Snapshot A 35-year-old G3P2 presents at 39 weeks gestation in labor. Her last 2 pregnancies were delivered by elective cesarean section and she had a repeat cesarean section scheduled in 2 days. She is admitted to the labor and delivery floor, where they prepped for a cesarean section. During this time, she screamed out in pain and noted that her contractions had stopped completely. The fetal monitor showed an abnormal fetal heartbeat. Upon physical exam, she has significant vaginal bleeding. She is rushed into the operating room. Introduction Overview uterine rupture is a rare cause of third trimester hemorrhage, a complication of pregnancy, and typically occurs during labor when it occurs it significantly increases the risk of fetal and maternal mortality this condition often requires emergency cesarean section for delivery of the fetus other causes of 3rd trimester hemorrhage placenta acreta placenta previa abruptio placentae Epidemiology incidence very rare risk factors previous cesarean section previously myomectomy congenital uterine anomaly placenta accrete, increta, previa, or abruption uterine distention (i.e., from multiple gestations or polyhydramnios) neglected labor uterine instrumentation oxytocin for induction of labor Pathogenesis weakened uterine wall uterine distention login to view 1 more bullet uterine scars login to view 1 more bullet uterine rupture often occurs during labor due to the significant level of force exerted during contractions use of oxytocin, which increase uterine contractions, can exacerbate this issue Prognosis worse when uterine tear is longitudinal Presentation Symptoms common symptoms uterine hemorrhage, often leading to shock fetal distress seen on the fetal monitor login to view 1 more bullet diminished baseline uterine pressure acute loss of uterine contractions abdominal pain login to view 1 more bullet Physical exam inspection vaginal bleeding hemodynamic instability abdominal tenderness loss of fetal station Studies Diagnostic approach this clinical diagnosis is time-sensitive and requires emergent management Serum labs complete blood count assess for need of transfusion Differential Uterine scar dehiscence key distinguishing factor scar dehiscence is not associated with disruption of visceral peritoneum, and the fetus, placenta, and umbilical cord remain in the uterine cavity may progress into uterine rupture Other causes of third trimester bleeding placenta acreta placenta previa abruptio placentae Treatment Lifestyle supportive care indications login to view 2 more bullets Surgical immediate cesarean delivery indications login to view 1 more bullet immediate laparotomy, surgical repair + hysterectomy indications login to view 2 more bullets Complications Fetal complications hypoxia death (50-75%) Maternal complications bladder injury hysterectomy may be needed death