BJOG: an International Journal of and Gynaecology DOI: 10.1111/j.1471-0528.2005.00725.x September 2005, Vol. 112, pp. 1221–1228

SYSTEMATIC REVIEW

WHO systematic review of maternal mortality and morbidity: the prevalence of

Objective To determine the prevalence of uterine rupture worldwide. Design Systematic review of all available data since 1990. Setting Community-based and facility-based reports from urban and rural studies worldwide. Sample Eighty-three reports of uterine rupture rates are included in the systematic review. Most are facility based using cross-sectional study designs. Methods Following a pre-defined protocol an extensive search was conducted of 10 electronic databases as well as other sources. Articles were evaluated according to specified inclusion criteria. Uterine rupture data were collected along with information on the quality of reporting including definitions and identification of cases. Data were entered into a database and tabulated using SAS software. Main outcome measures Prevalence of uterine rupture by country, period, study design, setting, participants, facility type and data source. Results Prevalence figures for uterine rupture were available for 86 groups of women. For unselected pregnant women, the prevalence of uterine rupture reported was considerably lower for community-based (median 0.053, range 0.016–0.30%) than for facility-based studies (0.31, 0.012–2.9%). The prevalence tended to be lower for countries defined by the United Nations as developed than the less or least developed countries. For women with previous , the prevalence of uterine rupture reported was in the region of 1%. Only one report gave a prevalence for women without previous caesarean section, from a developed country, and this was extremely low (0.006%). Conclusion In less and least developed countries, uterine rupture is more prevalent than in developed countries. In developed countries most uterine ruptures follow caesarean section. Future research on the prevalence of uterine rupture should differentiate between uterine rupture with and without previous caesarean section.

Background per 100,000).2 A systematic review found no randomised controlled trials comparing trial of labour with planned re- Uterine rupture is tearing of the uterine wall during peat caesarean section.3 or delivery. Rupture of a previously unscarred A major factor in uterine rupture is . is usually a catastrophic event resulting in death of Black African women have a high incidence of con- the baby, extensive damage to the uterus and sometimes tracted pelvis.4 Juveniles in a population with a high in- even from blood loss. The damage to the cidence of contracted pelvis were found to be at high uterus is sometimes beyond repair and a is risk of obstetric complications.5 Other risk factors for uter- required. ine rupture include multiparity and particularly grand Rupture of a previous caesarean section scar is fre- multiparity,6 the use of drugs to induce or aug- quently diagnosed on the basis of altered fetal heart rate ment labour, placenta percreta7 and rarely intrauterine ma- pattern, , maternal or unusual nipulations such as internal and breech pain during labour. In most cases which occur in a hospital extraction. setting, timely results in safe delivery of the In less and least developed countries, uterine rupture is baby and repair of the uterus. A recent review of uterine an important cause of maternal mortality, accounting for rupture limited to women with previous caesarean section as many as 9.3% of maternal deaths in one Indian study.8 in developed countries reported increased risk of uterine In the Second Report on Confidential Enquiries into Ma- rupture and perinatal death for women undertaking trial of ternal Deaths in South Africa 1999–2001, ruptured uterus labour compared with elective repeat caesarean section.1 caused 6.2% of deaths due to direct causes and 3.7% of all In a large, retrospective Canadian study, trial of labour deaths (1.9% due to rupture of an unscarred uterus and following previous caesarean section was associated with 1.8% due to rupture of a scarred uterus).9,10 Ruptured uter- increased risk of uterine rupture (by 0.56%), but fewer us was the only cause other than sepsis to have increased maternal deaths than elective caesarean section (1.6 vs 5.6 since the previous report, possibly due to the widespread

D RCOG 2005 BJOG: an International Journal of Obstetrics and Gynaecology www.blackwellpublishing.com/bjog 1222 SYSTEMATIC REVIEW

Fig. 1. Median and range of prevalence of uterine rupture in subgroups of studies.

use of in uncontrolled dosages for labour in- Methods duction (misoprostol was identified as the cause in several cases). There have been reports of uterine rupture when This study is a part of a bigger systematic review un- misoprostol was used in dosages above 25 Ag vaginally.11 –13 dertaken by the UNDP/UNFPA/WHO/World Bank Spe- No estimates exist to assess the magnitude of this po- cial Programme of Research, Development and Research tentially life-threatening condition. We conducted a system- Training in Reproduction (HRP), Department of atic review of available data on the prevalence of ruptured Reproductive Health and Research at the World Health Or- uterus with an emphasis on the contexts in which the pri- ganization (WHO) to obtain prevalence/incidence data on mary studies were conducted. The systematic review aimed maternal mortality and a range of morbidities including at establishing the global prevalence of this problem. uterine rupture. The methodology of the systematic review

Fig. 2. Population-based studies of the prevalence of uterine rupture in general pregnant populations, by the UN development classification of country. The horizontal bars represent 95% confidence intervals. D RCOG 2005 BJOG: an International Journal of Obstetrics and Gynaecology 112, pp. 1221–1228 SYSTEMATIC REVIEW 1223

Fig. 3. Facility-based studies of the prevalence of uterine rupture in general pregnant populations, by the UN development classification of country. The horizontal bars represent 95% confidence intervals. followed an a priori protocol and involved an extensive have been described elsewhere.22 In brief, we searched 10 search of all relevant published/unpublished data. The meth- electronic databases, WHO regional databases, internet and odology of the systematic review and the search strategy reference lists, contacted experts in the field and hand-searched

Rozenberg et al.66 (66) Stone et al.17 (17) Shipp et al.67 (67) Taylor et al.68 (68) Menihan69 (69) Ravasia et al.70 (70) Zelop et al.71 (71) Developed Countries Lyndon-Rochelle et al.72 (72) Neuhaus et al.73 (73) Sims et al.74 (74) Shipp et al.75 (75) Appleton et al.76 (76) Silberstein et al.77 (77) 78 Aboulfalah et al. (78) Less Developed Countries Beura and Panda79 (79)

0.00 1.00 2.00 3.00 4.00 5.00 6.00 7.00 Prevalence (%)

Fig. 4. Population- and facility-based studies of the prevalence of uterine rupture in women with previous caesarean sections, by the UN development classification of country. The horizontal bars represent 95% confidence intervals. D RCOG 2005 BJOG: an International Journal of Obstetrics and Gynaecology 112, pp. 1221–1228 1224 SYSTEMATIC REVIEW

Table 1. Facility-based studies of the prevalence of uterine dehiscence in specific clinical populations (identified in the column ‘participants’), by the UN development classification of country.

Study Country and period Study design Setting Participants Cases Sample Prevalence Facility Data source size (%) type

Developed Bouvier-Colle France 1991–1992 Cross sectional Unknown Obstetric patients 4 435 0.92 Intensive Case notes et al.80 being treated in care unit intensive care Miller et al.81 USA 1983–1994 Cross sectional Unknown Without previous 10 168,491 0.006 2j Case notes caesarean Rogers et al.82 USA 1992–1997 Cross sectional Unknown Pregnant women 3 372 0.81 Trauma Case notes with centres Magann et al.83 USA 1992–1997 Cohort Mixed Mostly black women, 1 522 0.19 3j Prospective with intrauterine data fetal demise collection

Less developed Ogunniyi et al.84 Nigeria 1981–1990 Cross sectional Unknown Women having 1 271 0.37 2j Case notes assisted delivery Ameh et al.85 Nigeria 1991–1995 Cross sectional Rural Women undergoing 3 217 1.4 3j Case notes ob/gyn surgery Udoma et al.86 Nigeria 1987–1996 Cross sectional Unknown Women with 129 672 19 3j Case notes obstructed labour Weibezahn et al.87 Venezuela 1991–1993 Cross sectional Unknown Hypertensive women 5 818 0.61 2j Case notes Quesnel Garcı´a Mexico 1985–1990 Cross sectional Unknown Obstetric hysterectomy 31 675 4.6 2j Case notes Benı´tez et al.88 Aboulfalah et al.89 Morocco 1994–1998 Cohort Unknown Previous caesarean 4 355 1.1 3j Prospective with macrosomic data infants collection Lawal90 Nigeria 1993–1997 Cross sectional Mixed Grand multiparae 12 228 5.3 3j Case notes (4 or more) Odukogbe et al.91 Nigeria 1987–1994 Cross sectional Mixed Grand multiparae 13 617 2.1 3j Case notes (5 or more) 6 1514 0.40 2j Maymon et al.92 Israel 1986–1994 Cross sectional Unknown Grand multiparae 12 12,296 0.10 3j Case notes (6 or more) Pereira et al.93 Mexico 1998–1999 Cohort Urban Adolescents 1 296 0.34 3j Case notes

Least developed Andriamady et al.94 Madagascar 1998 Cross sectional Mixed Deliveries with 9 4232 0.21 3j Case notes premature ROM Sepou et al.95 Central African Cross sectional Mixed Obstetric referrals 19 1011 1.9 Other Case notes Republic 1994–1995 from community hospital Zoundi96 Burkina Faso 1996 Cross sectional Mixed Grand multiparae 44 242 18 2j Case notes Gaym97 Ethiopia 1990–1999 Cohort Mixed Deliveries 234 945 25 3j Case notes complicated with obstructed labour

ROM ¼ ; ob/gyn ¼ obstetric/gynaecological. relevant articles in the WHO Library. Criteria for inclu- procedures used for diagnosis was part of the quality sion of studies in the review were as follows: inclusion of assessment. We did not assign quality scores to articles data relevant to pre-defined conditions, specified dates for but preferred to present available information on variables data collection period, including data from 1990 onwards, regarded as quality components (including reporting of def- sample size >200 and a clear description of methodology. initions, case-identification criteria and characteristics of A data extraction instrument was used to extract data setting and participants). from included studies. This instrument includes 48 items Nearly 65,000 reports were screened initially by titles distributed in five modules, three of which were relevant to and/or abstracts of which more than 4500 were retrieved this analysis. Modules were designed to collect information for full-text evaluation. More than 2500 of these were in- on (i) the general study-level characteristics such as design, cluded in the review. Data extracted were entered into a population, setting, (ii) outcomes and (iii) quality assessment specifically constructed database and tabulated using SAS of morbidity reports. Reporting of definitions and of the software. D RCOG 2005 BJOG: an International Journal of Obstetrics and Gynaecology 112, pp. 1221–1228 SYSTEMATIC REVIEW 1225

Because of considerable heterogeneity of results, no for- 0.006% for women without previous caesarean section from mal meta-analysis was performed. Studies were grouped a developed country and 25% for women with obstructed according to the clinical criteria for inclusion in the study labour in a least developed country. and the UN classification of the country (developed, less developed or least developed). Raw data from all the in- cluded studies were tabulated and reported, and summary Discussion statistics reported as median values and range of percent- ages. This allows readers to have information on the spread Uterine rupture is a serious obstetric complication, with of results, without studies with large sample sizes domi- high morbidity and mortality, particularly in less and least nating the summary statistics. developed countries. With ready access to obstetric care in- cluding caesarean section for obstructed labour, rupture of the unscarred uterus should be rare. The prevalence of Results uterine rupture in women with previous caesarean section is of considerable importance in calculating the long term A total of 83 reports of studies providing 86 data sets for risks associated with primary caesarean section. uterine rupture rates are included in the systematic review. For developed countries, the data available indicate that All except nine were facility based, mainly from second- the prevalence of uterine rupture for women with previ- ary and tertiary institutions and using cross-sectional study ous caesarean section is in the region of 1%, whereas for designs. Data sources were mainly case records in facility- women without previous caesarean section, based on one based studies whereas special database or registries were large report, it is extremely rare (<1 per 10,000). Overall, used in population-based studies. Only 24 studies reported the rates are below 1 per 1000. Efforts to reduce morbidity a definition for uterine rupture. and mortality from uterine rupture should be focussed on Figure 1 (and Table S1, available online as supplemen- reducing primary caesarean section rates and optimising tary material) shows the prevalence estimates for uterine care for women with previous caesarean section. rupture. We used medians and ranges to summarise results For less and least developed countries, uterine rupture is for different categories of data sets. Figures 2 and 3 (and a more prevalent and serious problem. The most important Tables S2 and S3, available online as supplementary ma- shortcoming of the data available is the lack of differenti- terial) show the characteristics of and the prevalence rates ation between uterine rupture with and without previous in population- and facility-based studies, respectively. With- caesarean section. Overall, most rates ranged between 0.1% in the tables, we categorised studies according to the devel- and 1%. Reports from Nigeria, Ghana, Ethiopia and Ban- opment status of the country in which they are conducted. gladesh indicated that about 75% of cases of uterine rupture Reports of women with previous caesarean section are pre- were associated with unscarred uterus.98 Maternal mortality sented in Fig. 4 (and Table S4 available online as supple- ranged between 1% and 13%, and be- mentary material). Groups with specific risk factors such tween 74% and 92%. Reduction of the prevalence of rup- as multiple pregnancy, specific health problems and women ture of unscarred uterus requires the following: reduction of undergoing assisted delivery and obstetric hysterectomy are unwanted , particularly for women of high presented separately in Table 1. parity; accessibility of obstetric services including caesar- For unselected pregnant women, the prevalence of uterine ean section for obstructed labour; where conventional rupture reported was considerably lower for population-based caesarean section facilities are not accessible, innovative (median 0.053, range 0.016–0.30%) than for facility-based solutions such as symphysiotomy99 or caesarean section studies (median 0.31, range 0.012–2.9%). The prevalence with local analgesia should be considered; and guidelines tended to be lower for countries defined by the United Na- to ensure that misoprostol for labour induction is used in tions as developed than the less or least developed countries. safe dosages. It is difficult to be sure of the extent to which women with previous caesarean section contributed to these numbers, and the proportion with previous caesarean section may Conclusions have varied considerably between populations studied. Only one report gave a prevalence for women without previous This systematic review summarises recent data available caesarean section, from a developed country, and this was on the prevalence of uterine rupture worldwide. In developed extremely low (0.006%, Table 1). countries, the main problem relates to uterine rupture fol- For women with a previous caesarean section, around lowing caesarean section. In less and least developed coun- 1% of women had a ruptured uterus. tries, uterine rupture is more prevalent and the consequences The reports of groups of women with specific clinical more serious. Innovative strategies are needed to address characteristics (Table 1) have not been aggregated, as the the problem. Future research on the prevalence of uterine characteristics varied between studies and aggregation rupture should differentiate between uterine rupture with would not be meaningful. The prevalence ranged between and without previous caesarean section. D RCOG 2005 BJOG: an International Journal of Obstetrics and Gynaecology 112, pp. 1221–1228 1226 SYSTEMATIC REVIEW

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