Uterine rupture is when the muscular wall of the

uterus The uterus (from Latin ''uterus'', plural ''uteri'') or womb () is the organ in the reproductive system of most female mammals, including humans that accommodates the embryonic and fetal development of one or more embryos until birth. Th ...

tears during

pregnancy Pregnancy is the time during which one or more offspring develops ( gestates) inside a woman's uterus (womb). A multiple pregnancy involves more than one offspring, such as with twins. Pregnancy usually occurs by sexual intercourse, but ...

childbirth Childbirth, also known as labour and delivery, is the ending of pregnancy where one or more babies exits the internal environment of the mother via vaginal delivery or caesarean section. In 2019, there were about 140.11 million births global ...

. Symptoms, while classically including increased pain, vaginal bleeding, or a change in contractions, are not always present. Disability or death of the mother or baby may result. Risk factors include vaginal birth after cesarean section (VBAC), other uterine scars,

obstructed labor Obstructed labour, also known as labour dystocia, is the baby not exiting the pelvis because it is physically block during childbirth although the uterus contracts normally. Complications for the baby include not getting enough oxygen which may ...

, induction of labor, trauma, and

cocaine Cocaine (from , from , ultimately from Quechua: ''kúka'') is a central nervous system (CNS) stimulant mainly used recreationally for its euphoric effects. It is primarily obtained from the leaves of two Coca species native to South Ame ...

use. While typically rupture occurs during labor it may occasionally happen earlier in pregnancy. Diagnosis may be suspected based on a rapid drop in the baby's heart rate during labor. Uterine dehiscence is a less severe condition in which there is only incomplete separation of the old scar. Treatment involves rapid surgery to control bleeding and delivery of the baby. A

hysterectomy Hysterectomy is the surgical removal of the uterus. It may also involve removal of the cervix, ovaries (oophorectomy), Fallopian tubes (salpingectomy), and other surrounding structures. Usually performed by a gynecologist, a hysterectomy may be ...

may be required to control the bleeding.

Blood transfusion Blood transfusion is the process of transferring blood products into a person's circulation intravenously. Transfusions are used for various medical conditions to replace lost components of the blood. Early transfusions used whole blood, but mo ...

s may be given to replace blood loss. Women who have had a prior rupture are generally recommended to have

C-section Caesarean section, also known as C-section or caesarean delivery, is the surgical procedure by which one or more babies are delivered through an incision in the mother's abdomen, often performed because vaginal delivery would put the baby or m ...

s in subsequent pregnancies. Rates of uterine rupture during vaginal birth following one previous

, done by the typical technique, are estimated at 0.9%. Rates are greater among those who have had multiple prior C-sections or an atypical type of C-section. In those who do have uterine scarring, the risk during a vaginal birth is about 1 per 12,000. Risk of death of the baby is about 6%. Those in the

developing world A developing country is a sovereign state with a lesser developed industrial base and a lower Human Development Index (HDI) relative to other countries. However, this definition is not universally agreed upon. There is also no clear agreem ...

appear to be affected more often and have worse outcomes.

Signs and symptoms

Symptoms of a rupture may be initially quite subtle. An old cesarean scar may undergo dehiscence; with further labor the woman may experience abdominal pain and vaginal bleeding, though these signs are difficult to distinguish from normal labor. Often a deterioration of the fetal heart rate is a leading sign, but the cardinal sign of uterine rupture is loss of fetal station on manual vaginal exam. Intra-abdominal bleeding can lead to

hypovolemic shock Hypovolemic shock is a form of shock caused by severe hypovolemia (insufficient blood volume or extracellular fluid in the body). It could be the result of severe dehydration through a variety of mechanisms or blood loss. Hypovolemic shock i ...

and death. Although the associated maternal mortality is now less than one percent, the fetal mortality rate is between two and six percent when rupture occurs in the hospital. In pregnancy uterine rupture may cause a viable

abdominal pregnancy An abdominal pregnancy is a rare type of ectopic pregnancy where the embryo or fetus is growing and developing outside the womb in the abdomen, but not in the Fallopian tube (usual location), ovary or broad ligament. Because tubal, ovarian a ...

. This is what accounts for most abdominal pregnancy births. *

Abdominal pain Abdominal pain, also known as a stomach ache, is a symptom associated with both non-serious and serious medical issues. Common causes of pain in the abdomen include gastroenteritis and irritable bowel syndrome. About 15% of people have a ...

and tenderness. The pain may not be severe; it may occur suddenly at the peak of a contraction. The woman may describe a feeling that something "gave way" or "ripped." *

Chest pain Chest pain is pain or discomfort in the chest, typically the front of the chest. It may be described as sharp, dull, pressure, heaviness or squeezing. Associated symptoms may include pain in the shoulder, arm, upper abdomen, or jaw, along with ...

, pain between the scapulae, or pain on inspiration—Pain occurs because of the irritation of blood below the woman's diaphragm *

Hypovolemic shock Hypovolemic shock is a form of shock caused by severe hypovolemia (insufficient blood volume or extracellular fluid in the body). It could be the result of severe dehydration through a variety of mechanisms or blood loss. Hypovolemic shock i ...

caused by bleeding, evidenced by falling blood pressure,

tachycardia Tachycardia, also called tachyarrhythmia, is a heart rate that exceeds the normal resting rate. In general, a resting heart rate over 100 beats per minute is accepted as tachycardia in adults. Heart rates above the resting rate may be normal (su ...

, tachypnea, pallor, cool and clammy skin, and anxiety. The fall in blood pressure is often a late sign of haemorrhage * Signs associated with fetal oxygenation, such as late deceleration, reduced variability, tachycardia, and

bradycardia Bradycardia (also sinus bradycardia) is a slow resting heart rate, commonly under 60 beats per minute (BPM) as determined by an electrocardiogram. It is considered to be a normal heart rate during sleep, in young and healthy or elderly adults, ...

* Absent fetal heart sounds with a large disruption of the placenta; absent fetal heart activity by ultrasound examination * Cessation of uterine contractions *

Palpation Palpation is the process of using one's hands to check the body, especially while perceiving/diagnosing a disease or illness. Usually performed by a health care practitioner, it is the process of feeling an object in or on the body to determin ...

of the fetus outside the uterus (usually occurs only with a large, complete rupture). The fetus is likely to be dead at this point. * Signs of an abdominal pregnancy * Post-term pregnancy

Risk factors

A uterine scar from a previous

cesarean section Caesarean section, also known as C-section or caesarean delivery, is the surgical procedure by which one or more babies are delivered through an incision in the mother's abdomen, often performed because vaginal delivery would put the baby or m ...

is the most common risk factor. (In one review, 52% had previous cesarean scars.) Other forms of uterine surgery that result in full-thickness incisions (such as a

myomectomy Myomectomy, sometimes also called fibroidectomy, refers to the surgical removal of uterine leiomyomas, also known as fibroids. In contrast to a hysterectomy, the uterus remains preserved and the woman retains her reproductive potential. Indic ...

), dysfunctional labor, labor augmentation by

oxytocin Oxytocin (Oxt or OT) is a peptide hormone and neuropeptide normally produced in the hypothalamus and released by the posterior pituitary. It plays a role in social bonding, reproduction, childbirth, and the period after childbirth. Oxyto ...

prostaglandins The prostaglandins (PG) are a group of physiologically active lipid compounds called eicosanoids having diverse hormone-like effects in animals. Prostaglandins have been found in almost every tissue in humans and other animals. They are deriv ...

, and high parity may also set the stage for uterine rupture. In 2006, an extremely rare case of uterine rupture in a first pregnancy with no risk factors was reported. Uterine rupture during pregnancy without a prior cesarean section is one of the major diagnostic criterion for vascular Ehlers-Danlos syndrome (vEDS).

Mechanism

In an incomplete rupture the

peritoneum The peritoneum is the serous membrane forming the lining of the abdominal cavity or coelom in amniotes and some invertebrates, such as annelids. It covers most of the intra-abdominal (or coelomic) organs, and is composed of a layer of mesothel ...

is still intact. With a complete rupture the contents of the uterus spill into the peritoneal cavity or the

broad ligament The broad ligament of the uterus is the wide fold of peritoneum that connects the sides of the uterus to the walls and floor of the pelvis. Structure Subdivisions Contents The contents of the broad ligament include the following: * Reprod ...

Treatment

Emergency exploratory

laparotomy A laparotomy is a surgical procedure involving a surgical incision through the abdominal wall to gain access into the abdominal cavity. It is also known as a celiotomy. Origins and history The first successful laparotomy was performed without an ...

with cesarean delivery accompanied by fluid and

blood transfusion Blood transfusion is the process of transferring blood products into a person's circulation intravenously. Transfusions are used for various medical conditions to replace lost components of the blood. Early transfusions used whole blood, but mo ...

are indicated for the management of uterine rupture. Depending on the nature of the rupture and the condition of the patient, the uterus may be either repaired or removed (cesarean hysterectomy). Delay in management places both mother and child at significant risk.

References

External links