31.12.4 To Determine the Frequency of Maternal and Fetal Outcomes of Uterine Rupture at a Tertiary Care Hospital

Original Article

 

Maternal and Fetal Outcomes of Uterine Rupture

To Determine the Frequency of Maternal and Fetal Outcomes of Uterine Rupture at a Tertiary Care Hospital

Zubia Bugti, Naila Ahsan and Misbah Hayat

ABSTRACT

Objective: To determine the frequency of maternal and fetal outcomes of uterine rupture at a tertiary care hospital.

Study Design: Descriptive / cross sectional study

Place and Duration of Study: This study was conducted at the department of Gynae/Obstetrics Unit-I Sandeman Provincial Hospital Quetta for 10 months. January 2020 to October 2020.

Materials and Methods: The total sample size was 126 patients which were consecutively enrolled were having presenting with uterine rupture. Cases of ruptured uterus, who were either admitted with or who will develop this complication in the hospital, were included in the study. Diagnosis was made on history and examination and was confirmed on laparotomy. These cases were analyzed with regard to their clinical presentation, past history complications, management and outcome were noted as maternal mortality and perinatal outcome were still birth, early neonatal death, alive and perinatal mortality. The surgical procedure depended on general condition of the patients, parity, and desire for future child bearing, site, severity and extent of rupture.

Results: A total of 126 women having uterine rupture were enrolled in this study. Mean age was 29.58± 876(SD), Mode was 29, and Median was 28.5 with ranging between (16-45) years. Ranged between 16 to 45 years, the maximum number of cases 76(60.3%) were less than 30 years of age. This shows that according to this study uterine rupture was more common at the age <30 years. Regarding the parity, majority of patients 73[57.9%] in this study were primigravidas, followed by 49[3.9%] in parity group of multigravida, only four cases having follow on multigravida. Most of the cases coming in our hospital were un-booked accounted for 81[64.3%]. Regarding the risk factors in current pregnancy in women presenting with uterine rupture was most of the commons was observed Scarred Uterus 22[17.5%] and Scarred uterus with spontaneous labour was 25[19.8%]. Some cases follow Scarred uterus with augmentation with syntocinon was 11[8.7%] Transverse lie was 10[7.9%]. No risk factor could be identified in Scarred uterus with induction with prostaglandin E2. Maternal morbidity in women with uterine rupture was identified as in women having shock was 41[32.5%], 27 [21.4%] were anemic, 22 [17.5%] had Puerperal Sepsis, Whereas DIC was presented in 13[10.3%] respectively. Perinatal mortality was 15 [11.9%]. Regarding neonatal morbidity or alive was 47 [37.3%], fifty patients was still birth respectively.

Conclusion: This study concluded that prolonged neglected obstructed labour is the main cause of ruptured uterus followed by scarred uterus. Proper antenatal care and updated training courses of health care providers should be stressed to prevent this catastrophic but avoidable complications. Regular antenatal care, hospital deliveries and care during labor with quick referral to well-equipped hospitals may reduce the incidence of this condition.

Key Words: Maternal, Fetal Outcomes, Uterine Rupture

Citation of article: Bugti Z, Ahsan N, Hayat M. To Determine the Frequency of Maternal and Fetal Outcomes of Uterine Rupture at a Tertiary Care Hospital. Med Forum 2020;31(12):17-20.

 

 

INTRODUCTION

Uterine rupture is defined as breach in the integrity of the myometrial wall with spillage of uterine contents into the peritoneal cavity1.

 

 

Department of Gynae, Sandeman Provincial Hospital Quetta

 

 

Correspondence: Zubia Bugti, Senior Registrar Gynae
Unit-I, Head of Department Gynae Unit-I, Sandeman Provincial Hospital Quetta.

Contact No: 0333-4073009

Email: z.asadullahbugti@gmail.com

 

 

Received:    November, 2020

Accepted:    November, 2020

Printed:        December, 2020

 

 

The rupture may occur in a scarred or unscarred uterus, with the unscarred uterine rupture leading to exceptionally immense hemorrhage2. Unfortunately, a ruptures uterus has been found to be most common cause of maternal and fetal demise in developing countries3.

The rate of caesarean delivery has risen from 6.7% in 1990 to 19.1% in 2014 worldwide, despite improvement in obstetrical procedures such as classic caesarean section, internal version, total breech exaction etc. This has also resulted in an increase in the frequency of uterine rupture, since women with previous caesarean sections have a greater possibility of a uterine rupture4. Prevalence ofuterine rupture is greater in patients who may have a history of caesarean section include former classical incision, labour initiation or argumentation, macrosomia, greater maternal age, post-term delivery, short maternal stature, no prior vaginal delivery, and prior periviable caesarian section5. The aim of this study is to determine the frequency of maternal and fetal outcome so as to highlight the grey areas where there might be a room for improvement of this avoidable catastrophe.

This study will also help us to educate women about the consequences of poor maternal & parental outcome. Thus the implementation of regular antenatal visits and proper family planning should be emphasized to reduce the morbidity and mortality.

MATERIALS AND METHODS

This study was conducted at Gynae Unit-I SPH Quetta. The total sample size was 126 patients which were consecutively enrolled were having presenting with uterine rupture. Cases of ruptured uterus, who were either admitted with or who will develop this complication in the hospital, were included in the study. Patients having ruptured uterus due to congenital abnormality were excluded from the study. Diagnosis were made on history and examination and were confirmed on laparotomy. These cases were analyzed with regard to their clinical presentation, past history complications, management and outcome were noted as maternal (shock, anemia, puerperal sepsis, wound infection, mortality and perinatal outcome were still birth, early neonatal death, alive and perinatal mortality. The surgical procedure depended on general condition of the patients, parity, and desire for future child bearing, site, severity and extent of rupture.

RESULTS

A total of 126 women having uterine rupture were enrolled in this study. Mean age was 29.58± 876(SD), Mode was 29, and Median was 28.5 with ranging between (16-45) years Table 1. Ranged between 16 to 45 years, the maximum number of cases 76(60.3%) were less than 30 years of age. This shows that according to this study uterine rupture was more common at the age <30 years. Regarding the parity, majority of patients 73[57.9%] in this study were primigravidas, followed by 49[3.9%] in parity group of multigravida, only four cases having follow on multigravida. Most of the cases coming in our hospital were un-booked accounted for 81[64.3%]. Regarding the risk factors in current pregnancy in women presenting with uterine rupture was most of the commons was observed Scarred Uterus 22[17.5%] and Scarred uterus with spontaneous labour was 25[19.8%]. Some cases follow Scarred uterus with augmentation with syntocinon was 11[8.7%] Transverse lie was 10[7.9%] Table 2. No risk factor could be identified in Scarred uterus with induction with prostaglandin E2.

Table No.1: Descriptive Statistics of the study characteristics (n=126)

Descriptive Statistics

Mean±SD

Maximum

Minimum

Age

29.58±8.76

45

16

Parity

2.5±1.0

5

1

Table No.2: Classification of different risk factors in women presenting with of uterine rupture(n=126)

Risk Factors

Frequency

Percentage

Scarred Uterus

22

17.50%

Scarred uterus with spontaneous labour

25

19.80%

Scarred uterus with augmentation with syntocinon

11

8.70%

Scarred uterus with induction with prostaglandin E2

0

0%

Grand Multiparity

4

3.20%

Injudicious use of oxytocin in unscarred uterus

2

1.60%

Obstructed labour

17

13.50%

Prostaglandin administration in Un-scarred uterus.

5

4.00%

Transverse lie

10

7.90%

Uterus repair

6

4.80%

Uterus Repair + Bilateral tubal ligation

4

3.20%

Uterus Repair + Bladder Repair

9

7.10%

Hysterectomy

11

8.70%

Total

126

100%

Table No.3: Different categories of Maternal Morbidity in women presenting with uterine rupture

Maternal

Morbidity

Yes

No

Total

Shock

41 [32.5%]

85 [67.5%]

126 [100%]

Anemia

27 [21.4%]

99 [78.6%]

126 [100%]

Puerperal Sepsis

22 [17.5%]

104 [82.5%]

126 [100%]

Wound Infection

4 [3.2%]

122 [96.8%]

126 [100%]

DIC

13 [10.3%]

113 [89.7%]

126 [100%]

Vesicovaginalfistula

12 [9.5%]

114 [90.5%]

126 [100%]

Maternal Mortality

7 [5.6%]

119 [94.4%]

126 [100%]

 

Maternal morbidity in women with uterine rupture was identified as in women having shock was 41[32.5%], 27 [21.4%] were anemic, 22 [17.5%] had Puerperal Sepsis, Whereas DIC was presented in 13[10.3%] respectively Table 3. Perinatal mortality was 15 [11.9%]. Regarding neonatal morbidity or alive was 47 [37.3%], fifty patients was still birth respectively Table 4.

Table No.4: Classification of perinatal outcome in women presenting with uterine rupture

Perinatal outcome

Yes

No

Total

Still Birth

50 [39.7%]

76 [60.3%]

126 [100%]

Early Neonatal Death

14 [11.1%]

112 [88.9%]

126 [100%]

Alive

47 [37.3%]

79 [62.7%]

126 [100%]

Perinatal Mortality

15 [11.9%]

111 [88.1%]

126 [100%]

DISCUSSION

Uterine rupture occurs extremely rarely - according to one study from France, the incidence of uterine rupture was found to be 6.2/10000 deliveries [6]. Another study shows the incidence to be 32/10000, with mean age of the patients to be 29.6±5.6 years. This was a frightening result since it indicates that the risk is highest in women of young and optimum fertility age7. Unscarred uteri have a lower risk of rupture. A study found the incidence rate to be 0.057%. Of those who did have a ruptured uterus, 76.9% were on term while 23.1% were preterm. The study suggests that a gravid woman with hypotension, abdominal pain, fetal distress, and vaginal bleeding, may be suspected of having a ruptured uterus8. Uterine rupture during pregnancy is a rare event and frequently results in life-threatening maternal and fetal compromise. It can either occur in women with (1) a native, unscarred uterus or (2) a uterus with a surgical scar from previous surgery. While a scarred uterus has a higher risk of uterine rupture, the blood loss of the mother in either cases of a scarred or unscarred uterus were not found to be significantly different9.

The normal, unscarred uterus is least susceptible to rupture10. Grand multiparity, neglected labor, malpresentation, breech extraction, and uterine instrumentation are all predisposing factors for uterine rupture. Despite the odds being low, if uterine rupture does occur, the morbidity and mortality rate is rather high. A higher awareness of the issue, regular checkups and low threshold for intervention can allow a better management of the case11.

It is found that 66% of cases occur in women who have had a previous caesarean section. A classical vertical and T-shaped incisions carry a higher risk of later uterine rupture than the standard modern low transverse approach and an inter-delivery interval of less than 18-24 months increases the risk. It is also found that the risk appears to be higher in pregnancies of gestational age greater than 40 weeks, and that prior uterine surgery (including myomectomy, curettage, induced abortion, manual removal of the placenta) also result in the prevalence in the occurrence of a uterine rupture. The aforementioned risk factors were found in about 90% of the cases of a uterine rupture12.

Trauma is also found to be a known cause of uterine rupture. As a matter of fact, it is the most common non-obstetrical cause of maternal mortality. A case study including seven patients shows that six out of seven patients were unable to survive a uterine rupture caused by trauma13.

Nearly all cases of a ruptured uterus are reported to occur during the third trimester14. Studies suggest that when a planned VBAC is induced, the uterine rupture risk is higher if prostaglandin is used than in a non-prostaglandin-based regimen. When a planned VBAC is augmented, the oxytocin dose should be titrated such that contraction frequency is no more than 4 in 10 minutes. Research supports a maximum oxytocin dose of 20 mU/minute in trials of labour, to avoid an unacceptably high (4 x greater) risk of uterine rupture. Labour induction using oxytocin, antepartum fetal loss, and prior miscarriage also increase the chances of a uterus rupture significantly15.

The most direct prevention strategy for minimizing the risk of pregnancy-related uterine rupture is to minimize the number of patients who are at highest risk. According to the aforementioned studies, if a gravida falls into the category of having multiple previous cesarean deliveries, previous classic midline cesarean delivery. previous low vertical cesarean delivery, previous low transverse cesarean delivery with a single-layer hysterotomy closure, previous cesarean delivery with an interdelivery interval of less than 2 years, previous low transverse cesarean delivery with a congenitally abnormal uterus, previous cesarean delivery without a previous history of a successful vaginal birth, previous cesarean delivery with either labor induction or augmentation, previous cesarean delivery in a woman carrying a macrosomic fetus weighing >4000 g, or previous uterine myomectomy accomplished by means of laparoscopy or laparotomy, the patient is at a higher risk of uterine rupture. Decreasing the threat factors of extended labor, cervical dilatation, induction of labor, augmentation of labor with oxytocin, diabetes, and blood loss may lessen the prevalence of uterine rupture16.

The most critical aspects of treatment in the case of uterine rupture are establishing a timely diagnosis and minimizing the time from the onset of signs and symptoms until the start of definitive surgical therapy. Once a diagnosis of uterine rupture is established, the immediate stabilization of the mother and the delivery of the fetus are imperative. A surgery is the primary mode of management for the mother17. As a rule, the time available for successful intervention after frank uterine rupture and before the onset of major fetal morbidity is only 10-37 minutes. Therefore, once the diagnosis of uterine rupture is considered, all available resources must quickly and effectively be mobilized to successfully institute a timely surgical treatment that results in favorable outcomes for both the newborn and the mother18.

Hysterectomy should be considered the treatment of choice when intractable uterine bleeding occurs or when the uterine rupture sites are multiple, longitudinal, or low lying19. Because of the short time available for successful intervention, the following 2 premises should always be kept firmly in mind: (1) Maintain a suitably high level of suspicion regarding a potential diagnosis of uterine rupture, especially in high-risk patients, and (2) when in doubt, act quickly and definitively.

CONCLUSION

This study concluded that prolonged neglected obstructed labour is the main cause of ruptured uterus followed by scarred uterus. Proper antenatal care and updated training courses of health care providers should be stressed to prevent this catastrophic but avoidable complications. Regular antenatal care, hospital deliveries and care during labor with quick referral to well-equipped hospitals may reduce the incidence of this condition.

Author’s Contribution:

Concept & Design of Study:

Zubia Bugti

Drafting:

Naila Ahsan

Data Analysis:

Misbah Hayat

Revisiting Critically:

Zubia Bugti, Naila Ahsan

Final Approval of version:

Zubia Bugti

Conflict of Interest: The study has no conflict of interest to declare by any author.

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