Uterine rupture is a partial or complete tear of the uterine wall that occurs in most cases during childbirth or labor induced. With an incidence of approximately 1 in 1500 births, uterine rupture is a relatively rare, although very life-threatening, complication because of its high lethality rate.
What is uterine rupture?
Uterine rupture refers to a tear or rupture of the uterine wall mostly during the birth process. In principle, a distinction is made between a complete rupture involving the serosa (smooth lining of the peritoneal cavity) and dehiscence (separation) of all layers and an incomplete or extraperitoneal rupture, which involves only the myometrium (layer of the uterine wall composed of smooth muscle) if the serosa remains intact and does not lead to bleeding into the peritoneal cavity. As a rule, the rupture is localized at the corpus-cervix junction (isthmus uteri), more rarely at a site with a weak wall (“silent subuterine rupture”). The main symptoms of uterine rupture are abrupt abdominal pain with marked tenderness and sudden cessation of labor. As a result of blood loss, signs of shock (hypotension, tachycardia, pale and cold sweaty skin, worsening clouding of consciousness) appear promptly. In addition, after uterine rupture, no movements of the unborn child are detectable, and the heart sounds of the same are bradycardic (slowed) or nonexistent.
Causes
In principle, uterine rupture is induced by a discrepancy between the load-bearing capacity of the uterine wall and the actual load present. Depending on the underlying cause, a distinction is made between different forms of rupture. For example, scar rupture can occur as a result of previous damage to the uterus such as enucleation of the uterine fibroid (myoma enucleation), placental abruption, metroplasty, or section. Previous surgical procedures on the uterus are the most common cause of rupture. A narrow pelvis as well as fetal positional anomalies (transverse position, mentoposterior facial position of the child, arm prolapse, macrosomia) may cause hyperextension rupture. In contrast, spontaneous rupture may be caused by endometriosis or hemangioma. Blunt or sharp abdominal trauma (eg, resulting from forceps extraction or a traffic accident) can also lead to violent or traumatic uterine rupture, respectively.
Symptoms, complaints, and signs
Uterine rupture announces itself with warning signs. Affected women express extreme concern during pregnancy. They complain of severe pain at the uterus. In particular, the so-called labor storm indicates complications during childbirth. The frequency of contractions then increases constantly in the run-up to the birth. If a rupture of the uterus occurs, pain is immediately noticeable. These spread beyond the uterus to the entire abdomen. Expectant mothers often describe the feeling of tearing from the inside. As a result of the injury, vaginal bleeding occurs, which in turn can cause shock. Blood pressure races to the basement and heart rate increases. Cold sweat appears on the forehead and the skin takes on a strange pale color in seconds. In this situation, labor stops. Women lose control of their birth and cannot feel, for example, the movements of their baby. Uterine rupture affects about one in 1,500 expectant mothers. Doctors distinguish between a complete and incomplete rupture. If it occurs, blood is still present in the mother’s urine a short time after birth. In rare cases, however, a uterine rupture can initially progress without any obvious symptoms. One affected woman described this to us as follows:
| “Complete uterine rupture may also be asymptomatic, that is, without vaginal bleeding. After strong contractions, a pause may set in during which nothing happens at all before rupture occurs with severe pain. Many doctors, paramedics and midwives don’t know this. I lost my baby because of this. My rupture was complete. I had no vaginal bleeding and no shock, just damn severe pain and vomiting. There was no suspicion.” |
Diagnosis and course
Uterine rupture is usually diagnosed on the basis of clinical symptoms.In addition, any unexplained postpartum or intrapartum shock should be interpreted as a clear indication of uterine rupture. In addition, an impending rupture of the uterus may be heralded by certain symptoms. Thus, hyperactive, painful contractions up to a labor storm (pathologically increased labor activity), pressure pain in the lower uterine segment on external palpation, a lifting of the Bandl ring above the navel, and restlessness and anxiety of the affected pregnant woman as a result of the pronounced pain indicate an impending uterine rupture. However, partial rupture of the uterus can also be asymptomatic in many cases. With a lethality of 10 percent in affected mothers and 50 percent in unborn fetuses, uterine rupture represents one of the most serious and life-threatening obstetric complications and should receive immediate emergency medical care in all cases.
Complications
Depending on the size of the tear, uterine rupture can result in serious complications. Most commonly, a uterine rupture causes heavy vaginal bleeding, which can cause anemia. Severe abdominal pain and sweating are among the possible accompanying symptoms. A pronounced rupture can lead to circulatory shock, associated with palpitations, hypotension, and other symptoms. Life-threatening complications occur if the uterine rupture is not treated immediately with intensive medical care. Then there is a risk that the affected woman will bleed to death or suffer a heart attack. A circulatory collapse can also be life-threatening. In the child, a uterine rupture causes a slowing of the heart rate. In many cases, the child dies of heart failure or severe circulatory shock. Other complications, usually serious, cannot be ruled out in cases of a pronounced uterine rupture. In the treatment of such a severe rupture, the risks come from the prescribed labor inhibitors, which are associated with various side effects and interactions. Any removal of the uterus may be accompanied by injury and infection. After the procedure, the fertility of the affected woman is limited and other physical and psychological sequelae occur. Loss of the child has far-reaching psychological consequences for the affected woman.
When should you go to the doctor?
A doctor must always be contacted in the event of a uterine rupture. As a rule, immediate treatment is also necessary to prevent further complications or discomfort, which in the worst case scenario could lead to the death of the mother or child. Therefore, a medical professional must be contacted at the first symptoms or signs of this complaint. A doctor should be contacted for this complaint if the frequency of contractions increases a lot before birth. In most cases, those affected suffer from very severe pain due to uterine rupture. There is also bleeding in the vaginal area, which is also associated with severe abdominal pain. Low blood pressure can also indicate uterine rupture and must be examined by a doctor. At the same time, bloody urine may also indicate this complaint. In most cases, uterine rupture is treated by a doctor immediately after birth. It cannot generally be predicted whether this will result in further complications or a decreased life expectancy for the mother or child.
Treatment and therapy
Immediate emergency medical measures are indicated for both threatened and successful uterine rupture. To inhibit labor activity, so-called tocolytics, which minimize the contractile activity of the uterus, are infused intravenously as part of acute tocolysis. By default, an intravenous bolus injection of 0.025 mg fenoterol (a beta-2 sympathomimetic) is the first-line agent, which can be repeated once without risking circulatory decompensation of the unborn child. In addition, shock prophylactic measures are required. If rupture is suspected or has occurred, immediate admission to a hospital is also indicated, where, as a rule, a laparatomy (surgical opening of the abdominal wall) is performed as soon as possible if the uterus is not in labor, or a sectio (incisional delivery, cesarean section) with subsequent reconstruction of the uterus if labor is present.If the bleeding cannot be stopped or is particularly severe, a total laparoscopic hysterectomy or uterine extirpation (removal of the uterus) may be necessary. If a rupture of the uterus is suspected during the delivery process, a sectio is also performed on an emergency basis. In parallel, hypovolemic shock (reduced circulating volume of flowers) resulting from blood loss in uterine rupture should always be managed with the use of volume and blood administration.
Prevention
Uterine rupture cannot be prevented in every case. If uterine surgery has already been performed, the risk of rupture, especially scar rupture, is slightly increased, and the course of pregnancy should be monitored and controlled accordingly because of the high mortality associated with uterine rupture.
Follow-up
As part of the medical follow-up for uterine rupture, the affected woman and, if applicable, the still unborn child must be considered. In addition, it is relevant whether organs adjacent to the uterus are also affected. Medical aftercare for a ruptured uterus depends on how well the rupture could be controlled surgically and what damage the bleeding has caused to the mother (and child). For the woman affected by uterine rupture, the main focus of aftercare is stabilization of the body. It is not uncommon for a uterine rupture to be accompanied by shock-like symptoms, which necessitates observation as well as follow-up. Furthermore, wound care and, if necessary, hemostatic medication are indicated as aftercare. If a cesarean section was performed due to the rupture, the child must be examined in detail. A uterine rupture directly endangers the child in the abdomen and, among other things, causes the heart rate to drop. Accordingly, any consequential damage must be determined. If a hysterectomy was performed to treat the uterine rupture, aftercare for the affected person consists not only of check-ups, but also of psychological care if necessary. In the case of a covered uterine rupture, which does not lead to bleeding into the abdominal cavity, medical follow-up is often not acutely necessary. Observation of the tissue, especially during any further pregnancy, is sufficient.
What you can do yourself
If this birth complication has already announced itself in advance or if risk factors were present, the expectant mothers have been closely monitored by their doctors or in the clinics. If, on the other hand, the expectant mothers are surprised by the symptoms of a uterine rupture shortly before the birth, urgency is required. If the patient is already in the clinic, she must receive intensive medical care. If she is not yet in the hospital, rapid transport to the hospital must be arranged, as there is a danger to the life of both the mother and the still unborn child. The uterine rupture is treated surgically. Regardless of how the situation turned out, it is very stressful for the patient involved. Either because she and her unborn child were in mortal danger, or because she even lost her child in the process and may not be able to become a mother in the future. To cope with this situation, she is advised to undergo psychotherapeutic follow-up treatment. Joining a support group can also be helpful. For example, the website Schmetterlingskinder.de offers immediate help in the event of child loss. The sites Elternforen.com or Familienplanung.de also provide helpful information under the term uterine rupture. The bleeding that occurred during uterine rupture may also have caused an iron deficiency. Therefore, the patient should have her iron status monitored and take iron supplements regularly if necessary.