Gowri Dorairajan1
(1)
Obstetrics and Gynecology, JIPMER, Puducherry, India
Management of ruptured uterus depends on the cause, the presentation, the need to preserve the uterus, and the part of the uterus involved in the rupture.
Resuscitation is a very important first aid and must be initiated as soon as rupture is suspected. Effective resuscitation to keep the blood pressure above 90 mm of Hg systolic is a very important step to prevent postoperative complications. Initial resuscitation with crystalloids (maximum up to 1.5 l in 1 h) and blood is necessary. Overuse of crystalloids without blood would result in dilution and consumption coagulopathy, compounding the bleeding. However, resuscitation and preparation for definitive surgical management should be carried out parallel. Delay beyond 1 h from diagnosis is likely to result in the life-threatening sequel and even death. With abnormal foetal heart rate pattern in a woman with a previous caesarean scar in labour, the time delay beyond 15 min to a half hour would result in perinatal mortality. It is important to ensure round-the-clock availability of blood, anaesthetist and operation theatre facility, and skilled obstetricians before planning the delivery of women with higher risk of rupture like women with a previously scarred uterus.
Most of the ruptures associated with previous lower segment caesarean sections have a subacute maternal presentation with the rupture restricted to the lower segment. Most of these are amenable to repair. Repair should always be attempted and is most likely to be successful when the rupture is restricted to the lower segment and is a fresh rupture. In a study period of 10 years, Alemayehu and co-authors [1] observed that 98 % of cases with rupture were successfully repaired by the doctors even though they were nonspecialized doctors. The authors further observed that the maternal mortality increases sevenfold if there is more than 1 h delay in definitive treatment.
One needs to keep in mind the recurrence of rupture in subsequent pregnancies. Eshkoli and co-authors [3] observed a recurrent risk of rupture to be 15 %. Fox et al. [4] studied the outcome of pregnancies with previous ruptures and observed that those who had a dehiscence of scar in the previous pregnancy or labour had a higher risk of repeat dehiscence at 7.5 %. However, they observed that management of these patients with standard protocol by repeat elective caesarean sections would not increase the maternal or perinatal morbidity or mortality.
In situations where there is associated colporrhexis or extension of the rupture to the lateral wall, a hysterectomy might become necessary. In a population-based study spanning over 23 years, Charach and Sheiner [2] recorded 164 ruptures and observed that the woman is likely to have a hysterectomy if she is subjected to relaparotomy, if there is an extension of a tear to cervix or fornix, if there is continued bleeding requiring multiple transfusions, and if she is a multiparous woman.
Ruptures involving the upper segment invariably merit a hysterectomy. Similarly, tears of the lateral wall involving the uterine artery or bleeding into the broad ligament are also likely to require a hysterectomy. Repair can be attempted if the tear is linear, but future pregnancies should be avoided as the risk of subsequent rupture is very high, and so tubal ligation should be performed along with repair after counselling. If the rupture is due to an invasive mole or the margins are ragged, and there is a loss of tissue, hysterectomy becomes necessary.
Caesarean hysterectomy is a skilled procedure. The surgery needs to be very fast. Preoperative urinary catheterization is must to not only rule out bladder rupture but also aid in the diagnosis of urinary tract injuries during the surgery as the chances of urinary tract injuries are high during caesarean hysterectomy, and of course, urine output during the surgery is an important measure of effective maintenance of circulation. In women suspected with a rupture, the abdomen should be preferably opened by vertical midline sub-umbilical incision. After the foetus and placenta are extracted from the abdominal cavity, the uterus should be delivered out and inspected for the site and size of rupture, the condition of the edges, the involvement of the uterine arteries, and the bleeding from the edges, as also for broad ligament bleeding in situations involving the lateral wall and the uterine arteries.
One needs to keep in mind that engorged distended vasculature of pregnancy can result in brisk bleeding and there is a higher chance of retraction of the uterine artery. Though working at the level of the abdominal wall with the enlarged uterus and tissue oedema makes the exposure and the identification of the tissue plane easier. One also needs to regard the fact that ruptures older than 12 h are likely to be associated with oedema of the ruptured edges and are likely to result in cut through making the repair difficult. Rupture following obstructed or neglected labour is likely to be associated with thinned-out friable edges and sometimes infected edges making any attempt at repair futile and frustrating.
The caesarean hysterectomy typically starts with clamping, cutting, and ligating the tubo-ovarian ligaments. The ovaries should be preserved. Tissue oedema and engorged vessels pose a serious threat for making the ligature loose so they should be tightened securely. The next clamp is in the structures of broad ligament including the round ligament. The utero-vesical fold of peritoneum is identified and incised to push the bladder down.
In situations where the utero-vesical fold has been already incised to perform lower segment caesarean section, the first step could be to clamp, cut, and ligate the round ligaments. The urinary bladder is further pushed down. One has to be careful at this step as the lower segment may be thinned out friable or the bladder itself may be oedematous and pulled up especially in cases with lateral wall ruptures following neglected labour. During pregnancy, the venous plexuses supplying the bladder are engorged and prominent and might bleed when pushing the bladder on the sides. Clamps are now applied at the level of the isthmus to the uterine arteries. The uterine arteries have a tendency to retract on cutting so the pedicle should be kept thick and double clamping may be necessary at the proximal stump. This drastically reduces the blood loss. The tubo-ovarian ligament is then clamped, cut, and ligated.
After uterine artery ligation, progressively medial clamps are applied parallel to the uterine cervix on the cardinal ligament and then the vaginal angles. The cervix can be felt as a bulge or with a finger guided within the cavity of the uterus from the tear. Sometimes cervix may be difficult to identify when the uterus gets avulsed or when the rupture has happened in the second stage. If the patient is in shock and poor circulation, subtotal hysterectomy may be sufficient if that serves the purpose of haemostasis as it saves a lot of time.
In a subtotal hysterectomy, after the uterine artery ligation, we need to direct the next clamp, towards the lower segment or the cervix. The same can be cut with a knife and the cervix is sutured anteroposteriorly.
The other technique is “cut and go” where serial clamps are applied and cut from the tubo-ovarian ligament downwards till the uterine arteries to achieve quick arrest of bleeding. The clamps are replaced by ligatures after all the clamps have been applied above downwards. However, this has the disadvantage that not all the laparotomy trays will have so many clamps readily available and too many clamps may create clutter in the operative field and any jumping clamp could make the situation worse and result in a struggle to hold back the pedicles. Once all the pedicles have been ligated, one should double-check for any bleeders. There is a higher risk of injury to the urinary tract during surgery. Blind haemostatic sutures without skeletonizing and identifying the bleeder in the broad ligament or near the vault pose a significant threat to the ureters. Guiding the hand to lift the posterior leaf of broad ligament after identifying the ureter and ensuring it is away from the field can prevent such inadvertent injury to the distal third of the ureter. If there is any doubt about bladder integrity, it can be checked by retrograde filling with methylene blue or opaque sterile fluid or intravenous indigo carmine injection. If the haemostasis is good, closing blood pressure is normal, and there is no feature of consumption coagulopathy, then usually intraperitoneal drain is not necessary.
The complications of rupture of the uterus include shock, acute tubular necrosis of kidney consequent to the shock, consumption coagulopathy, hypoxic brain damage, ischaemic necrosis of the posterior pituitary, and sepsis. Quick exsanguination can cause death. Multiple transfusions can further compound the situation with acute lung injury, pulmonary oedema, and haemolysis. There is a high risk of thromboembolism due to anaemia, prolonged surgery, immobilization, hypercoagulability of pregnancy, and supervening sepsis.
Effective and prompt resuscitation, definitive surgical treatment without delay, broad-spectrum antibiotics, and prompt but prudent use of blood and products will prevent most of these complications. Prolonged catheterization and rest to the bladder may be necessary depending on the cause of rupture and the intraoperative condition of the urinary bladder.
Remote complications include anaemia, chronic pelvic pain, psychological trauma, and the sequel-like Sheehan syndrome. Urinary fistulae can form in a woman who has had neglected labour prior to rupture.
A high index of suspicion, early recognition, prompt resuscitation, prompt surgery without delay, and gentle handling of tissues would reduce the mortality and morbidity. Intensive monitoring in the post operative period, appropriate replacement of fluids, blood and components, and antibiotics is necessary for smooth recovery. Early recognition and appropriate treatment of threatening complications would further reduce the mortality and the long-term morbidity.
References
1.
Alemayehu W, Ballard K, Wright J. Primary repair of obstetric uterine rupture can be safely undertaken by non-specialist clinicians in rural Ethiopia: a case series of 386 women. BJOG. 2013;120(4):505–8.CrossRefPubMed
2.
Charach R, Sheiner E. Risk factors for peripartum hysterectomy following uterine rupture. J Matern Fetal Neonatal Med. 2013;26(12):1196–200 (ISSN: 1476–4954).CrossRefPubMed
3.
Eshkoli T, Weintraub AY, Baron J, Sheiner E. The significance of a uterine rupture in subsequent births. Arch Gynecol Obstet. 2015;292(4):799–803.CrossRefPubMed
4.
Fox NS, Gerber RS, Mourad M, Saltzman DH, Klauser CK, Gupta S, Rebarber A. Pregnancy outcomes in patients with prior uterine rupture or dehiscence. Obstet Gynecol. 2014;123(4):785–9.CrossRefPubMed