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Open AccessOriginal ArticleUterine rupture revisited: Predisposing factors, clinicalfeatures, management and outcomes froma tertiary care center in TurkeyAbdulkadir Turgut1, Ali Ozler2, Mehmet Siddik Evsen3,Hatice Ender Soydinc4, Neval Yaman Goruk5, Talip Karacor6, Talip Gul7ABSTRACTObjective: To determine the predisposing factors, modes of clinical presentation, management modalitiesand fetomaternal outcomes of uterine rupture cases at a tertiary care center in Turkey.Methodology: A 14-year retrospective analysis of 61 gravid ( 20 weeks of gestation) uterine rupture casesbetween January 1998 to March 2012 was carried out.Results: The incidence of ruptured uteri was calculated to be 0.116%. Persistence for vaginal deliveryafter cesarean was the most common cause of uterine rupture (31.1%). Ablatio placenta was the mostcommon co-existent obstetric pathology (4.9%). Bleeding was the main symptom at presentation (44.3%)and complete type of uterine rupture (93.4%) was more likely to occur. Isthmus was the most vulnerablepart of uterus (39.3%) for rupture. The longer the interval between rupture and surgical intervention, thelonger the duration of hospitalization was. Older patients with increased number of previous pregnancieswere likely to have longer hospitalization periods.Conclusion: Rupture of gravid uterus brings about potentially hazardous risks. Regular antenatal care,hospital deliveries and vigilance during labor with quick referral to a well-equipped center may reduce theincidence of this condition.KEY WORDS: Cesarean section, Perinatal outcome, Uterine rupture.doi: http://dx.doi.org/10.12669/pjms.293.3625How to cite this:Turgut A, Ozler A, Evsen MS, Soydinc HE, Goruk NY, Karacor T, et al. Uterine rupture revisited: Predisposing factors, clinical features,management and outcomes from a tertiary care center in Turkey. Pak J Med Sci 2013;29(3):753-757.doi: http://dx.doi.org/10.12669/pjms.293.3625This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0),which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.1.2.3.4.5.6.7.1-7:Abdulkadir Turgut, MD,Ali Ozler, MD,Mehmet Siddik Evsen, MD,Hatice Ender Soydinc, MD,Neval Yaman Goruk, MD,Talip Karacor, MD,Talip Gul, MD,Department of Obstetrics and Gynecology,Dicle University School of Medicine,Diyarbakir, Turkey.Correspondence:Abdulkadir Turgut, MD,Department of Obstetrics and Gynecology,Dicle University School of Medicine,Diyarbakir, Turkey.E-mail: [email protected]***Received for Publication:November 6, 2012Revision Received:April 1, 2013Revision Accepted:April 3, 2013INTRODUCTIONUterine rupture (UR) is a serious, life-threateningevent that may cause peripartum hysterectomy,hemorrhage, shock, and even maternal and newbornmortality. Good antenatal care and advancedmanagement of labour may aid in decreasing theincidence of UR. However, UR still appears to be arelatively common and serious obstetric catastropheespecially in developing countries.1-3 Immediatecomplications like anemia, urinary bladder ruptureor shock and long-term complications such asinfertility, foot drop or vesicovaginal fistula may beencountered due to UR.4,5Previous cesarean section (CS) incision or otheruterine scars, uterine anomalies, grand multiparity,Pak J Med Sci 2013 Vol. 29 No. 3www.pjms.com.pk 753
Abdulkadir Turgut et al.tumours, use of oxytocin, placenta percreta, andfetal anomalies are postulated risk factors for UR.4Prevalence of UR varies between 1:250 and 1:5000deliveries.3,6 A complete UR involves the entire uterine wall leading to a direct connection between theperitoneal space and the uterine cavity, whereas acover of visceral peritoneum or the broad ligamentis left over the uterus in case of an incomplete UR.4The underlying factors for UR include a poor referral system, non-attendance to antenatal care, delayin seeking medical care and delay of essential interventions.5 Low socioeconomic status, the delivery of babies 3.5 kg, HIV positivity and history ofprevious cesarian section are other postulated riskfactors for UR. Oxytocin stimulation and previousuterine scars are assumed to be the direct causesof UR in developed countries, while obstructed labour is the main culprit in developing countries.5Maternofetal outcomes of UR vary from country tocountry depending on the availability and qualityof health facilities.The aim of this study was to review the riskfactors and causes of UR and define the modes ofclinical presentation, complications, management,maternal and fetal outcome.METHODOLOGYStudy design: A 14-year retrospective analysis ofgravid ( 20 weeks of gestation) UR case recordsfrom January 1998 to March 2012 was performedat the obstetrics and gynecology department of atertiary care center. Approval of local InstitutionalReview Board had been obtained. Patients wereassessed in terms of demographics such as age,parity, gestational age, obstetric history, modeof presentation, the use of uterine stimulant, thecourse of labour, clinical features, type and site ofrupture and operative treatment, hospital stay andfetomaternal outcome.In this series, complete UR was defined either as afull-thickness uterine wall defect accompanied withacute maternal bleeding that calls for operativeintervention. Cases of uterine dehiscence or otherpartial defects of uterine wall were termed asincomplete UR.Statistical analysis: Data were analyzed usingthe Statistical Package for Social Sciences (SPSS)software version 19.0 for Windows (SPSS Inc.,Chicago, IL). Parametric tests were applied to data ofnormal distribution and non-parametric tests wereapplied to data of questionably normal distribution.Pearson Chi Square and Mann–Whitney U-testswere used to compare independent groups. To754 Pak J Med Sci 2013 Vol. 29 No. 3www.pjms.com.pkcalculate correlation coefficients Kendall’s tau b wasused. Data are expressed as mean SD or median(interquartile range), as appropriate. Statisticalsignificance was assumed for p 0.05.RESULTSA total of 61 UR cases consisting of 57 (93.4%)complete and 4 (6.6%) incomplete cases have beenidentified during the 14-year period of the study. Inthis period, there were a total of 52,398 deliveriesof which 61 patients had rupture of the graviduterus giving a ratio of 1: 858 deliveries and theincidence of ruptured uteri was calculated to be0.116%. Six patients delivered via vaginal route athome and reffered to our clinic due to excessivevaginal bleeding. Three of them had a previousCS history and tried to deliver via vaginally andone of them had a Kristeller maneuver trial athome. Uterine rupture detected in these patientsduring the operation performed for intraabdominalhemorrhage. In addition 10 patient reffered to ourclinic from a city hospital due to excessive vaginalbleeding, accompanying pathologies (2 placentapercreta, 1 placenta accrete) that are lately diagnosedintraoperatively because of the vaginal delivery trialof the patients at home. The maternal demographiccharacteristics are displayed in Table-I. The meanmaternal age was 32 (20-45) years, and the meanparity was 4.4 (0-11). The cesarean delivery wasperformed in 27 (44.3%) patients and 34 (55.7%) hadgiven birth via vaginal route. The most commonobstetric pathologies accompanying UR wereablatio placenta (4.9%), placenta previa percreata(3.3%), placenta previa accreata (1.6%) and uterinedidelphys (1.6%). The most common complaint atinitial admission was vaginal bleeding followedby hemodynamic instability defined as systolicblood pressure 90 mm Hg or heart rate 50 beats/min (bpm), fetal distress and abdominal pain. Theperiod between the start of uterotonic infusion andlabor was 8.44 4.12 h. And the duration of the laborin the patients with prolonged course of labor wasTable-I: Demographic featuresof uterine rupture cases.AgeNo. of pregnanciesNo. of paritiesGestational weeksPrevious .1(Abbreviation: CS Cesarean section)
Uterine rupture revisitedTable-II: Details regarding the etiology and management of uterine rupture.CausesSymptomSite of ruptureType of interventionNo. of casesPersistence for vaginal delivery after CSCephalopelvic disproportionProlonged course of labourInjudicious use of uterotonicsMalpresentationApplication of external force (Kristeller maneuver)Partum precipitatesExternal abdominal traumaUnknownVaginal bleedingHemodynamic instabilityFetal distressAbdominal painIsthmusPrevious CS lineUterine hornTAHSuture 4.431.1(Abbreviations: TAH total abdominal hysterectomy, SAH subtotal abdominal hysterectomy.)29.15 9.28 h. The most frequently ruptured sitesinvolved isthmus, previous CS line and uterinehorns. Persistence for vaginal delivery in patientswith a history of CS, cephalopelvic disproportionand prolonged course of labour were presumablythe leading causes. In total, 19 patients (31.1%) hada previous history of CS. Total (34.4%) and subtotal(31.1%) abdominal hysterectomies were the mostfrequent surgical procedures performed. Suturerepair was preferred in 34.4% of cases. Hypogastricartery ligation was performed to 18 patients(29.5%). The clinical and procedure related detailsare demonstrated on Table-II.The mean operative time was 128.5 minutes (90180). The average postoperative hospital stay was8.4 days (4-27). Only two fetal anomalies weredetected in this series. All patients needed bloodtransfusion and mean blood volume transfusedwas 6.02 Unit. The febrile morbidity rate was18%. Urinary system injuries were encounteredin 14 cases (22.9%). No mortalities have occurredin our UR series. Maternal and fetal outcomes aredemonstrated on Table-III.Correlation analysis of variables revealed thatage (rs 0.237, p 0.012) and number of previouspregnancies (rs 0.078, p 0.019) were correlatedwith the duration of hospital stay after surgery forUR. The delay between UR and surgical interventionwas correlated with the duration of hospitalization(rs 0.207, p 0.029) (Table-IV).DISCUSSIONRupture of the gravid uterus is an unexpectedand devastating complication of pregnancy withhigh maternal and fetal mortality and morbidity.Even though it can be prevented in most cases, ratesof maternal and perinatal morbidity and mortalityare still high.5,7,8Modes of presentation in UR may differ in scarredand unscarred uteri: Hypotension and intrauterinedeath occur frequently in the unscarred UR, whereas abdominal tenderness and fetal distress are morecommon in the scarred uteri. Rupture of the unscarred uterus carries more hazardous fetomaternalrisks compared to scarred uterus.4,5 Even though themode of presentation was similar for patients withand without CS history, instability, deterioration ofvital parameters and vaginal bleeding after labourmust remind likelihood of UR.Hysterectomy -whether total or subtotal- wasthe main surgical procedure in case of UR. Incircumstances where preservation of fertility isan issue to be remembered, suture repair canbe considered. However, UR has a potential formortality and cost-benefit ratio must be evaluatedvery well. Improved access to resources and servicesmay aid in the avoidance of the vast majority ofthese mortalities and morbidities.In the literature, maternal mortality rate can be ashigh as 13.5%, whereas several other studies fromPak J Med Sci 2013 Vol. 29 No. 3www.pjms.com.pk 755
Abdulkadir Turgut et al.Table-III: Maternal and fetal outcomes.No. of casesMaternalUterine atony19Vesicouterine rupture8Blood transfusion61Relaparataromy7due to intraabdominalhemorrhageFebrile morbidity11Wound infection5and dehiscenceAcute renal failure2DIC6Ureter injury4Uretra injury1ARDS1Mortality0FetalApgar score 1.min5.22 1.76*Apgar score 5.min7.56 1.42*Fetal birth weight (g) 2940.86 1011.63**Mortality25Site ofIsthmus24rupturePrevious CS line19Uterine horn18Type ofTAH21intervention Suture 4139.331.129.634.434.431.1(Abbreviations: DIC disseminated intravascularcoagulation, ARDS Acute respiratory distresssyndrome, * mean standart deviation (SD) values inlive borns, **mean SD)developing countries have reported lower rates.1,3,5,7Even though we did not come across any mortality,deaths may have occurred prior to the admission tothe hospital. Hypovolemic shock is claimed to bethe main cause of death and rapid transfer of thesepatients to tertiary care centers is imperative.A high index of suspicion and quick referral to awell-equipped center may reduce the incidence ofthis condition. All patients with a history of cesareansection should deliver in hospitals with facilities forsurgery and blood transfusion.8,9 Regular antenatalcare and meticulous screening of high-risk patientsare very important for effective prevention. Familyplanning advice to reduce grandmultiparity,improved access to maternal care, decentralizationof obstetric services into peripheral units to preventhome deliveries and good supervision during laborcan reduce the incidence of UR.8,9Although Turkey is a developing country, ourrelatively low UR incidence may be a reflectionof the high standard of obstetric care and hospitaldeliveries. In general, patients had adequateantenatal care by trained physicians and they756 Pak J Med Sci 2013 Vol. 29 No. 3www.pjms.com.pkTable-IV: Correlation analysis of variables correlatedwith the duration of hospitalization.Correlationsrp ValueAge * Duration of hospitalization0.2370.012Number of previous pregnancies0.0780.0190.2070.029* Duration of hospitalizationSurgical delay* Duration of hospitalization(Kendall’s tau-b)usually delivered at hospital by obstetricians. Theimpact of defensive medical practice and the declinein traumatic rupture may be the other reasons forour low incidence.2,4 The predisposing factors of URin developing countries have been demonstratedas: age 31–35, para 3, and poor antenatal care,grandmultiparity, obstetric trauma from prolongedor neglected labour, malpresentation, externaland internal podalic version, breech extraction,manual cervical dilatation, and injudicious use ofoxytocin, prostaglandins by untrained paramedicsand previous unknown corporeal scar.5,7-10 In ourseries, the average parity was higher than 4. Inaddition, we observed that delay of diagnosis forappropriate surgical intervention was correlatedwith prolongation of hospital stay. Especially,UR encountered in pregnancies at advancedages may cause longer hospital stays. Therefore,such pregnancies should be more closely andmore carefully monitored in terms of potentialcomplications and morbidities.Close monitoring of maternal and fetal responseto uterine stimulants is mandatory to avoid complications of obstructed labour and overuse of uterinestimulants. Application of external force, vacuumforceps and breech extraction are other possiblecauses of UR.8,9 In our study, external force application was performed in four patients.The relationship between UR and previous CS iscontroversial. Various reports have shown that apreviously scarred uterus is a major factor whichpredisposes towards UR.2,4,5 Cesarean delivery isthe most common cause for a scarred uterus. Owing to the increased rates of CS worldwide, thenumber of women presenting to the labor wardwith a scarred uterus is increasing. This fact bringsabout an increased risk for any maternal morbidity,including UR.1,4,5,7,8 Nineteen of our patients had ahistory of CS. The reasons of uterine rupture in thepatients with a history of CS in the southeastern ofTurkey are low socioeconomic status, the long period of transport from villages to the hospital and
Uterine rupture revisitedtrial of labor via vaginal route at home to have achance of more babies. Whereas, the majority of ourpatients had no history of CS and any other uterinesurgery, therefore the role of previous CS in pathophysiology of UR must not be ignored but shouldnot be exaggerated either.The choice of the surgical procedure dependsupon the type, location and extent of the tear as wellas the patient’s condition and desire for future fertility. Total hysterectomy is the operative procedureof choice, unless cardiovascular decompensationnecessitates subtotal hysterectomy or simple suturerepair and bilateral tubal ligation. Unhealthy tissue remaining after uterine repair may predisposeto problems like infection, DIC, abscess formationand haemorrhage. In circumstances where suturerepair is undertaken to preserve fertility, the risk ofrecurrent rupture is always there.2,9-11 We considerhysterectomy to be the best treatment for patientswho have completed their family.Sudden fetal heart abnormality in laboring patients should be taken as a potential sign of danger.Total abdominal hysterectomy is the routine operative procedure of choice unless cardiovascular decompensation necessitates subtotal abdominal hysterectomy or simple suture repair and bilateral tuballigation.11,12 The procedure selected in the management of UR must be individualized depending onthe patient’s condition and the type, location, andextent of the rupture. Since UR is a life-threateningobstetric hazard, it should always be kept in mindin the care of obstetrics patients. Non-specific symptoms like epigastralgia and severe vomiting mightbe critical hints for UR. Gastrointestinal symptomsmay increase the abdominal pressure and triggerUR.9 With awareness, timely diagnosis, prompt surgical management and neonatal care, rates of maternal and perinatal mortality and morbidity can bereduced.10-12Assisted breech delivery and malpresentationhave been reported to be significantly higher amongwomen with UR.4 It is interesting that women withhypertensive disorders had higher rates of UR. Alogical explanation might be that these women hadhigher rates of labor induction. An association between hypertensive disorders and other risk factors, such as advanced maternal age and possibly aprevious CS, may partially explain the significance.4UR in pregnancy is a major obstetric complicationthat occurs often without warning. This hazardousevent should be kept in mind especially in thepresence of predisposing factors. Reduction offetomaternal morbidity and mortality can beachieved via awareness, prompt diagnosis, rapidreplacement of blood loss and improved techniquesin surgical management and neonatal care.Prevention is more important than management,and regular antenatal care and hospital deliveriesmay prevent many cases of UR in pregnancy.In conclusion, UR constitutes a major risk factor forfetomaternal morbidity and mortality. A high indexof suspicion for UR must be reserved for womenpresenting with evidence of hypovolemia and fetalcompromise. Early diagnosis and prompt recourseto exploratory laparotomy can be necessary to savethe fetus and avoid further complications. Increasedaccessibility to antenatal care as well as a functionalreferral system and popularization of information,education and communication programmes forpregnant women may aid in prevention of UR.REFERENCES1.2.3.4.5.6.7.8.9.10.11.12.Chuni N. Analysis of uterine rupture in a tertiary center inEastern Nepal: lessons for obstetric care. J Obstet Gynaecol Res.2006;32(6):574-579.Ozdemir I, Yucel N, Yucel O. Rupture of the pregnant uterus: a9-year review. Arch Gynecol Obstet. 2005;272(3):229-231.Al Sakka M, Hamsho A, Khan L. Rupture of the pregnant uterus--a21-year review. Int J Gynaecol Obstet. 1998;63(2):105-108.Ofir K, Sheiner E, Levy A, Katz M, Mazor M. Uterine rupture:risk factors and pregnancy outcome. Am J Obstet Gynecol.2003;189(4):1042-1046.Kadowa I. Ruptured uterus in rural Uganda: prevalence,predisposing factors and outcomes. Singapore Med J. 2010;51(1):3538.Nyengidiki TK, Allagoa DO. Rupture of the gravid uterus in atertiary health facility in the Niger delta region of Nigeria: A 5-yearreview. Niger Med J. 2011;52(4):230-234.Walsh CA, Baxi LV. Rupture of the primigravid uterus: a review ofthe literature. Obstet Gynecol Surv. 2007;62(5):327-334.Ronel D, Wiznitzer A, Sergienko R, Zlotnik A, Sheiner E. Trends,risk factors and pregnancy outcome in women with uterine rupture.Arch Gynecol Obstet. 2012;285(2):317-321.Spong CY, Landon MB, Gilbert S, Rouse DJ, Leveno KJ, Varner MW,et al. National Institute of Child Health and Human Development(NICHD) Maternal-Fetal Medicine Units (MFMU) Network: Risk ofuterine rupture and adverse perinatal outcome at term after cesareandelivery. Obstet Gynecol. 2007;110(4):801-807.Olagbuji BN, Okonofua F, Ande AB. Uterine rupture and risk factorsfor caesarean delivery following induced labour in women with oneprevious lower segment caesarean section. J Matern Fetal NeonatalMed. 2012;25(10):1970-1974.Sun HD, Su WH, Chang WH, Wen L, Huang BS, Wang PH. Ruptureof a pregnant unscarred uterus in an early secondary trimester: acase report and brief review. J Obstet Gynaecol Res. 2012;38(2):442445.Fofie C, Baffoe P. A two-year review of uterine rupture in a regionalhospital. Ghana Med J. 2010;44(3):98-102.Authors Contribution:Abdulkadir Turgut, Ali Ozler: Designed theresearch protocol and literature search.Abdulkadir Turgut, Mehmet Siddik Evsen, HaticeEnder Soydinc, Neval Yaman Goruk, Talip Karacor:Conducted the study and did data analysis.Abdulkadir Turgut, Talip Gul: Prepared the finaldraft for publication.Pak J Med Sci 2013 Vol. 29 No. 3www.pjms.com.pk 757
Ablatio placenta was the most common co-existent obstetric pathology (4.9%). Bleeding was the main symptom at presentation (44.3%) and complete type of uterine rupture (93.4%) was more likely to occur. Isthmus was the most vulnerable part of uterus (39.3%) for rupture. The longer the interval between rupture and surgical intervention, the
