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I have completed bits of my EM training from India. Currently I am boarded with credentials from Christian Medical College, Vellore and also from the prestigious Royal College of Emergency Medicine, UK.  I am currently working in London as an A&E doctor, trying to appreciate the differences in the practise and culture of Emergency Medicine across different healthcare systems. I have always been an avid FOAMed supporter because FOAMed played an indispensable role during the days of my initial training. Through this blog, I aspire to disseminate knowledge and stay up to date with the EM literature. 

Monday, March 28, 2016

Uterine Rupture - An obstetric catastrophe

Introduction
Uterine rupture is defined as a non-surgical disruption or tear of the myometrium and serosa of the uterus with or without expulsion of the fetus. It is a life threatening condition for both the mother and the fetus. The overall incidence of uterine rupture is low but in India and other developing nations, it is 10 fold higher.




Etiology
  • Scarred Uterus Rupture: Previous caesarean scar or myomectomy
  • Unscarred Uterus Rupture: Obstructed labour, Trauma, Grand-multiparty, Uterine anomaly or injudicious use of oxytocin or prostaglandins


Clinical Features
  • Severe haemorrhage, Tachycardia, Hypotension (Shock)
  • Palpable fetal parts with loss of fetal station
  • Recession of presenting fetal parts
  • Prolonged, Persistent, Profound fetal bradycardia
  • Loss of uterine contractility
  • Hematuria
  • Appearance of placenta at vulva 
  • Prolapsed loops of gut into vagina 

Typically seen in patient with history of CS but also possible in Primigravida

USG: Fetus in peritoneal cavity, Free fluid seen

Differential Diagnosis
  • Abruptio Placentae (Similar presentation)
  • Hepatic Rupture in severe pre eclampsia (Look for other signs of pre-eclampsia)
  • Chorioamnionitis (Look for fever, PROM, Tender uterus)

Management
ABC (Wide bore cannulas, fluids, O2, Blood Products)
Stop oxytocin if in progress
Type and Cross Match
Mobilising resources quickly is the key (OBGYN, Anaesthesia, Neonatology)
Immediate laparotomy is indicated 
  • Vertical incision gives better access
  • Fetus lies partially or completely in the abdominal cavity
  • Rent repair or hysterectomy are the surgical options depending on the degree of rupture and damage
Several studies have shown that delivery of the fetus within 10-37 minutes of uterine rupture is necessary to prevent serious fetal morbidity and mortality.


Take Home
  • When dealing with trauma in pregnancy, think Placental Abruption and Uterine Rupture (Both can co-exist)
  • Establishing diagnosis early and mobilising the resources quickly and effectively results in favourable outcomes for the mother and fetus

For further reading:
  1. Qudsia, Q. A. Z. I., et al. "Woman health; uterus rupture, its complications and management in teaching hospital bannu, pakistan." Maedica 7.1 (2012): 49.
  2. Blanchette H, Blanchette M, McCabe J, Vincent S. Is vaginal birth after cesarean safe? Experience at a community hospital. Am J Obstet Gynecol. 2001 Jun. 184(7):1478-84; discussion 1484-7.
  3. Leung AS, Leung EK, Paul RH. Uterine rupture after previous cesarean delivery: maternal and fetal consequences. Am J Obstet Gynecol. 1993 Oct. 169(4):945-50. 
  4. Yap OW, Kim ES, Laros RK Jr. Maternal and neonatal outcomes after uterine rupture in labor. Am J Obstet Gynecol. 2001 Jun. 184(7):1576-81
  5. Essentials of Obstetrics - Lakshmi Seshadri and Gita Arjun
  6. Batra, Kanika, et al. "Determinants of rupture of the unscarred uterus and the related feto-maternal outcome: current scenario in a low-income country." Tropical doctor (2015): 0049475515598464.
  7. A Massinde, E Ndaboine, A Kihunrwa. An unusual case of placenta abruption complicated with ruptured uterus: case report. The Internet Journal of Gynecology and Obstetrics. 2009 Volume 13 Number 1.

Author:


   Kritika Atrey 
   Intern
   Aarupadai Veedu Medical College
   Pondicherry
   Twitter: @atrey_kritika

   Edited by Lakshay Chanana @EMDidactic

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