitals. There were seven (35%) perinatal deaths attributable to uterine rupture. Occurrence of uterine rupture is significantly associated with grand multiparity, scarred uterus, lack of antenatal care, unsupervised labour at home and low socioeconomic status of the patients. These factors are largely preventable.     

Rupture of the uterus in labor. A review of 96 cases

Ninety-six cases of ruptured uterus in labor treated in the University Teaching Hospitals, Benghazi, Libya between 1977 and 1980 are reported. An incidence of 1 in 585 deliveries remained unchanged during the period of study. Twenty uterine ruptures occurred in a previously scarred uterus. Rupture of the unscarred uterus is a more catastrophic event. There is a marked difference in both fetal and maternal outcome between the group with a previously scarred uterus and the group without a previous scar. The incidence and causes of uterine rupture in Libya differ greatly from those in developed countries. High parity is a frequent cause. Other common etiological factors were cephalopelvic disproportion, fetal malpresentation, oxytocin stimulation of labor and unwise obstetrical interference. The fetal wastage was high, a perinatal mortality of 75% being recorded, but 95% of the mothers were saved. Hysterectomy was commonly performed in this group. Repair of the uterus and sterilization should only be performed when the rupture is simple and transverse in the lower segment and without any sign of infection.     

9. Pregnancy outcome following previous caesarean section, previous vesicovaginal fistula and previous surgical treatment of ectopic pregnancy

Summary. Some women in this survey population had a history of one or more surgical procedures including treatment for ectopic pregnancy (41), repair of vesicovaginal fistula (97), caesarean section (866), ectopic pregnancy and caesarean section (2) and repair of vesicovaginal fistula and caesarean section (47), leaving 21672 who had not had any of these operations before. Pregnancy outcomes in these six groups of women were compared. The main problems were lack of antenatal care in all groups, disproportion and prolonged labour in the previous caesarean section group, urinary tract infections, an excess of low-birth-weight babies and perinatal mortality rate exceeding 140 per 1000 total births in the previous vesicovaginal fistula repair group. Rupture of the scarred uterus, always a danger, occurred in 10% of those without antenatal care and in 1.4% of those with antenatal care. Of those who had had a previous section, 45% required a further caesarean section and the overall operative delivery rate in this group was 55%     

Trends in uterine rupture in Enugu, Nigeria.

Our objective was to determine the trend of rupture of the gravid uterus at Enugu, Nigeria and to determine any change in pattern of presentation, management and outcome of such patients. The birth register of 4,333 deliveries at the University of Nigeria Teaching Hospital Enugu from January 1997 and December 2000 were reviewed. Forty-one cases of ruptured uterus were identified and analysed. The incidence of uterine rupture was 1 in 106 deliveries with a mean maternal age of 31.2 years. The majority (75.6%) of the patients were multiparous and had some form of antenatal care (61%) with 19.5% of the total booked at the Teaching Hospital. Many (78.1%) of the patients were in labour for 24?hours or less and 22.0% had oxytocin to augment or induce labour. The majority (68.3%) had a previously scarred uterus and many (53.6%) had lower segment ruptures. At laparotomy 31.7% had repair alone, 29.2% had repair with tubal ligation, 22.0% subtotal hysterectomy and 17.1% total hysterectomy. Perinatal mortality was high (87.8%) and maternal mortality rate 48.8 per 1,000 deliveries. Labour in a previously scarred uterus was the most common aetiological factor followed by obstructed labour in a multiparous woman.The incidence of ruptured uterus is still rising at Enugu, Nigeria but maternal mortality, due to uterine rupture continues to fall. The most commonly performed surgery is repair with or without sterilisation rather than hysterectomy.     

Rupture of the uterine scar during term labour: contractility or biochemistry?

OBJECTIVE: Vaginal birth after a prior low transverse caesarean section (VBAC) is advocated as a safe and effective method to reduce the total caesarean section rate. However, the risk of uterine rupture has dampened the enthusiasm of practising clinicians for VBAC. Uterine rupture occurs more frequently in women receiving prostaglandins in preparation for the induction of labour. We hypothesised that similar to the cervix, prostaglandins induces biochemical changes in the uterine scar favouring dissolution, predisposing the uterus to rupture at the scar of the lower segment as opposed to elsewhere. DESIGN: We tested aspects of this hypothesis by investigating the location of uterine rupture associated with prostaglandins and compared it with the sites of rupture in the absence of prostaglandins. SETTINGS: Two North American University Hospitals. POPULATION: Twenty-six women with a prior caesarean section, experiencing uterine rupture in active labour. METHODS: Retrospective review of all pregnancies complicated by uterine rupture at two North American teaching hospitals from 1991 to 2000. MAIN OUTCOME MEASURE: Site of the uterine rupture. RESULTS: Thirty-four women experienced rupture after a previous caesarean section with low transverse uterine incision. Ten of the women who ruptured (29%) received prostaglandins for cervical ripening (dinoprostone: n= 8 or misoprostol: n= 2) followed by either spontaneous contractions (n= 3) or oxytocin augmentation during labour (n= 7). In 16 women (47%), oxytocin alone was sufficient for the induction/augmentation of labour. Eight (23%) women ruptured at term before reaching the active phase of labour in the absence of pro-contractile agents or attempted VBAC. There were no differences among the groups in terms of age, body mass index, parity, gestational age, fetal weight or umbilical cord pH measurements. Women treated with prostaglandins experienced rupture at the site of their old scar more frequently than women in the oxytocin-alone group whose rupture tended to occur remote from their old scar (prostaglandins 90%vs oxytocin 44%; OR: 11.6, 95% CI: 1.2-114.3). CONCLUSION: Women in active labour treated with prostaglandins for cervical ripening appear more likely to rupture at the site of their old scar than women augmented without prostaglandins. We propose that prostaglandins induce local, biochemical modifications that weaken the scar, predisposing it to rupture.     

Vaginal delivery after one caesarean section in Nigerian women.

A total of 120 Nigerian women at term pregnancy with one previous caesarean delivery were studied between June 1988 and May 1993. Elective caesarean section was performed in 3 (2.5%). Vaginal delivery was achieved in 101 (86.5%) of those allowed a trial of labour. Intrapartum caesarean section was done in 16 (13.7%) cases. Rupture of the uterus occurred in 3 cases (2.6%) with perinatal loss of 2 babies. There was no maternal mortality. There was no significant correlation between vaginal delivery and birth weight, gestational age or initial indication for the primary caesarean section. It is concluded that trial of labour is safe after a previous caesarean section in selected patients.     

Case series of uterine rupture and subsequent pregnancy outcome

OBJECTIVE: TO review the incidence of ruptured uterus at Women's Hospital, Hamad Medical Corporation (HMC), highlight the management approach of suture repair in relation to maintaining the patient's future fertility, and study subsequent pregnancy outcome and the risk of recurrent uterine rupture. METHODS: Case notes were reviewed for every patient with a ruptured uterus at the Women's Hospital in Doha for a period of 15 years, from 1 January 1983 to 31 December 1997. RESULTS: There were 17 cases of ruptured uterus. The incidence of ruptured uterus was calculated to be 0.012%; eight (47%) of these occurred in patients with previous cesarean scars, while nine cases (52.9%) were grand multiparas (5 or more). In nine cases (52.9%), uterine rupture was associated with oxytocin use, and four patients (23.5%) were associated with prostaglandin E2 (PGE2) use. The ruptures occurred in the posterior uterine wall in one patient, the scar of a classical cesarean section in another, and in the lower segment in the remainder. Fetal heart abnormalities were observed in all cases in which the uterus ruptured during labor. Abdominal hysterectomy was performed in eight cases (47%). The remaining nine patients had suture repair, two with sterilization, and the other seven without sterilization. Six of these subsequently became pregnant, for a total of ten babies, all delivered by cesarean section. CONCLUSION: Even though rupture of the uterus was rare in our study, its occurrence should be suspected when there are sudden fetal heart abnormalities during labor or unexpected antepartum or postpartum hemorrhage. Suture repair should be considered whenever possible to maintain the patient's future fertility.