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