223

Review 2010;12:223230 10.1576/toag.12.4.223.27613 http://onlinetog.org The Obstetrician & Gynaecologist

2010 Royal College of Obstetricians and Gynaecologists
ReviewUterine rupture: a revisit
Authors Madhavi Manoharan / Rekha Wuntakal / Katrina Erskine
Key content:
Uterine rupture is an uncommon complication of pregnancy associated with
potentially catastrophic consequences for both mother and baby.
Previous uterine surgery is the most common underlying cause; however,
multiparous women without uterine scarring are also at risk if labour becomes
obstructed.
A review of CEMACH reports has shown a consistent decrease in maternal
mortality secondary to uterine rupture despite increasing caesarean section rates.
The risk of uterine rupture during attempted vaginal birth after caesarean section
is widely recognised; however, there needs to be greater awareness of this
emergency occurring in multiparous women undergoing
induction/augmentation of labour.
Learning objectives:
To dene uterine rupture.
To examine the causes and risk factors for antepartum and intrapartum uterine
rupture.
To review the signs and symptoms.
To revise the management of uterine rupture.
To increase awareness of this very serious complication and to suggest how
clinicians can make a case-based individual assessment of uterine rupture risk.
Ethical issues:
Are those women at risk of uterine rupture adequately counselled about the
possibility and potential consequences?
Keywords CEMACH reports / maternal mortality / previous caesarean section / risk
factors / scarred uterus / vaginal birth after caesarean
Please cite this article as: Manoharan M, Wuntakal R, Erskine K. Uterine rupture: a revisit The Obstetrician & Gynaecologist 2010;12:223230.
Author details
Madhavi Manoharan MRCOG
Clinical Fellow, Fetal Medicine
Department of Obstetrics and Gynaecology,
Homerton University Hospital NHS
Foundation Trust, Homerton Row,
London E9 6SR, UK
Email: madhumano70@yahoo.co.uk
(corresponding author)
Rekha Wuntakal MRCOG
Specialist Registrar in Obstetrics
and Gynaecology
Department of Obstetrics and Gynaecology,
Homerton University Hospital NHS
Foundation Trust, London, UK
Katrina Erskine MD MRCP MRCOG
Consultant Gynaecologist
Consultant Obstetrician and Gynaecologist
Department of Obstetrics and Gynaecology,
Homerton University Hospital NHS
Foundation Trust, London, UK
TOG12_4_223-230_Manoharan.qxd 10/1/10 9:25 AM Page 223
224
Review 2010;12:223230 The Obstetrician & Gynaecologist
2010 Royal College of Obstetricians and Gynaecologists 224
Introduction
Uterine rupture is an uncommon but serious and
sometimes tragic occurrence. It can result in serious
complications for both mother and baby, such as
haemorrhagic shock, the need for peripartum
hysterectomy, hypoxic ischaemic encephalopathy,
permanent brain injury and even death.
It occurs most commonly in women with a scarred
uterus but this is not a prerequisite. Rupture of an
unscarred uterus is unexpected and diagnosis
may, therefore, be delayed. Outcomes in such cases
are possibly worse than after scar rupture during
vaginal birth after caesarean section (VBAC).
Denition
Symptomatic or complete uterine rupture is
dened as separation of the entire thickness of the
uterine wall, with extrusion of fetal parts and
intra-amniotic contents into the peritoneal cavity.
1
Uterine dehiscence is dened as a disruption of the
uterine muscle with intact serosa.
2
This is usually
asymptomatic. Diffentiation between the two
terminologies has not been consistent in many
studies. In a systematic review of uterine rupture
by Guise et al.
3
the terms symptomatic and
asymptomatic uterine rupture were used to
distinguish between uterine rupture and
dehiscence.
Incidence
Uterine rupture occurs at a frequency of 1% in
women with a previously scarred uterus, with
retrospective studies quoting rates of approximately
0.65%.
4
Rupture of an unscarred uterus is a rare
event, with the incidence being reported as 1/12
960 deliveries to 1/17 000 (Table 1).
59
In contrast, a study from Nepal,
10
a developing
country, quotes the incidence of uterine rupture
as 0.09 % (1/1100 live births). This was a
retrospective study spanning over 20 years
(272 245 live births) in a busy tertiary centre
with 16 000 deliveries a year and a caesarean
section rate of 11%. There were 251 uterine
ruptures (60% in an unscarred uterus, 29% in a
scarred uterus and 11% were traumatic
ruptures) with a mortality rate of 7.9%. Of the
deaths, 2% occurred before intervention
because of arrival in a moribund condition.
Most women were multiparous, in their third or
fourth pregnancy. The main concerns were poor
or no antenatal care and failure to recognise the
symptoms of uterine rupture. This wide
variation in incidence between developed and
developing countries is probably related to
issues with access to care and inadequate
intrapartum care.
Risk factors for uterine
rupture
See Box 1.
Antepartum
Rupture during pregnancy is rarely reported
from motor vehicle accidents.
11,12
It can also occur
in women with a previously scarred uterus,
particularly if this involves the upper segment,
where it classically occurs before labour and
before term.
13
Several cases of spontaneous
rupture of the uterus during pregnancy following
previous myomectomy have been reported.
14
No
difference in adverse pregnancy outcomes such as
uterine rupture was noted in a study comparing
laparoscopic myomectomy with open
myomectomy.
15
Larger series evaluation is needed
to confirm this finding.
The nulliparous uterus has been described as
being virtually immune to rupture,
16
especially
before the onset of contractions. Isolated case
reports of rupture in primigravid women have
been described in association with connective
tissue disease such as Ehlers-Danlos syndrome,
17
chronic steroid use
17
and cocaine misuse.
18
Mllerian anomalies of the uterus
19
and
abnormal placentation, especially placenta
percreta,
20
have been associated with ruptured
uterus and can occur from the second trimester.
More recently, several less common risk factors
such as previous difficult uterine curettage and
Population Incidence of
Study characteristics Denition Sample size uterine rupture
Miller et al. (1997)
5
Included only women Only uterine rupture 16 849 deliveries 1in 16 849 deliveries
retrospective review with unscarred uterus reported (0.006%)
Or et al. (2003)
6
10% of women had Only complete rupture 117685 singleton 0.035%
retrospective review previous scar reported deliveries
Landon et al. (2004)
7
All LSCS and 1LSCS Both rupture and dehiscence 17898 deliveries 0.7%
prospective study scars allowed reported separately
Landon et al. (2006)
8
All women had LSCS scar Only uterine rupture Single previous 0.7%
prospective study reported LSCS: 16 915 deliveries
Multiple LSCS: 0.9%
975 deliveries
Bashiri et al. (2008)
9
All had LSCS, multiple Only uterine dehiscence 7833 deliveries 1.03%
retrospective review LSCS included reported
LSCS lower segment caesarean section
Table 1
Incidence of uterine rupture
TOG12_4_223-230_Manoharan.qxd 10/1/10 9:25 AM Page 224
operative hysteroscopy (hysteroscopic
metroplasty) have been identified, especially
when they have been complicated by uterine
perforation.
21
Women should be counselled
regarding these risks and evaluation for residual
damage with hysterography may be useful.
Hysterography may demonstrate a defect or
fistula in the uterine wall, which may be
considered sufficient evidence to consider
delivery by planned caesarean section and, in
some cases, interval repair.
22
Intrapartum
The most common risk factors for intrapartum
rupture in an unscarred uterus are grand
multiparity; fetal malpresentation, such as
unrecognised brow, face and shoulder
presentation; cephalopelvic disproportion; and
oxytocin augmentation in multiparous
women. Less common risk factors are assisted
breech delivery, instrumental delivery
(injudicious use of Kielland forceps), tumours
obstructing the birth canal and pelvic
deformity.
6
A number of case reports have been published
detailing uterine rupture occurring in
association with the use of misoprostol as an
induction agent, in both primiparous and
multiparous women.
23
Caution should be
exercised with the use of misoprostol in
multiparous women and in women with a
previously scarred uterus, even in the context of
intrauterine fetal death or termination of
pregnancy.
Intrapartum rupture is a well recognised
complication of labour when a uterine scar
exists. The risk is undoubtedly related to the site
of the uterine scar and probably to the number
of previous uterine surgeries (Table 2).
7,8,2426
A retrospective study
27
found that women with
previous preterm caesarean section had the
same risk of uterine rupture as women with
previous term caesarean section, suggesting
that gestation per se at the time of caesarean
section does not influence subsequent rupture
risk. In this study 98% of women had a lower
tranverse incision.
Whether method of closure (single/double
layer) at the time of primary caesarean section
has a role to play in the risk of subsequent
rupture is not clear. The incidence of uterine
rupture in women who had single-layer closure
is one of the long-term outcomes being studied
in the CAESAR study. The findings of this study
are eagerly awaited. In the largest trial to date,
single-layer closure was strongly associated with
subsequent uterine rupture.
28
A case control study
29
has noted an increased
risk of uterine rupture during VBAC in women
who experienced postpartum fever following
their previous caesarean delivery (odds ratio
4.0, 95% CI 1.015.5).
Opinions are divided over the issue of rupture
risk in labour following previous
myomectomy. Recent retrospective analysis
225
Review 2010;12:223230 The Obstetrician & Gynaecologist
2010 Royal College of Obstetricians and Gynaecologists
Box 1
Causes of uterine rupture
During pregnancy
Previous classical caesarean section
Previous hysterotomy (very rare)
Previous myomectomy
Placenta accreta
Motor vehicle accidents
Mllerian anomalies of uterus
Hysteroscopic metroplasty
Difcult curettage for miscarriage
Rare causes described in primigravida women
EhlerDanlos syndrome
Chronic steroid use
Use of cocaine
During labour
Previous caesarean section
Previous myomectomy
Grand multiparity
Malpresentation: unrecognised brow, face and shoulder
presentation
Unrecognised cephalopelvic disproportion
Obstructed labour
Prostaglandin and oxytocin augmentation in women with
high parity and previous caesarean section
Use of high doses of misoprostol in parous women
Instrumental delivery (injudicious use of Kielland
forceps)
Assisted breech deliveries
Rare causes
Tumours obstructing the birth canal
Pelvic deformity
Post delivery
Precipitate labour
Manual removal of placenta
Uterine manipulation (intrauterine balloon)
Placenta accreta
Site and type of uterine scar and
number of previous uterine surgeries Incidence (%)
One previous lower segment scar
Landon et al. (2006)
8
0.7
SOGC (2005)
25
0.21.5
Two previous lower segment scars
Caughey et al. (1999)
24
3.7
Previous low vertical incision
Landon et al. (2004)
7
2
ACOG (2004)
26
17
SOGC (2005)
25
11.6
Unknown prior incision
Landon et al. (2004)
7
0.5
Previous classical/inverted T/J-shaped incision
Landon et al. (2004)
7
1.9
ACOG (2004)
26
49
Two or more previous caesarean births
Landon et al. (2006)
8
0.9
ACOG American Congress of Obstetricians and Gynecologists;
SOGC Society of Obstetricians and Gynaecologists of Canada
Table 2
Incidence of rupture in women with a
scarred uterus
TOG12_4_223-230_Manoharan.qxd 10/1/10 9:25 AM Page 225
shows that this group of women does have a
greater risk of scar rupture.
30
The general
opinion is that it is safe for women who have
had previous myomectomy to aim for vaginal
birth provided the endometrial cavity has not
been breached, but the evidence base is
sparse.
31
Induction of labour either with oxytocin or
prostaglandins is an independent risk factor for
uterine rupture in women with a scarred uterus
(Table 3).
3236
Use of misoprostol as an induction agent in
women with a previous scar is associated with an
increased risk of uterine rupture of 5.6%.
37
Unlike
prostaglandins or oxytocin, cervical ripening with
transcervical Foley catheters in women with
previous caesarean delivery is not associated with
increased risk of uterine rupture.
38
Certain demographic factors have been
identified as markers of higher rupture risk.
Retrospective reviews of women attempting
VBAC have shown that among the different
racial groups, black women are 40% less likely
to experience uterine rupture,
39
despite
increased rates of VBAC attempt and VBAC
failure. A possible explanation for this racial
disparity is that it could be due to ethnic
differences in pelvic connective tissue, as shown
by differences in rates of pelvic organ prolapse
40
and collagen composition.
41
Women aged 30 years have a greater risk of
uterine rupture than women aged 30 years,
42
although more recent studies have not shown
this association.
6
Short interpregnancy interval (6 months) has
been found to increase the risk of uterine
rupture two to three-fold in women attempting
trial of labour following caesarean delivery.
43
In a cohort study, Hammoud et al.
44
demonstrated that increasing gestational age of
at least 41 weeks at the time of trial of labour
was associated with a significantly higher rate of
uterine rupture.
Diagnosis
Signs and symptoms of uterine rupture are
varied. The woman can sometimes be
asymptomatic: this occurs when the fetal sac
herniates through an avascular scar and the
uterus retracts.
Prior to uterine rupture, the woman may
exhibit restlessness and constant pain in the
lower part of the uterus. She may become
tachycardic and have tetanic uterine
contractions with CTG abnormalities such as
sudden and persistent bradycardia consistent
with fetal compromise. The fetal parts may
become difficult to palpate. Bandls ring is
described as a late warning sign of impending
rupture. It is a pathological retraction ring
which demarcates the junction of the thinned
lower uterine segment and the thick retracted
upper uterine segment. Bandls ring usually
appears before uterine rupture when it occurs
secondary to obstructed labour.
Following rupture, the woman may describe a
sudden feeling of something giving way with
complete cessation of uterine activity.
On examination a loss of uterine contour may
be identified and two swellings may be
distinguished: one is the fetus lying in the
abdominal cavity and the other is the contracted
and retracted uterus. The fetal parts may then
be easily palpable. Vaginal bleeding is a rare
occurrence. Vaginal examination will reveal a
receding presenting part. Bleeding into the
abdominal cavity can be profuse and the woman
may present with shock and collapse. The
amount of bleeding depends on the location of
the scar relative to the vessels. Rarely, rupture is
recognised only after delivery of the baby and
should be a differential diagnosis for
postpartum collapse. If the rupture extends into
the broad ligament, the woman can present with
gradually increasing abdominal pain and a very
tender abdominal mass.
An abnormal cardiotocograph is present in
5587% of uterine ruptures,
3
with bradycardia
being the most common fetal heart rate
abnormality.
No particular pattern of uterine activity is
pathognomonic of uterine rupture,
45
although
one case report described the staircase sign as
characteristic of uterine rupture. This sign
classically describes a stepwise gradual
decrease in contraction amplitude followed by
the sudden onset of profound and prolonged
fetal bradycardia which can be demonstrated
by both external and internal pressure
transducers.
46
Uterine contraction pattern may
226
Review 2010;12:223230 The Obstetrician & Gynaecologist
2010 Royal College of Obstetricians and Gynaecologists
Study Incidence of rupture
Grossetti et al. (2007)
32
Not in labour 0.3%
In spontaneous labour 1.0%
Oxytocin-induced labour 1.4%
Prostaglandin cervical ripening 2.2%
Kwee et al. (2007)
33
PGE
2
alone or combined with oxytocin OR 6.8, 95% CI 3.214.3
augmentation
Oytocin augmentation OR 2.2, 95% CI 1.045
Locatelli et al. (2006)
34
Prostaglandin and oxytocin induction 0.3% (no difference)
Kayani and Alrevic (2005)
35
Induction of labour 2.4%, 95% CI 0.85.6
Yogev et al. (2004)
36
No difference noted
OR odds ratio; PGE
2
prostaglandin E
2
Table 3
Risk of uterine rupture and
induction/augmentation of
labour in women with a
previous low transverse scar
TOG12_4_223-230_Manoharan.qxd 10/1/10 9:25 AM Page 226
differ depending on the presence or absence of
a pre-existing scar or with the site and
direction of rupture. This explains the
contradictory reports in the literature. These
are anecdotal reports and the practicality of
routine use of intrauterine transducers is
questionable.
Management
Diagnosis of uterine rupture warrants
resuscitation and exploratory laparotomy. The
importance of immediate senior involvement
and teamwork cannot be overemphasised.
Repair of the uterus is possible in the majority
of women. In others, haemorrhage from
extension of the rupture into the broad
ligament or extensive damage to the uterus
requires hysterectomy.
Hysterectomy rates following uterine rupture
have been quoted as 3.4/10 000 women choosing
trial of labour following caesarean section.
3
The
risk of hysterectomy following uterine rupture
in women with previous caesarean section is
413%.
4751
No difference has been noted in the
rates of hysterectomy in pregnancies with
uterine rupture in women with scarred and
unscarred uterus.
1
Postoperative care is equally important as
uterine rupture is associated with a high risk of
bladder injury, massive transfusion because of
haemorrhage, admission to intensive care,
endometritis and longer hospital stay.
A review of the literature found that 5% of
symptomatic uterine ruptures were associated
with perinatal mortality and that 7142 elective
repeat caesarean sections were required to be
performed to prevent one rupture-related
perinatal death. The additional risk of perinatal
death from rupture of uterine scar was
1.4/10 000.
3
Maternal death due to uterine rupture following
trial of labour in a review of the literature
(142 075 women) has been quoted as 0.002%.
52
In the same study, neonatal acidosis was seen in
0.15% and perinatal death in 0.04% as a
consequence of uterine rupture. Significant
neonatal morbidity can occur when
18 minutes have elapsed between the onset of
prolonged deceleration and delivery.
53
Rupture occurring in an unscarred uterus is
associated with high rates of fetal loss and
higher rates of hysterectomy.
54
Rupture of a
previously scarred uterus is usually incomplete
and the tear is transverse, therefore, maternal
and fetal prognosis is much better and repair of
the uterus is often feasible.
55
Is it possible to predict
uterine rupture antenatally?
Several models for antepartum prediction of
risk of failed VBAC and thus of possible uterine
rupture have been formulated. Smith et al.
56
postulated a method similar to that used for
trisomy 21 screening from risk factors identified
in the antenatal period. They found that women
with high predicted caesarean section risk also
had a higher risk of uterine rupture (odds ratio
for a 5% increase in predicted risk 1.22,
95% CI 1.141.31).
A more user-friendly scoring system to quantify
the risk of symptomatic uterine rupture based
on factors identified at the first antenatal visit
has been reported.
57
Risk factors identified early
in pregnancy such as an inter-delivery interval
of 18 months, maternal age of 3039 years,
maternal age 40 years, two or more prior
caesareans and prior vaginal delivery are
assigned numerical scores ranging from 1 to
2. The rate of uterine rupture varies by the total
score: 1 0.26%; 0 0.25%; 1 1.11%;
2 2.43%; 3 3.70%; and 4 14.29%, P 0.001.
Measurement of the thickness of the lower
uterine segment by ultrasound in the third
trimester can be performed and a value of
3.5 mm has been found to carry a significant
negative predictive value (99.3%).
58
This was a
prospective observational study of 642 women
in France which found that the risk of uterine
rupture and dehiscence was directly related to
thinning of the lower segment at around
37 weeks. With a positive predictive value of
only 11.8%, however, further studies are
warranted. There is no evidence that
measurement of thickness of the lower segment
is superior to careful clinical practice in the
prevention of uterine rupture. Moreover, all the
ultrasound examinations and interpretation in
this study were carried out by a single
investigator. Hence questions regarding the
reproducibility and accuracy of ultrasonic
assessment of scar thickness in routine clinical
practice have been raised.
59
Is it possible to predict
uterine rupture during
labour?
Use of a simple tool such as the partograph in
the prediction of uterine rupture has been
reinforced by Khan and Rizvi.
60
They predicted
that the partographic zone 23 hours after the
alert line in women undergoing trial of labour
following caesarean section represents a time of
high risk of rupture. Women attempting VBAC
should, therefore, be closely observed for
progression of labour. Recognition of active
227
Review 2010;12:223230 The Obstetrician & Gynaecologist
2010 Royal College of Obstetricians and Gynaecologists
TOG12_4_223-230_Manoharan.qxd 10/1/10 9:25 AM Page 227
phase arrest disorders, in both multiparous
women and those aiming for VBAC, should
prompt senior obstetric involvement and a
careful riskbenefit analysis of continuing the
labour against immediate delivery by caesarean
section, or instrumental birth if appropriate.
Many would consider these situations as an
absolute contraindication to the use of oxytocin
augmentation.
Clinical judgement is very important in the
diagnosis of uterine rupture, as no scoring
system is totally reliable in predicting the risk.
Pregnancy following uterine
rupture
If the uterine rupture is confined to the lower
segment, the risk of rupture in a future
pregnancy is 6%; if the rupture involves the
upper segment, the risk is increased to 32%.
61
Women who have had a previous uterine
rupture are, therefore, advised to give birth by
repeat caesarean section prior to onset of labour.
Maternal mortality
Maternal death from uterine rupture is rare.
The rate is less than 1/100 000 cases in women
having a trial of labour in the developed world.
62
Causes of maternal death as detailed in the
Confidential Enquiry into Maternal and Child
Health (CEMACH) (19552005) are briefly
summarised in Table 4.
With an increasing caesarean section rate the
worry is that there will be an increase in the
incidence of uterine rupture in a scarred uterus.
Fortunately, this has not been the case in the UK
because of increased awareness and meticulous
monitoring. The present trend appears to be for
rupture, when it happens, to occur in an
unscarred uterus with the use of prostaglandins
and non-recognition of the warning signs and
symptoms. For example, the CEMACH report of
20002002
63
describes the case of a woman who
had induction of labour with prostaglandins
and went on to have a precipitous labour and
forceps delivery. Subsequently, she collapsed
and on laparotomy a uterine tear was noted. She
underwent hysterectomy but died after several
days in intensive care.
The CEMACH report of 20032005
64
reported one
death from uterine rupture. High doses of
prostaglandin E
2
were given to a parous woman
with previous precipitous labour. In this induced
labour she also laboured extremely quickly and a
fetal bradycardia was followed by rapid delivery.
Subsequently, she became haemodynamically
unstable because of massive intra-abdominal
haemorrhage. Laparotomy with hysterectomy was
performed but she died later.
Uterine rupture can be prevented if women are
assessed for risk factors antenatally and a plan
for delivery is documented in the notes.
Risk management
Despite the remote risk of uterine rupture in
grand multiparous women and those attempting
trial of labour following caesarean delivery and
the lesser subsequent risks of maternal or fetal
death from this catastrophe, the gravity of these
risks warrants detailed discussion.
In view of the increased risk of ruptured uterus in
women with previous caesarean delivery undergoing
induction of labour with prostaglandins or oxytocin,
the decision to proceed should only be made after
obtaining a fully informed consent. In addition, the
process of obtaining informed consent must be
secured without coercion. Many obstetric units in
the UK consider it prudent to avoid using
prostaglandins to induce and oxytocin to induce and
augment labour in women undergoing a trial of
VBAC. Delivery should be offered to women in a
hospital setting where timely operative delivery is
available; this includes availability of obstetric,
anaesthetic, paediatric and theatre staff.
25
Prior successful VBAC offers some protection
from uterine rupture, as shown in a large
prospective multicentre study.
65
Risk of uterine
rupture decreased after one successful VBAC and
did not change substantially with additional
prior VBAC. Women with one or more prior
successful VBAC attempts were found to have
228
Review 2010;12:223230 The Obstetrician & Gynaecologist
2010 Royal College of Obstetricians and Gynaecologists
Number of cases
Year of uterine rupture Causes of rupture and death
19551957 33 Obstructed labour/uterine
manipulation (5VBAC, 2MRP, 8
multiparas)
19641966 30 Obstructed labour/traumatic
delivery
19671969 19 9 traumatic, 8 spontaneous, 2
scar ruptures. Delay performing
laparotomy in suspected cases
19731975 11 Inappropriate use of oxytocin
19781981 4 All in women with scarred uterus,
with delay in diagnosis and
performing caesarean section
19911993 4 Genital tract trauma including
uterine rupture. Inadequate
supervision of junior doctors
19941996 5 Use of prostaglandin in women
with scarred uterus, failure to
identify intraperitoneal bleeding in
a known case of placenta accreta.
Two occurred in primigravidae: one
had a traumatic vaginal delivery
and the other presented in early
labour with hypovolaemic shock
19971999 1 Failure to identify uterine rupture
following ventouse delivery in a
woman undergoing trial of scar
20002002 1 Prostaglandin for IOLand
precipitous labour
20032005 1 Use of repeated doses of
prostaglandin E
2
in a parous
woman
IOLinduction of labour; MRPmanual removal of placenta;
VBAC vaginal birth after caesarean
Table 4
Summary of causes of maternal
death from uterine rupture
19552005
TOG12_4_223-230_Manoharan.qxd 10/1/10 9:25 AM Page 228
approximately half the risk of uterine rupture of
those attempting their first VBAC (0.40.5%
compared with 0.9%). Thus, successive labours
in women with previous caesarean delivery do
not place additive or multiplicative strain on the
uterine scar. This is important in counselling
women who are planning VBAC.
Clinical management decisions ultimately rest
with the woman; our role as clinicians is to
convey accurate information that will assist
women to make informed decisions. The final
decision should also take into consideration any
wish for future pregnancies.
Conclusion
Uterine rupture is a rare complication but it has
potentially catastrophic implications for both
mother and baby. It is associated with high
maternal and fetal mortality and morbidity. In
theory, an increase in uterine rupture is expected
with increasing caesarean section rates. This has
not been the case in the UK because of increased
vigilance, rigorous monitoring in labour and the
adoption of strict interventional criteria. In the
past, parous women with an intact uterus have
been overlooked and this is reflected in the
maternal deaths due to uterine rupture in the
last two CEMACH reports.
63,64
The aim should be to prevent this serious
complication from occurring. The authors believe
that this can only be achieved by increasing
awareness among doctors and midwives and
counselling women adequately. Both doctors and
midwives require adequate training to detect the
early warning signs and symptoms of uterine
rupture, as they are non-specic.
Equally important is the assessment of risk factors
for uterine rupture, both antenatally and in the
intrapartum period. The authors suggest that
this should be agged up in the antenatal notes,
including a plan for delivery and use of
prostaglandins for induction of labour.
Caution should be exercised during oxytocin
augmentation, especially in poorly progressing
multiparous women and those with a history of
prior caesarean section. Senior input is vital in
these decisions.
References
1 Or K, Sheiner E, Levy A, Katz M, Mazor M. Uterine rupture: differences
between a scarred and an unscarred uterus. Am J Obstet Gynecol
2004;191,425-9. doi:10.1016/j.ajog.2004.01.026
2 Hamar BD, Levine D, Katz NL, Lim KH. Expectant management of uterine
dehiscence in the second trimester of pregnancy. Obstet Gynecol
2003;102:113942.
3 Guise JM, McDonagh MS, Osterweil P, Nygren P, Chan BK, Helfand M.
Systematic review of the incidence and consequences of uterine rupture
in women with previous caesarean section. BMJ 2004;329:1925.
4 Wen SW, Rusen ID, Walker M, Liston R, Kramer MS, Basket T, et al.
Comparison of maternal mortality and morbidity between trial of labour
and elective caesarean section among women with previous caesarean
delivery. Am J Obstet Gynecol 2004;191:12639.
doi:10.1016/j.ajog.2004.03.022
5 Miller DA, Goodwin TM, Gherman RB, Paul RH. Intrapartum rupture
of the unscarred uterus. Obstet Gynecol 1997;89:6713.
doi:10.1016/S0029-7844(97)00073-2
6 Or K, Sheiner E, Levy A, Katz M, Mazor M. Uterine rupture: risk factors
and pregnancy outcome. Am J Obstet Gynecol 2003;189:10426.
doi:10.1067/S0002-9378(03)01052-4
7 Landon MB, Hauth JC, Leveno KJ, Spong CY, Leindecker S, Varner MW,
et al. Maternal and perinatal outcomes associated with a trial of labour
after prior caesarean delivery. N Engl J Med 2004;351:25819.
doi:10.1056/NEJMoa040405
8 Landon MB, Spong CY, Thom E, Hauth JC, Bloom SL, Varner MW, et al.
Risk of uterine rupture with a trial of labor in women with multiple and
single prior cesarean delivery. Obstet Gynecol 2006;108:1220.
9 Bashiri A, Burstein E, Rosen S, Smolin A, Sheiner E, Mazor M. Clinical
signicance of uterine scar dehiscence in women with previous
caesarean delivery: prevalence and independent risk factors. J Reprod
Med 2008;53:814.
10 Padhye SM. Rupture of the pregnant uterus: a 20 year review. Kathmandu
University Medical Journal 2005;3:2348.
11 Vaysse C, Mignot F, Benezech JP, Parant O. Traumatic uterine rupture: a rare
complication of motor vehicle accidents during pregnancy. A case report. J
Gynecol Obstet Biol Reprod (Paris) 2007;36:6114. Epub 2007Jun 14.
12 Weir LF, Pierce BT, Vazquez JO. Complete fetal transection after a motor
vehicle collision. Obstet Gynecol 2008;111:5302.
13 Halperin ME, Moore DC, WHannah WJ. Classical versus low-segment
transverse section: maternal complications and outcome of subsequent
pregnancies. Br J Obstet Gynaecol 1988;95:990996.
14 Parker WH, Lacampo K, Long T. Uterine rupture after laparoscopic
removal of a pedunculated myoma. J Minim Invasive Gynecol
2007;14:3624. doi:10.1016/j.jmig.2006.10.024
15 Soriano D, Dessolle L, Poncelet C, Benia JL, Madelenat P, Darai E.
Pregnancy outcome after laparoscopic and laparoconverted
myomectomy. Eur J Obstet Gynecol Reprod Biol 2003;108:1948.
16 ODriscoll K, Meagher D, Robson M. Active Management of Labour: The
Dublin Experience. 4th ed. London: Mosby; 2004.
17 Gelbmann CM, Kollinger M, Gmeinwieser J, Leser HG, Holstege A,
Scholmeric J. Spontaneous rupture of lever in a patient with Ehlers Danlos
disease type IV. Dig Dis Sci 1997;42:172430. doi:10.1023/A:1018869617076
18 Gonsoulin W, Borge D, Moise KJ Jr. Rupture of unscarred uterus in
primigravid woman in association with cocaine abuse. Am J Obstet
Gynecol 1990;163:5267.
19 Kore S, Pandole A, Akolekar R, Vaidya N, Ambiye VR. Rupture of the left horn of
bicornuate uterus at twenty weeks of gestation. J Postgrad Med2000;46:3940.
20 LeMaire WJ, Louisy C, Dalassendri K, Muschenheim F. Placenta percreta
with spontaneous rupture of an unscarred uterus in the second triemster.
Obstet Gynecol 2001;98:9279. doi:10.1016/S0029-7844(01)015800
21 Reed WC. Large uterine defect found at caesarean section. A case report.
J Reprod Med 2003;48:602.
22 Deaton JL, Maier D, Andreoli J Jr. Spontaneous uterine rupture during
pregnancy after treatment of Ashermans syndrome. Am J Obstet
Gynecol 1990;162:13523.
23 Khabbax AY, Usta IM, El-Hajj MI, Abu-Musa A, Seoud M, Nassar AH.
Rupture of an unscarred uterus with misoprostol induction: case report
and review of literature. J Maternal Fetal Med 2001;10:1415.
24 Caughey AB, Shipp TD, Repke JT, Zelop CM, Cohen A, Lieberman E. Rate
of uterine rupture during trial of labour in women with one or two prior
caesarean deliveries. Am J Obstet Gynecol 1999;181:8726.
doi:10.1016/S0002-9378(99)70317-0
25 Society of Obstetricians and Gynaecologists of Canada. SOGC clinical
practice guidelines. Guidelines for vaginal birth after previous caesarean
birth. Number 155. Int J Gynaecol Obstet 2005;89:31931.
26 American Congress of Obstetricians and Gynecologists. ACOG Practice
Bulletin. Clinical Management Guidelines for Obstetricians-
Gynaecologists. Number 54, July 2004.
27 Kwee A, Smink M, Van Der Laar R, Bruinse HW. Outcome of
subsequent delivery after a previous early preterm caesarean section.
J Matern Fetal Neonatal Med 2007;20:337.
doi:10.1080/14767050601036527
28 Bujold E, Bujold C, Hamilton EF, Harel F, Gauthier RJ. The impact of single
layer or double layer closure on uterine rupture. Am J Obstet Gynecol
2002;186:132630. doi:10.1067/mob.2002.122416
29 Shipp TD, Zelop C, Cohen A, Repke JT, Lieberman E. Post-caesarean
delivery fever and uterine rupture in a subsequent trial of labour. Obstet
Gynecol 2003;101:1369. doi:10.1016/S0029-7844(02)02319-0
30 Kelly BA, Bright P, Mackenzie IZ. Does the surgical approach used for
myomectomy inuence the morbicity in subsequent pregnancy? J
Obstet Gynecol 2008;28:7781. doi:10.1080/01443610701811738
31 Landi S, Zaccoletti R, Ferrari L, Minelli L. Laparoscopic myomectomy:
technique, complications and ultrasound scan evaluations. J Am
Assoc Gynecol Laparosc 2001;8:23140.
doi:10.1016/S1074-3804(05)60583-X
32 Grossetti E, Vardon D, Creveuil C, Herlicoviez M, Dreyfus M. Rupture of the
scarred uterus. Acta Obstet Gynecol Scand 2007;86:5728.
doi:10.1080/00016340701257141
33 Kwee A, Bots ML, Visser GH, Bruinse HW. Obstetric management and
outcome of pregnancy in women with a history of caesarean section in
the Netherlands. Eur J Obstet Gynecol Reprod Biol 2007;132:1716.
doi:10.1016/j.ejogrb.2006.07.017
34 Locatelli A, Ghidini A, Ciriello E, Incerti M, Bonardi C, Regalia AL. Induction
of labour: comparison of a cohort with uterine scar from previous
caesarean section vs a cohort with intact uterus. J Matern Fetal Neonatal
Med 2006;19:4715. doi:10.1080/14767050600746654
229
Review 2010;12:223230 The Obstetrician & Gynaecologist
2010 Royal College of Obstetricians and Gynaecologists
TOG12_4_223-230_Manoharan.qxd 10/1/10 9:25 AM Page 229
35 Kayani S, Alrevic Z. Uterine rupture after induction of labour in women
with previous caesarean section. BJOG2005;112:4515.
36 Yogev Y, Ben-Haroush A, Lahav E, Horowitz E, Hod M, Kaplan B. Induction
of labour with prostaglandin E2in women with previous caesarean
section and unfavourable cervix. Eur J Obstet Gynecol Reprod Biol
2004;116:173-6. doi:10.1016/j.ejogrb.2004.02.019
37 Plaut MM, SchwartzML, Lubarsky SL. Uterine rupture associated with the use
of misoprostol in the gravid patient with a previous caesarean section. Am J
Obstet Gyncecol 1999;180:153542. doi:10.1016/S0002-9378(99)70049-9
38 Bujold E, Blackwell SC, Gauthier RJ. Cervical ripening with transcervical foley
catheter and the risk of uterine rupture. Obstet Gynecol 2004;103:1823.
39 Cahill AG, Stamilio DM, Odibo AO, Peipert J, Stevens E, Macones GA.
Racial disparity in the success and complications of vaginal birth after
caesarean. Obstet Gynecol 2008;111:6548.
40 Howard D, Delancey JO, Tunn R, Ashton-Miller JA. Racial differences in
the structure and function of the stress urinary continence mechanism.
Obstet Gynecol 2000;95:7137. doi:10.1016/S0029-7844(00)00786-9
41 Leppert PC, Catherino WH, Segars JH. A new hypothesis about the
origin of uterine fibroids based on gene expression profiling with
microarrays. Am J Obstet Gynecol 2006;195:41520.
doi:10.1016/j.ajog.2005.12.059
42 Shipp TD, Zelop C, Repke JT, Cohen A, Caughey AB, Lieberman E.
The association of maternal age and symptomatic uterine rupture
during a trial of labor after prior cesarean delivery. Obstet Gynecol
2002;99:5858. doi:10.1016/S0029-7844(01)01792-6
43 Stamilio DM, DeFranco E, Pare E, Odibo AO, Peiper JF, Allsworth JE, et al.
Short interpregnancy interval: risk of uterine rupture and complications of
vaginal birth after caesarean delivery. Obstet Gynecol 2007;110:107582.
44 Hammoud A, Hendler I, Gauthier RJ, Berman S, Sansregret A, Bujold EJ. The
effect of gestational age on trial of labour after caesarean section. Matern
Fetal Neonatal Med 2004;15:2026. doi:10.1080/14767050410001668329
45 Phelan JP, Korst LM, Settles DK. Uterine activity patterns in uterine
rupture: a case control study. Obstet Gynecol 1998;92:3947.
doi:10.1016/S0029-7844(98)00232-4
46 Matsuo K, Scanlon JT, Atlas RO, Kopelman JN. Staircase sign: a newly
described uterine contraction pattern seen in rupture of unscarred gravid
uterus. J Obstet Gynecol Res 2008;34:1004.
47 McMahon MJ, Luther ER, Bowes WA, Olsham AF. Comparison of a trial of
labour with an elective caesarean section. N Engl J Med
1996;335:68995. doi:10.1056/NEJM199609053351001
48 Duff P, Southmayd K, Read JA. Outcome of trial of labour in patients with
a single previous low transverse caesarean section for dystocia. Obstet
Gynecol 1988;71:3804.
49 Flamm BL, Lim OW, Jones C, Fallon D, Newman LA, Mantis JK. Vaginal
birth after caesarean section: results of a multicentre study. Am J Obstet
Gynecol 1988;158:107984.
50 Flamm BL, Goings JR, Liu Y, Wolde-Tsadik G. Elective repeat caesarean
delivery versus trial of labour: a prospective multicentre study. Obstet
Gynecol 1994;83:92732. doi:10.1056/NEJM199609053351001
51 Flamm BL, Newman LA, Thomas SJ, Fallon D, Yoshida MM. Vaginal birth after
caesarean delivery: results of a 5year multicentre collaborative study. Obstet
Gynecol 1990;76:7504. doi:10.1097/00006250-199011000-00004
52 Chauhan SP, Martin JN Jr, Henrichs CE, Morrison JC, Magann EF. Maternal
and perinatal complications with uterine rupture in 142,075patients who
attempted vaginal birth after caesarean delivery: a review of the literature. Am J
Obstet Gynecol 2003;189:408-17. doi:10.1067/S0002-9378(03)00675-6
53 Leung AS, Leung EK, Paul RH. Uterine rupture after previous caesarean delivery:
maternal and fetal consequences. Am J Obstet Gynecol 1993;169:94550.
54 Lao TT, Leung BF. Rupture of the gravid uterus. Eur J Obstet Gynecol
Reprod Biol 1987;25:17580. doi:10.1016/0028-2243(87)90096-7
55 Golan A, Sandbank O, Rubin A. Rupture of the pregnant uterus. Obstet
Gynecol 1980;56:54954.
56 Smith GC, White IR, Pell JP, Dobbie R. Predicting cesarean section and uterine
rupture among women attempting vaginal birth after prior cesarean section.
PLoS Med 2005;2:e252. Epub 2005Sep 13. doi:10.1371/journal.pmed.0020252
57 Shipp TD, Zelop C, Lieberman E. Assessment of the rate of uterine rupture
at the rst prenatal visit: a preliminary evaluation. J Maternal Fetal
Neonatal Med 2008;21:12933. doi:10.1080/14767050801891606
58 Rozenberg P, Gofnet F, Phillippe HJ, Nisand I. Echographic
measurement of the inferior uterine segment for assessing the risk of
uterine rupture. J Gynecol Obstet Biol Reprod (Paris) 1997;26:5139.
59 Turner M. Uterine rupture. Best Pract Res Clin Obstet Gynecol
2002;16:6979. doi:10.1053/beog.2001.0256
60 Khan KS, Rizvi A. The partograph in the management of labour following
caesarean section. Int J Gynecol Obstet 1995;50:1517.
doi:10.1016/0020-7292(95)02431-B
61 Ritchie EH. Pregnancy after rupture of the pregnant uterus. A report of 36
pregnancies and a study of cases reported since 1932. J Obstet Gynecol
Br Common 1971;78:6428.
62 Wen SW, Rusen ID, Walker M, Liston R, Kramer MS, BaskettT, et al.
Comparison of maternal mortality and morbidity between trial of labour and
elective caesarean section among women with previous caesarean delivery.
Am J Obstet Gynecol 2004;191:12639. doi:10.1016/j.ajog.2004.03.022
63 Lewis G; CEMACH. Why Mothers Die 20002002. The Sixth Report of
the Condential Enquiries into Maternal Deaths in the United Kingdom.
London: RCOG Press; 2004.
64 Lewis G, editor. The Condential Enquiry into Maternal and Child Health.
Saving Mothers Lives: Reviewing Maternal Deaths to Make Motherhood
Safer 20032005. The Seventh Report on Condential Enquiries into
Maternal Deaths in the United Kingdom. London: CEMACH; 2007.
65 Mercer BM, Gilbert S. Labour outcomes with increasing number of prior
vaginal births after caesarean delivery. Obstet Gynecol 2008;111:28591.
230
Review 2010;12:223230 The Obstetrician & Gynaecologist
2010 Royal College of Obstetricians and Gynaecologists
TOG12_4_223-230_Manoharan.qxd 10/1/10 9:25 AM Page 230