Uterine rupture

Background

Normal female anatomy with uterus highlighted.

Schematic showing transverse rupture of the anterior uterine wall.

Uterine rupture, with extruded amniotic sac seen with abdomen opened.

• Spontaneous tearing of the uterus
• May result in fetus being expelled into peritoneal cavity.
• Occurs in late pregnancy or active labor
• Rare, prevalence:
  • No prior c-section = 0.01%
  • Prior c-section = 0.2-0.8%
• Risk factors:
  • Prior c-section (major)- rupture most commonly occurs along prior scar lines
  • Malpresentation
  • Labor dystocia
  • Hypertension
  • Bicornuate uterus
  • Grand multiparity
  • Connective tissue disorder
  • Placenta percreta
  • Prior myomectomy
  • Misoprostol use (oxytocin likely safe)

Clinical Features

• Persistent abdominal pain with peritoneal signs
• Vaginal bleeding
• Shock
• Palpable uterine defect
• Loss of fetal station
• Fetal bradycardia (most suggestive), variable decelerations, evidence of hypovolemia

Differential Diagnosis

Vaginal Bleeding in Pregnancy (>20wks)

• Emergent delivery
• Placental abruption
• Placenta previa
• Vasa previa
• Uterine rupture
• Preterm labor
• Vaginal trauma
• Placenta accreta
• Intrauterine fetal demise

3rd Trimester/Postpartum Emergencies

• Acute fatty liver of pregnancy
• Amniotic fluid embolus
• Chorioamnionitis
• Eclampsia
• HELLP syndrome
• Mastitis
• Peripartum cardiomyopathy
• Postpartum endometritis (postpartum PID)
• Postpartum headache
• Postpartum hemorrhage
• Preeclampsia
• Resuscitative hysterotomy
• Retained products of conception
• Septic abortion
• Uterine rupture

Evaluation

Before emergency cesarean section, the fetus was stillborn. Uterine rupture with protrusion of amniotic cavity and placenta, massive hemoperitoneum, and the uterine wall defect (white arrow) are found on abdominal computerized tomography

Workup

• CBC, chemistry
• Coags
• Type & screen
• Upreg / b-HCG
• Rh
• Pelvic ultrasound

Diagnosis

Typically determined by pelvic ultrasound or (if emergent) OR visualization:

• Disruption of myometrium
• Free peritoneal fluid (FAST+)
• Anhydramnios/empty uterus
• Herniated amniotic sac
• Fetal anatomy outside of uterus
• Absence of FHR

Management

• Fluid resuscitation
• Blood product replacement
• Emergent delivery of fetus via cesarean section

Disposition

• Admission (emergently to operating room)

See Also

• Postpartum Emergencies