Cervical rupture is a traumatic violation of the integrity of the walls of the organ during childbirth or invasive interventions. It is manifested by bleeding of varying intensity with the release of bright scarlet blood in the late and early consecutive periods. The main importance for diagnosis is the revision of the walls of the neck using wide mirrors. When a rupture is detected, surgical intervention is indicated, the volume of which is determined by the degree of damage and concomitant complications. Usually the cervix is sutured through vaginal access. When a rupture passes to the walls of the uterus or a hematoma is detected in the parametral fiber, a cavity operation is performed.
General information
Most primiparous women have lateral tears (cracks) of the edges of the external uterine pharynx, the dimensions of which do not exceed 1 cm. Such injuries are not pathological, are accompanied by a small amount of bloody discharge and do not need suturing. After their healing, the external pharynx of the uterus becomes slit-like, which indicates a postponed birth. Cervical injury with more than a centimeter gap, according to various data, is observed in 6-15% of births and is one of the most common obstetric injuries. It usually occurs in women giving birth for the first time, much less often in repeat births. Since an undiagnosed rupture is the cause of many gynecological diseases, all maternity hospitals are shown a special examination to exclude this pathology.
Causes
There are several groups of factors that can cause such a trauma to the birth canal. The risk of damage to the cervix during childbirth increases significantly with rigidity or loosening of its tissues, which can lead to:
- Inflammatory diseases. In chronic cervicitis, the connective tissue stroma of the organ is infiltrated and compacted, which worsens the opening of the uterine pharynx.
- Age-related changes. In primiparous women over 30 years of age, the number of elastic fibers in the neck tissues decreases, which reduces their tensile strength.
- Cicatricial deformity. The extensibility of tissues worsens due to the formation of connective tissue scars after previous ruptures and therapeutic manipulations (diathermocoagulation, cryodestruction, laser vaporization, conization, etc.).
- Cervical dystocia. Due to discoordinated labor activity, the edges of the organ, instead of smoothing and relaxing, are compacted, become thick and rigid.
- Placenta previa. Attachment and development of the baby’s place in the lower uterine segment and the pharynx area leads to loosening of the cervical tissues, which increases the risk of rupture.
- Rapid childbirth. During violent labor, the fetus passes through an insufficiently smoothed and open cervix, injuring the edges of its throat.
- Incomplete opening of the pharynx. Problems with smoothing the cervix may occur with weakness of labor, insufficient volume or premature discharge of amniotic fluid. The organ is also damaged by stimulation of attempts before its full disclosure.
- Tissue hypoxia. The strength of the neck decreases with a violation of its nutrition due to prolonged compression between the baby’s head and the bone ring. This condition occurs more often in women in labor with a narrow pelvis.
The probability of injury also increases with excessive loads on the edges of the external pharynx. The rupture can lead to:
- Giving birth to a large fetus. The circumference of the head of a child weighing more than 4 kg in most cases exceeds the size to which the external pharynx can stretch. A similar situation occurs when a child with hydrocephalus is born.
- Extensor position of the fetus. In such cases, not only the physiological mechanism of childbirth is disrupted or they become impossible, but also the birth canal is more often injured.
- Surgical manipulations. The cervix is damaged when applying obstetric forceps, using a vacuum extractor, removing the child by the pelvic end, etc. Outside of childbirth, ruptures can be observed with the rough conduct of invasive manipulations.
Pathogenesis
The mechanism of traumatic damage to the cervix is based on the discrepancy between the ability of tissues to stretch and the significant loads that occur during childbirth. At first, elastic fibers cope well with the efforts created by the fetal head, instruments for childbirth or the hand of an obstetrician. With overgrowth, the tissue becomes thinner, and the blood vessels that feed it are squeezed. Hypoxia occurs, leading to the development of dystrophic processes. In the end, the integrity of the tissues is violated.
The gap is usually radial longitudinal, less often — stellate. In some cases, necrosis is so pronounced that it is accompanied by complete rejection of the anterior lip. If significant loads act on the unprepared cervix, a complete circular separation of its vaginal part is possible. In some cases, with late spontaneous abortions and premature birth, there is a so-called “central” rupture with the formation of a false stroke in the posterior wall of the cervix with a diameter of 1.5-2.0 cm above the intact external pharynx.
Classification
When assessing the type and characteristics of damage, the mechanism of its formation, size and the presence of complications are taken into account. Depending on the reasons that led to a violation of the integrity of the cervix, ruptures are distinguished:
- Spontaneous — arising spontaneously in the course of labor against the background of rigidity or excessive stretching.
- Violent — provoked by delivering vaginal interventions to speed up the delivery process.
Taking into account the size of the ruptures there are three degrees:
- I degree — one- or two-sided damage to the cervix up to 2 cm long.
- II degree — the size of the gap exceeds 2 cm, but it does not reach the vaginal arch by at least 1 cm.
- III degree — the rupture reaches the vaginal arches and passes to them.
Grade I and II ruptures are considered uncomplicated. Specialists in the field of obstetrics and gynecology include the following types of damage to complicated ruptures:
- Ruptures of the III degree.
- Ruptures extending beyond the internal uterine pharynx.
- Ruptures that involve the peritoneum or the surrounding uterus parametrium.
- Circular separation of the cervix.
Symptoms of cervical rupture
In the case of small injuries up to 1 cm in size, clinical symptoms are usually absent. The main manifestation of cervical rupture is bleeding. Sometimes its signs can be observed already during the period of exile, when the parts of the fetus that are being born are covered with bright scarlet blood. However, usually bleeding occurs or increases after the birth of a child, despite the good contractile activity of the myometrium. At the same time, blood flows from the vagina in a trickle or is released in a significant amount. Less often it contains a lot of clots. If the rupture occurred against the background of large fractures with prolonged compression of tissues, bleeding is not always observed, since the vessels have time to thrombose. In such cases and with damage to areas without large blood vessels, little blood is usually released, which increases the importance of postpartum examination of the cervix in mirrors.
Complications
If the cervical-vaginal branch of the uterine artery is damaged, the rupture of the cervix may be complicated by profuse bleeding. Due to significant blood loss, the skin and mucous membranes of the maternity hospital turn pale, the woman complains of weakness, dizziness, cold sweat, may lose consciousness. If untimely care is provided, the patient develops hemorrhagic shock, which is life-threatening. Deep injuries reaching the vaginal arch may be accompanied by rupture of the uterus and massive hemorrhage in the parametrium. With a missed and untreated rupture of the cervix, the risk of developing parametritis, postpartum endometritis, and subsequently ectropion, chronic endocervicitis, erosion, neoplasia increases significantly. Long-term consequences are scarring of the cervix, cervical insufficiency with miscarriage, the formation of cervical-vaginal fistula.
Diagnostics
Postpartum bleeding occurs both with ruptures of the cervix and with other pathological conditions. Therefore , for the correct diagnosis , perform:
- External obstetric examination. After giving birth, the uterus shrank well. When the bladder is emptied, its bottom is located below the navel.
- Inspection in mirrors. With the help of wide mirrors, bullet or hemorrhoidal forceps, a revision of the neck is performed with stretching the edges of the pharynx and examining all the folds.
If a rupture of the 3rd degree is detected, the uterine walls are manually examined to exclude their damage. Differential diagnosis is carried out with rupture of varicose veins of the vagina, postpartum hypotension and atony of the uterus, delay in its cavity of fetal membranes or placenta lobules, the development of DIC syndrome. If necessary, an anesthesiologist, therapist, and surgeon are involved in the diagnosis and management of the maternity hospital.
Treatment of cervical rupture
If a pathological rupture is detected, the integrity of the organ is surgically restored. The choice of surgical intervention depends on the degree of damage and the presence of complications. The damaged area is sutured with a transvaginally absorbable material, the suture is applied to the entire thickness of the tissue with the exception of the endocervix. If a rupture is detected, passing over the internal pharynx, or hemorrhage in the parametrium, laparotomy is recommended, during which the bleeding is stopped, the hematoma is removed. In the postoperative period, antianemic drugs are indicated. To prevent infectious complications, a short course of antibacterial therapy is usually prescribed.
Prognosis and prevention
The prognosis for uncomplicated ruptures is favorable. In the presence of complications, the results depend on the timeliness and adequacy of treatment. The key role in the prevention of ruptures is played by the correctness of labor management and the reasonable use of surgical delivery methods in the presence of appropriate indications. In exceptional cases, with a high probability of rupture due to rigidity, a narrow conical shape of the neck or the need for urgent delivery with incomplete opening of the pharynx, trachelotomy (surgery to dissect the walls of the cervical canal) can be performed proactively.
