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I completed my medical school and background EM training from India (Christian Medical College, Vellore and Apollo Hospitals, Hyderabad) where I worked for 4 years. Following this, I devoted (with all my heart) about 1.5 years to do US Medical Licensing Exams. My stint towards an EM Residency in States did not work but it took me to places and it has been quite a journey. I then relocated to London, England to work as a Registrar (Non-Trainee) in A&E. This gave me an opportunity to better understand NHS, EM training pathways and more importantly the EM Mindsets in the United Kingdom. 

Currently, I am pursuing Higher Specialist Training in Emergency Medicine at South East Scotland Deanery where I have the honour and privilege of training under some of the most innovative brains in the field of Emergency Medicine. Over the past few years, I have realised that LEARNING and UNLEARNING (which can be challenging!) is equally important to deliver cutting edge care to our patients.And through this blog, I aspire to disseminate knowledge, assist trainees with exams and stay up to date with contemporary EM literature. I have always been an avid FOAMed supporter because FOAMed has always played an indispensable role during my training. 


Lakshay Chanana
ST4 EM Trainee 
Edinburgh, Scotland
drlakshayem@gmail.com

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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