Uterine rupture is a pathological condition characterized by a violation of the integrity of the uterine walls during labor. The main clinical manifestations include sharply painful intensified contractions, impaired urination, signs of blood loss and erectile or torpid phase of shock. The diagnosis of uterine ruptures is based on the preliminary collection of anamnesis and the identification of characteristic symptoms, if necessary, ultrasound data. Therapeutic tactics consist in delivery by caesarean section, median laparotomy or fruit-destroying operations with stopping bleeding, stitching a rupture or extirpation of the uterus in the future.
General information
Uterine rupture is a violation of the integrity of the uterus during pregnancy or during childbirth. For the first time this pathology was described in the XVI century. At the moment, this is one of the least common pathological conditions in obstetrics. The total frequency of uterine ruptures ranges from 0.1-0.01% of all births. Before the onset of labor, only 8-10% of ruptures occur. In the I and II trimesters, this pathology is rarely observed. At the same time, uterine ruptures are characterized by high rates of maternal and perinatal mortality – 3-5% and 35-40%, respectively. In modern obstetrics, the leading role is given to prevention by early identification of potential etiological factors and rational selection of the method of delivery against their background.
Causes
At the moment, there are several variants of the etiopathogenesis of uterine ruptures during childbirth: a mechanical barrier to the fetus, histological changes in uterine tissues and violent exposure. The first group includes all anatomical and physiological features of the mother and/or fetus that complicate or make it impossible for the child to pass through the female birth canal. An extensor or transverse position, asyngilitic insertion of the head, dropsy of the brain, a large fetus, anomalies in the development of pelvic bones, the presence of neoplasms of the genital tract can provoke a rupture of the uterus.
Histological changes are currently the most common cause of uterine ruptures – over 90% of all cases. This group includes the presence of scars or areas of trophic changes in the myometrium after more than 3 births, including complications, multiple curettage, cesarean sections or other operations on the uterus, frequent endometritis. The mechanism of development is based on the loss of elasticity of tissues or their weakness and, as a result, the inability to withstand the load. Violent rupture of the uterus caused by the use of obstetric aids or operations is rare. The cause of the rupture in such cases is the exertion of excessive pressure on the uterus by the hands of a doctor or medical instruments. Rupture of the uterus can be caused by non-compliance with the technique of the operation, the use of a Crystal, prolonged stimulation with oxytocin, the rotation of the fetus with a running transverse presentation.
Classification
Depending on the pathogenesis , uterine ruptures are divided into:
- Spontaneous. These are ruptures that occur independently, against the background of anatomical and physiological characteristics of the mother and / or child (mechanical obstruction, histological changes).
- Violent. Such uterine ruptures are the result of medical actions (using a vacuum extractor, forceps, too fast birth of a child), abdominal and pelvic injuries.
According to the degree of damage to the wall , uterine ruptures can be divided into two groups:
- Complete ruptures of the uterus, in which endo-, myo-, and perimetrium are damaged. In this case, an opening is formed between the uterine and abdominal cavity, through which the fetus can exit.
- Incomplete uterine ruptures are limited only to the endometrium and/or myometrium. The main manifestation is the formation of a hematoma under the visceral peritoneum or between the leaves of the broad ligament.
Symptoms of uterine rupture
The rupture of the uterus can be at one of 3 stages: threatening, begun or accomplished. This division is due to the sequence of violation of the integrity of the walls of the uterus and the clinical manifestations that occur against this background. With a threatening rupture of the uterus, the clinic is due to excessive stretching of the tissues, but their integrity is still preserved. The leading symptoms of this stage are: severe pain in hypogastria, increased intensity and reduction of pauses between contractions, increased heart rate and BH, subfebrility, urinary retention, edema of the external genitalia. In the middle third of the abdomen or slightly higher, a contractile ring can be detected palpationally. With a threatening rupture of the uterus, fetoplacental blood flow worsens, fetal hypoxia occurs, which leads to damage in the central nervous system or even death of the child.
The incipient rupture of the uterus is characterized by a violation of the integrity of the endometrium and myometrium, damage to arteries or veins and the formation of a hematoma. Clinical manifestations of this stage include convulsive contractions with pronounced pain syndrome, vaginal discharge of a bloody or bloody nature and blood impurities in the urine. This condition often leads to the development of shock. His initial (erectile) stage is accompanied by general excitement, intense fear, screaming and mydriasis. Often, the rupture of the uterus that has begun ends with the death of the child due to prolonged hypoxia.
A complete rupture of the uterus is manifested by a complete rupture of the wall. At the same time, the fetal pressure on the genital tract disappears sharply. Clinically, this is characterized by increased pain at the height of one of the contractions, after which labor activity stops completely. The earlier shock passes from the erectile phase to the torpid one, signs of massive blood loss appear: sharp pallor of the skin, shallow breathing and threadlike pulse, “collapse” of blood pressure, occlusion of the eyeballs, vomiting, turbidity and loss of consciousness. Against the background of a complete rupture of the uterus, the child can move into the abdominal cavity. In such cases, parts of the fetus are clearly palpated under the abdominal wall, and the fetus itself is displaced above the entrance to the pelvis.
Diagnosis
Diagnosis of uterine rupture is based on anamnesis and physical examination of the woman in labor, if necessary, ultrasound results. In most cases, the time for diagnosis is very limited, because uterine rupture is an urgent condition that requires immediate medical intervention. In case of incorrect interpretation of the identified symptoms, incorrect or late determination of the nature of the pathology, the risk of death of both the child and the mother increases significantly.
During the survey, women pay attention to the nature of pain, the presence of secretions from the genital tract, previously suffered gynecological diseases and operations, features of previous births. As a rule, the risk of uterine rupture is assessed even before the onset of labor, including by the results of ultrasound scanning. The obstetrician-gynecologist taking delivery is necessarily informed about the results. During a physical examination of a woman with a suspected rupture of the uterus, blood pressure, BH and heart rate are assessed, palpation of the abdomen is performed. Next, an external obstetric examination is performed in order to assess the size and tone of the uterus, the position of the fetus in it. If the result of a physical examination is questionable, a control ultrasound scan can be performed. Ultrasound makes it possible to assess the thickness of the walls of the uterus and identify a violation of their integrity, determine the stage at which the rupture of the uterus is located. In order to assess the vital activity of the fetus, cardiotocography can be performed.
Treatment of uterine rupture
Therapeutic tactics in case of rupture of the uterus is reduced to the fastest possible delivery and stopping bleeding. In all cases, this condition is a direct indication for immediate surgical intervention. Regardless of the stage, BCC is replenished by intravenous infusion of blood products or blood substitutes and prevention of bacterial complications with the help of antibacterial agents.
In a state of threatening rupture of the uterus, the immediate termination of labor activity of the uterus is carried out. This is provided by medical muscle relaxation against the background of general anesthesia. Further, depending on the presence of signs of vital activity of the fetus, a cesarean section or craniotomy is performed. When a rupture of the uterus has begun and has occurred, median laparotomy is indicated for the purpose of a full revision of the abdominal and uterine cavities. Also, such access allows for excision of the edges and stitching of small tears or extirpation in case of massive damage, infection or multiple crushing of tissues. With incomplete ruptures of the uterus, emptying of the hematoma and hemostasis is performed.
Prognosis and prevention
The prognosis for a woman with a ruptured uterus directly depends on the severity of the damage, the amount of blood loss and the modernity of care. The prognosis for a child with a complete rupture of the uterus, as a rule, remains unfavorable, due to placental abruption. Preventive measures in relation to uterine ruptures imply the preliminary exclusion of all circumstances in which there is an excessive effect on the walls of the organ. To do this, a pregnant woman must regularly attend a women’s consultation and undergo a full examination. In the presence of factors that can potentially cause rupture of the uterus, the method of delivery is selected individually by the attending obstetrician-gynecologist.
