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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
        • i.e., from multiple gestations of polyhydramnios
      • uterine scars
        • i.e., prior uterine procedures (cesarean section or myomectomy)
    • 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
        • typically bradycardia
      • diminished baseline uterine pressure
      • acute loss of uterine contractions
      • abdominal pain
        • note, epidural anesthesia rarely masks the signs of uterine rupture
  • 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
        • intravenous fluids
        • blood transfusions
  • Surgical
    • immediate cesarean delivery
      • indications
        • all patients
    • immediate laparotomy, surgical repair ­+ hysterectomy
      • indications
        • some patients may want to preserve uterus for future childbearing; this may be possible but depends on extent of tear, hemorrhage, and the patient’s overall condition
        • if uterine tear is extensive, or hemorrhage is uncontrolled, hysterectomy may be necessary
Complications
  • Fetal complications
    • hypoxia
    • death (50-75%)
  • Maternal complications
    • bladder injury
    • hysterectomy may be needed
    • death
 

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