Uterine Rupture
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Direct answer
Uterine rupture is a full or partial tear of the uterine wall during pregnancy or labour, most often in a scarred uterus after previous caesarean, and it threatens both fetal and maternal life. Sudden abdominal pain, cessation of contractions and fetal bradycardia are the classic signs. Emergency laparotomy with delivery, followed by either uterine repair or hysterectomy, is the standard response.
What you must remember
- Complete rupture: full-thickness tear with the peritoneum breached, while incomplete rupture or dehiscence leaves the serosa intact.
- Scarred uterus: previous caesarean, especially a classical incision, myomectomy or other uterine surgery; risk with a trial of labour after caesarean is low but real, under about 1 per cent.
- Unscarred uterus: obstructed labour, oxytocin hyperstimulation, abdominal trauma and grand multiparity.
- Classic signs: sudden severe pain, cessation of contractions, fetal bradycardia or distress, haematuria and loss of the presenting part.
- Pathological retraction ring: Bandl's ring in obstructed labour warns of impending rupture.
- Prostaglandins: dinoprostone and misoprostol are avoided for induction in a scarred uterus.
- Repair versus hysterectomy: repair is considered when tissue is viable and fertility is wanted; hysterectomy when damage is extensive or bleeding uncontrolled.
A pathway from suspicion to repair or hysterectomy
A 30-year-old with one previous caesarean is in labour and her contractions suddenly stop with a fetal heart rate of 80. Rupture is the diagnosis to exclude first, and each step below has to be taken quickly because both mother and baby are at risk.
- Recognise rupture: sudden pain with cessation of contractions and fetal distress in a woman with a scar or obstructed labour is rupture until proved otherwise.
- Resuscitate: place two large-bore cannulae, send crossmatched blood, give fluids and transfuse early, with a urinary catheter in place.
- Operate urgently: perform emergency laparotomy and deliver the baby, with the neonatal team present.
- Decide the repair: repair if tissue is viable and fertility is wanted; hysterectomy for extensive damage or uncontrolled bleeding.
- Examine other organs: check the bladder, bowel and broad ligament for injury during the procedure.
- Plan the future: counsel on any further pregnancy, which may be inadvisable after rupture, and review the decision about trial of labour.
Where the exam tries to catch you
Uterine rupture questions test recognition of the signs, the correct surgical choice and the rule that prostaglandins are avoided in a scar.
- Trap: "Uterine rupture occurs only in women attempting vaginal birth after caesarean." Correct: an unscarred uterus can rupture in obstructed labour, with oxytocin excess or trauma.
- Trap: "Always repair a ruptured uterus to preserve fertility." Correct: repair depends on tissue viability, bleeding and the woman's wishes, and hysterectomy is needed for extensive damage.
- Trap: "Use misoprostol to induce labour in a scarred uterus." Correct: prostaglandins are avoided because they raise the risk of rupture in a scarred uterus.
Frequently asked questions
What are the classic signs of uterine rupture in labour?
Classic signs of uterine rupture include sudden severe abdominal pain, cessation of uterine contractions, fetal bradycardia or distress, and loss of the presenting part. Haematuria and shock may also appear, and rupture can be silent in some women.
Which uterine scar carries the highest risk of rupture in labour?
A classical uterine incision carries the highest risk of rupture in a subsequent labour, higher than a low transverse scar. A trial of labour is therefore generally avoided after classical caesarean, and this decision should be made before labour.
When is hysterectomy preferred to repair in uterine rupture?
Hysterectomy is preferred over repair when the uterine damage is extensive, the tissue is not viable, bleeding cannot be controlled, or the woman does not wish to preserve fertility. The decision is made intraoperatively by the surgeon with the anaesthetic team.
Why are prostaglandins avoided in women with a previous caesarean?
Prostaglandins are avoided in a scarred uterus because they increase the risk of uterine rupture during induction of labour. Dinoprostone and misoprostol carry this warning, and mechanical ripening is generally considered first.