12/21/2020 Uterine Rupture 1 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) 2 1 12/21/2020 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. 3 Who Is At High Risk for Complications? • Previous classical or T-incision • Prior uterine rupture • Extensive transfundal surgery • ACOG, 2017 4 2 12/21/2020 Uterine Rupture •Can also occur in a primigravida with no history of a uterine scar 5 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 6 3 12/21/2020 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 7 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 8 4 12/21/2020 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 9 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) 10 5 12/21/2020 Other Clinical Findings • Decrease or cessation of uterine contractions • Not always…. • Loss of presenting part or ascent of presenting part • Not always…. • Vaginal bleeding 11 •Vaginal or intraabdominal bleeding is associated with •anxiety •restlessness •weakness •dizziness •gross hematuria •shoulder pain •shock •(signs often attributed to abruption) 12 6 12/21/2020 • 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 13 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 14 7 12/21/2020 In this case, contractions ceased 15 IUPC in place. In this case, there was elevated resting tone; no cessation of contractions 16 8 12/21/2020 IUPC; tachysystole and elevated resting tone 17 FHR and Uterine Rupture •Three examples… 18 9 12/21/2020 •Case One 19 39 weeks gestation previous cesarean for breech admitted in labor 20 10 12/21/2020 Left side; pitocin off, bloody show, FSE applied 5 to 6 cm 21 Prepared for cesarean 22 11 12/21/2020 Case 2 • TOLAC • 39 1/2 weeks gestation • Previous cesarean for breech • low-transverse uterine incision • Induction 23 bloody show; 4 to 5 cm; IUPC in place 24 12 12/21/2020 Complete and pushing… 25 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 26 13 12/21/2020 Note • In Ouzounian et al (2015) study, fetal tachycardia was associated with poor maternal outcomes • Abruption • Maternal blood loss • Transfusion • Chorioamnionitis 27 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 28 14 12/21/2020 station changes from a +3 on admission to a 0 to +1 29 Patient c/o sharp abdominal pain like a muscle was torn; taken to OR 30 15 12/21/2020 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. 31 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. 32 16 12/21/2020 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 33 17.