Uterine Rupture – Clinical Analysis of a Case Series in Riga Maternity Hospital

Abstract

Summary Introduction. Uterine rupture is a tearing of uterine wall during pregnancy or delivery. There are two types of uterine rupture described in literature: symptomatic (SUR) and asymptomatic (AUR) uterine rupture. In case of SUR there is a full thickness uterine wall tear which leads to clinical symptoms and high perinatal and maternal morbidity and mortality. In case of AUR the visceral peritoneum remains intact and it is typically diagnosed during Cesarean section. Rupture of previously intact uterus is very rare and is associated with extensive uterine damage, severe hemorrhage and in most cases leads to hysterectomy. Fetal complications include admission to neonatal intensive care unit, hypoxic - ischemic injury and death. Maternal complications include hemorrhage, hypovolemic shock, bladder injury, hysterectomy and maternal death. The incidence and prevalence of uterine rupture as well as the perinatal and maternal rate of complications in Latvia is unknown. Aim of the Study. Aim of the study is to analyze clinical cases of SUR and AUR, calculate the incidence and prevalence and detect the risk factors (RFs) and diagnostic difficulties of clinical cases which occurred in Riga Maternity Hospital from year 2010 to 2017. Material and methods. A case series study of 41 uterine ruptures which occurred in Riga Maternity Hospital from the 1st of January 2010 until the 31st of December 2016 was performed. An average birth rate for this time period was 6554 live births per year. Results. Over the time period 41 women with uterine rupture were diagnosed in Riga Maternity Hospital. AUR was diagnosed in 33 patients during Cesarean section. SUR occurred in seven patients, but in total there were eight cases of SUR, because one of the patients had a uterine rupture twice. SUR incidence in Riga Maternity Hospital is 1.7 per 10000 deliveries (8 per 45875 deliveries) and the prevalence is 0.0175%. In three cases SUR was diagnosed after labor and in five cases - during emergency laparotomy. SUR most frequently manifested with hypovolemic shock and/or acute abdomen. In two cases uterine defect was repaired and in six cases hysterectomy was performed. One patient had acute kidney injury and there was one case of maternal death. Nine babies were delivered and the Apgar score after the 1st minute was ≥ 7 in three cases and < 7 in three cases, but after the 5th minute it was ≥ 7 in five cases and <7 in one case. There were three intrauterine fetal demises. All the patients with either SUR or AUR had multiple RFs for uterine rupture. Conclusions. Uterine rupture is associated with multiple RFs. If trial of labor after Cesarean section is the preferred mode of delivery it is necessary to detect all of the RFs. Antenatal measurement of lower uterine segment thickness seems unreliable but further research should be carried out with statistical data analysis. For the safety of patients trial of vaginal delivery in patient with uterine scar should be performed in appropriately equipped and staffed medical facilities.