II. Epidemiology

  1. Overall risk: Up to 0.03 to 0.08% of all deliveries
  2. Uterine scar risk: Up to 0.3 to 1.7% of all deliveries with prior cesarean
    1. Low transverse scar (VBAC, Vaginal Birth after Cesarean): 0.8% Incidence

III. Etiology

  1. Rupture of uterine scar
    1. Cesarean Section scar (most common cause)
    2. Prior uterine curettage or perforation
    3. Abdominal Trauma
  2. Obstructed labor due to Cephalopelvic Disproportion
  3. Uterine hyperstimulation with Labor Induction
    1. Oxytocin induction and augmentation
    2. Cervical Ripening (Misoprostol or Dinoprostone)
    3. Maternal Cocaine Abuse
  4. Other factors
    1. Uterine distention
    2. Amnioinfusion
    3. Gestational Trophoblastic Neoplasia
    4. Difficult manual removal of placenta
  5. Findings not related to Uterine Rupture
    1. Oxytocin at high infusion rates
    2. Five or more contractions in 10 minutes
    3. Tetanic contractions lasting >90 seconds
    4. Phelan (1998) Obstet Gynecol 92:394-7 [PubMed]

IV. Types

  1. Rupture of Classical Cesarean Scar (Vertical)
    1. Occurs in late pregnancy or early labor
    2. Presents as Acute Abdominal Pain and shock
    3. Risk of rupture in labor as high as 9%
  2. Rupture of Lower Uterine segment scar
    1. Often occult presentation
    2. Occurs with Trial of Labor after Cesarean (TOLAC)
      1. Absolute risk of rupture
        1. One prior Cesarean Section: 0.6% of TOLACs
        2. Two prior Cesarean Sections: 3.9% of TOLACs
      2. Absolute risk of neonatal death: 0.02% of TOLACs
      3. Lydon-Rochelle (2001) N Engl J Med 345:3-8 [PubMed]
  3. Spontaneous Uterine Rupture
    1. Risk of rupture in labor is less than 0.0125%
    2. Multiparous woman with labor obstruction
      1. Fetal Malpresentation
      2. Cephalopelvic Disproportion
    3. Strong contractions result in rupture
    4. Presents as Acute Abdominal Pain and bleeding

V. Signs

  1. Classic Signs (unreliable)
    1. Sudden tearing uterine pain (13% of cases)
    2. Vaginal Bleeding (11%)
    3. Decreased uterine contractions
  2. Fetal Distress
    1. Sudden deterioration in Fetal Heart Rate pattern
      1. Most frequent finding
    2. Prolonged Late Decelerations and Fetal Bradycardia
    3. Most reliable sign of Uterine Rupture
  3. Maternal distress
    1. Hypotension
    2. Tachycardia

VI. Differential Diagnosis

VII. Diagnosis

  1. Intrauterine pressure catheter (unreliable sign)
    1. Readings may show no loss of tone despite rupture

VIII. Management

  1. General Resuscitation measures
    1. See Fetal Distress
    2. Intravenous FluidResuscitation
    3. Type and cross match for Blood Products
    4. Stop Oxytocin
    5. Maternal position change
    6. Subcutaneous Terbutaline to stop any contractions
  2. Emergent delivery (usually by Cesarean Section)
    1. Indication: Sudden and persistent Fetal Bradycardia
    2. Consider Hysterectomy after infant delivered
    3. Best outcomes if delivery in <17 minutes of diagnosis
  3. Uterine Rupture noted after delivery
    1. Emergent Surgery
      1. Repair of Uterine Rupture
      2. Consider Hysterectomy
    2. Close observation indications
      1. Small, asymptomatic rupture
      2. Rupture often occurs in lower uterine segment

IX. Complications

  1. Severe maternal Hemorrhage and Anemia
    1. Blood loss approaches 2 liters in 50% of cases
    2. Average Blood Transfusion requires 5 units pRBC
  2. Hysterectomy (Up to 23% of Uterine Rupture cases)
  3. Bladder rupture (0.05%)
  4. Maternal mortality (rare, except pre-hospital rupture)
  5. Neonatal mortality
    1. Rupture occurred at tertiary center: 2.6%
    2. Rupture occurred pre-hospital: 6%

X. Prevention

  1. Select VBAC patients very carefully

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Ontology: Uterine Rupture (C0042143)

Definition (MSH) A complete separation or tear in the wall of the UTERUS with or without expulsion of the FETUS. It may be due to injuries, multiple pregnancies, large fetus, previous scarring, or obstruction.
Concepts Pathologic Function (T046)
MSH D014597
SnomedCT 156231001, 34430009
LNC LA20046-1, LA18987-0
English Rupture, Uterine, Ruptures, Uterine, Uterine Rupture, Uterine Ruptures, UTERINE RUPTURE, Ruptured uterus, rupture of uterus (diagnosis), rupture of uterus, Rupture uterus, Uterus rupture, Uterus ruptured, Uterine Rupture [Disease/Finding], uterine rupture, rupture uterus, uterus rupture, rupture uterine, uterus ruptured, ruptured uterus, Ruptured uterus (disorder), Uterus--Rupture, Uterine rupture, Rupture of uterus (disorder), Rupture of uterus, rupture; uterus, uterus; rupture, Rupture of uterus, NOS, Uterine rupture, NOS
French RUPTURE UTERINE, Utérus rompu, Rupture utérine, Rupture de l'utérus
German UTERUSRUPTUR, Ruptur des Uterus, Uterus rupturiert, rupturierter Uterus, Uterusriss, Gebärmutterriss, Uterusriß, Gebärmutterriß, Uterusruptur, Gebärmutterruptur
Dutch geruptureerde uterus, ruptuur van uterus, uterus ruptuur, ruptuur; uterus, uterus; ruptuur, baarmoederruptuur, Ruptuur, uterus-, Uterusruptuur
Portuguese Útero com ruptura, RUTURA UTERINA, Ruptura do útero, Ruptura Uterina
Spanish Útero roto, UTERO RUPTURA, Rotura de útero, Rotura uterina, ruptura del útero (trastorno), ruptura del útero, ruptura uterina, Rotura Uterina
Japanese 子宮破裂, シキュウハレツ
Swedish Livmoderbristning
Finnish Kohdun repeämä
Russian MATKI RAZRYV, МАТКИ РАЗРЫВ
Czech Ruptura dělohy, ruptura dělohy, děložní ruptura, děloha - ruptura, ruptura děložní, ruptura uteri, uterus - ruptura
Polish Pęknięcie macicy
Hungarian Ruptura uteri
Norwegian Uterusruptur, Livmorruptur, Brist i livmoren
Italian Rottura dell'utero

Ontology: Rupture of gravid uterus (C0269885)

Concepts Injury or Poisoning (T037)
SnomedCT 15504009
English Rupture of gravid uterus (diagnosis), uterine rupture gravid, Obstetrical rupture of uterus, Rupture of gravid uterus (disorder), Rupture of gravid uterus, Obstetrical rupture of uterus, NOS
Spanish ruptura obstétrica del útero (trastorno), ruptura obstétrica del útero, ruptura uterina obstétrica

Ontology: Rupture of uterus during labor (C3812903)

Concepts Pathologic Function (T046)
SnomedCT 23431000119106
English Rupture of uterus during labour, Rupture of uterus during labor (disorder), Rupture of uterus during labor