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Uterine Rupture

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Definition of Uterine Rupture

• Complete nonsurgical disruption of all uterine layers • Severity of hemorrhage and maternal-fetal morbidity depends on extent of rupture • Uterine dehiscence • incomplete or occult uterine scar separation • Uterine serosa remains intact • Usually no adverse outcomes associated with this • Francois & Foley, (2017, pp. 416)

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Incidence in Women With Prior Cesareans • The risk of rupture is dependent on the type and location of the previous uterine incision • Low transverse incision • 0.5 to 0.9% • ACOG, 2017 • Low vertical incision • Absence of consistent evidence of increased risk • Prior classical or T or J shaped incision • 2 to 6% • Francois & Foley (2017, p. 416) citing a 2004 study by Landon et al.

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Who Is At High Risk for Complications?

• Previous classical or T-incision • Prior uterine rupture • Extensive transfundal surgery • ACOG, 2017

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Uterine Rupture •Can also occur in a primigravida with no history of a uterine scar

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For the Test………….Be Prepared…

• Continuous fetal heart rate monitoring during TOLAC is recommended • No data to suggest that internal devices (IUPC and FSE) are superior to external monitoring • There is evidence that the use of intrauterine pressure catheters DOES NOT HELP in the diagnosis of uterine rupture • ACOG, 2017

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For the Test…Be Prepared…. • Most common sign of uterine rupture is fetal heart rate tracing abnormalities • Associated with up to 70% of cases of uterine rupture • (ACOG, 2017) • Acute signs of rupture are variable and may include: • Fetal bradycardia • Increased uterine contractions • Vaginal bleeding • Loss of fetal station • New onset intense uterine pain • ACOG, 2017, p. e223

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Fetal Heart Rate

• “Fetal bradycardia with or without preceding variable or late decelerations is the most common clinical manifestation of symptomatic uterine rupture and occurs in 33% to 70% of cases.” • Francois & Foley, 2017, p. 416

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Fetal Heart Rate

• 73% of laboring patients exhibited some type of FHR abnormality • FHR abnormalities varied • One third of cases exhibited a prolonged deceleration or bradycardia • Ouzounian et al (2015). • Note: this study predated NICHD FHR classifications

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Fetal Heart Rate

• In 36 cases of clinically overt uterine rupture • Variable decelerations in 30.5% of patients • Prolonged fetal bradycardia in 19.4% of patients • (Note prolonged fetal bradycardia is not an NICHD term)

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Other Clinical Findings

• Decrease or cessation of uterine contractions • Not always…. • Loss of presenting part or ascent of presenting part • Not always…. • Vaginal bleeding

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•Vaginal or intraabdominal bleeding is associated with •anxiety •restlessness •weakness •dizziness •gross hematuria •shoulder pain •shock •(signs often attributed to abruption)

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• Abdominal pain out of proportion than would normally be expected during labor (especially pain between contractions) • Uterine or abdominal pain most commonly occurs in the area of the previous incision, but it may range from mild to “tearing” in nature • Maternal hypotension or shock

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Contraction Characteristics

• Uterine rupture may be preceded or accompanied by several types of changes in uterine contractility • Tachysystole, or • (in the article authors use the term hyperstimulation) • Reduced number of contractions, or • Increased or reduced baseline uterine tonus • Vlemminx, de Lau, & Oei, 2016

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In this case, contractions ceased

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IUPC in place. In this case, there was elevated resting tone; no cessation of contractions

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IUPC; tachysystole and elevated resting tone

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FHR and Uterine Rupture •Three examples…

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•Case One

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39 weeks gestation previous cesarean for breech admitted in labor

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Left side; pitocin off, bloody show, FSE applied

5 to 6 cm

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Prepared for cesarean

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Case 2 • TOLAC • 39 1/2 weeks gestation • Previous cesarean for breech • low-transverse uterine incision • Induction

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bloody show; 4 to 5 cm; IUPC in place

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Complete and pushing…

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To OR During cesarean, uterine rupture was found… note in this case, the IUPC did not help identify the rupture, and contractions did not cease

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Note

• In Ouzounian et al (2015) study, fetal tachycardia was associated with poor maternal outcomes • Abruption • Maternal blood loss • Transfusion • Chorioamnionitis

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Final Example

• Gravida 2, para 1 at 39 weeks • Admitted in labor • Complete dilation and +3 station • History of previous cesarean for breech • low-transverse uterine incision

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station changes from a +3 on admission to a 0 to +1

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Patient c/o sharp abdominal pain like a muscle was torn; taken to OR

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References • American College of Obstetricians and Gynecologists (2017). Vaginal birth after previous cesarean delivery. ACOG Practice Bulletin Number 184, November. Washington, DC: ACOG. • Francois, K. E., & Foley, M. R. (2017). Antepartum and postpartum hemorrhage, Chapter 18 in Steven G. Gabbe, Jennifer R. Niebyl, & Joe Leigh Simpson’s (eds) Obstetrics Normal and Problem Pregnancies, 7th ed. Philadelphia: Elsevier. • Holmgren, C., Scott, J. R., Porter, F., Esplin, M. S., & Bardsley, T. (2012). Uterine rupture with attempted vaginal birth after cesarean delivery: Decision-to- delivery time and neonatal outcome. Obstetrics & Gynecology, 119(4), 725-731.

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References

• Ouzounian, J. G, Quist-Nelson, J., Miller, D. A., & Korst, L.M. (2015). Maternal and fetal signs and symptoms associated with uterine rupture in women with prior cesarean delivery. The Journal of Maternal-Fetal & Neonatal Medicine, 28:11, 1270-1277. • Phelan, J. P., Korst, L. M., & Settles, D. K. (1998). Uterine activity patterns in uterine rupture: A case-control study. Obstetrics & Gynecology, 92(3), 394-397. • Pryor, E. C., Mertz, H. L., Beaver, B. W., et al (2007). Intrapartum predictors of uterine rupture. American Journal of Perinatology, 24(5), 317-321.

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References • Ridgeway, J. J., Weyrich, D. L., & Benedetti, T. J. (2004). Fetal heart rate changes associated with uterine rupture. American Journal of Obstetrics Gynecology, 103(3), 506-512. • Vlemminx, M. W. C., de Lau, H., & Oei, S. G. (2016). Tocogram characteristics of uterine rupture: A systematic review. Arch Gynecol Obstet, published online: 08 October 2016. DOI 10.1007/s00404-016-4214-7

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