Int J Gynaecol Obstet 15: 405-409, 1978

Rupture of the Uterus Mehdi Paydar and Abass Hassanzadeh Department of Obstetrics and Gynecology, Pahlavi University, Shiraz, Iran

ABSTRACT Paydar, M. and Hassanzadeh, A. (Dept. of Obstetrics and Gynecology, Pahlavi University, Shiraz, Iran). Rupture of the uterus. Int J Gynaecol Obstet 15: 405-409, 1978 Sixty-four cases of rupture of the uterus were managed from March 1967 to March 1977. The maternal morbidity was 81.0%, and there were six maternal deaths (9.4%). Fifty-five patients (85.5%) had hysterectomies. The average hospital stay for patients who survived was 15.5 days. The fetal mortality rate was 89%. The etiology, diagnostic evaluation and the mode of prevention are discussed.

INTRODUCTION In spite of advances in the treatment of shock, control of infection, quality of anesthesia and operative techniques, rupture of the uterus remains one of the most serious obstetric tragedies for both the mother and her fetus. A study was undertaken of all cases of uterine rupture managed during the past 10 years (March 1967 to March 1977) in the Department of Obstetrics and Gynecology of the Pahlavi University, Shiraz, Iran, to determine whether or not some of the resulting maternal and fetal deaths or damages could have been prevented. MATERIALS AND METHODS Sixty-four cases of uterine rupture have been managed among the 47 000 deliveries performed at our institution during the past 10 years. Private patients represent about 7 000 of the total deliveries; the remaining 40 000 deliveries were among indigent patients from the city of Shiraz and surrounding areas. While the great majority of private patients receive optimal care during pregnancy and labor, about two thirds of the indigent patients receive no prenatal care and arrive in the delivery unit during either active labor or dystocia. Almost all indigent patients are subjected to obstetric manipulation by nonspecialist physicians, by unqualified traditional midwives and, after hospital admission, by medical personnel who are still in

training. Therefore, it is not surprising that cases of uterine rupture occurred only among indigent patients. RESULTS The youngest patient studied was 18 years old, and the oldest was 44. Fifty-eight percent of the patients were 30 years old or older, while 42% were younger than 30 years (Table I). Only one patient was nulliparous (1.6%), 52 patients (81.2%) were para 2 or more and 11 patients (17.2%) were primíparas. There was no incidence of uterine rupture among the private patients included in this study, but the incidence rate for the indigent patients was 1:625 births. Twenty-five of the indigent patients (39%) were from an urban environment and 39 others (61%) were from rural areas. Sixty-three of the 64 uterine ruptures occurred at term and intrapartum (98.5%); only one occurred before term and antepartum (1.5%). The latter was a 30-year-old para 6 who presented with vaginal bleeding and severe abdominal pain. Uterine rupture was suspected, and laparotomy was performed immediately. The uterine rupture was in the anterolateral aspect and incomplete (only the serosa was left intact). A live, premature fetus weighing 2 300 g was delivered abdominally. The placental site was close to the ruptured area and one third of the placenta was abrupted. In this case, it was not determined whether abruptio was the cause or the effect of the uterine rupture. The various etiologic factors contributing to the 64 cases of uterine rupture studied are shown in Table I. Age distribution for 64 patients with uterine rupture Age

No.

%

Ti v¡\ $ patients. In this study, the uterine ruptures were so advanced that the diagnosis was correct in all but one patient. In more than 80% of the patients, the major clinical findings were external bleeding, severe abdominal tenderness and the absence of both uterine contraction and fetal heart sounds (Table III). The other significant clinical findings were a floating presenting part and easily palpable fetal parts under the skin. Shock was observed in only 35.5% of the patients. Hemoconcentration due to severe dehydration made the hemoglobin level less valuable for estimating blood loss and diagnosing uterine rupture. Strenuous attempts were made to restore each patient's blood volume before surgical intervention. Indications for transfusion were: general appearance, pallor, rapid pulse and, to a limited extent, estimated blood loss (EBL). Twenty-six patients (40.5%) sustained a blood loss of 1 001-2 000 ml; 32 patients (50%) lost 2 001 + ml of blood. The EBL for 60 patients (94%) was greater than 1 000 ml. Mainly because of dehydration, the hemoglobin concentration was 10 g/100 ml or more (hematocrit 30%) in almost 50% of these patients. A total of 152 pints of blood was transfused into the 62 patients, with an average of 2.45 pints per patient. A combination of penicillin and a second broad spectrum antibiotic was administered to 81% of the patients. Patients were managed by monitoring their fluid intake, urine output and (in some cases) central venous pressure, along with other necessary supportive measures. Thirty-six total hysterectomies and 17 subtotal hysterectomies were performed on 85.5% of the patients. Uterine ruptures were repaired in nine patients (14.5%) who were either young, nulliparous women or low parity women with small and fresh Table III. Clinical findings evident in 62 cases of uterine rupture treated at our institution (two other women were dead on arrival) Findings External bleeding Severe abdominal tenderness Rapid pulse rate (120) Shock Absence of contraction Absence of fetal heart sounds Easily palpable fetal part Floating presenting part in longitudinal lie (53 vertex, 9 breech) Low hemoglobin (

Rupture of the uterus.

Int J Gynaecol Obstet 15: 405-409, 1978 Rupture of the Uterus Mehdi Paydar and Abass Hassanzadeh Department of Obstetrics and Gynecology, Pahlavi Uni...
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