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A Study On Rupture uterus In Women with Previous Caesarean Sections
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  • 1. BY : DR. FARHAT MAZHARI
  • 2. INTRODUCTION Uterine rupture is an uncommon but potentially catastrophic outcome of pregnancy where the integrity of myometrial wall is breached. Ruptured uterus still remains one of the serious causes of maternal and perinatal mortality and morbidity. Since 1916, the time of Edward Cragin’s famous quote, “Once a caesarean,always a caesarean”, the medical profession has been concerned about the risks of catastrophic uterine rupture in women with previous caesarean deliveries. In the past 20 yrs, VBAC has been encouraged but recent studies reporting an increased incidence of uterine rupture and perinatal mortality.
  • 3. INTRODUCTION Cont.. Has stirred controversy about the safety of VBAC. Subsequently there has been an increase in the rate of caesarean deliveries. The rate of caesarean delivery has increased from 5% in 1970 to 26% in 1993 .( J Okla state med Assoc,1997) The incidence of scar rupture in low transverse incision is 0.2-1.5% ,and 4-9% in classical scar. The incidence is increasing due to increased incidence of primary caesarean deliveries. Uterine rupture leads to maternal mortality upto 1-13 % and perinatal mortality of 74 - 92 % . Lack of health information, illiteracy, poor ANC,home deliveries by traditional birth attendants, uncontrolled fertility contribute to uterine rupture.
  • 4. Total and Primary Caesarean delivery rates and VBAC rates 30 25 20 total LSCS 15 VBAC rate primary LSCS 10 5 0 1989 1995 2000 2005
  • 5. Types of Prior Uterine Incisions and Estimated Risks for Uterine Rupture PRIOR INCISION ESTIMATED RUPTURE RATE CLASSICAL 4–9% T- SHAPED 4–9% LOW VERTICAL 1–7% LOW TRANSVERSE 0.2 – 1.5 % ( data from ACOG 1999,2004 ; MARTIN 1997, REYES 1971 )
  • 6. INCIDENCE National guidelines and large reviews quote different risks of uterine rupture in previous caesarean sections: WHO ( 2005 ) – 1.0 % ACOG ( 2010) – 0.5% - 0.9% The objective of my study was to determine the incidence , the risk factors and fetomaternal outcome of uterine rupture in women with previous caesarean sections .
  • 7. METHODOLOGY This study was conducted over a period of six months from January 2013 to June 2013 at Deptt. Of Obstetrics & Gynaecology , PMCH. The cases were selected from the patients attending to Labour Room Emergency. All cases of ruptured uterus who were either admitted with or who developed this complication in hospital were included in the study. Diagnosis was made on history and examination and was confirmed on laparotomy. The cases were analysed with regard to their past history, clinical presentation, management and outcome.
  • 8. RESULTS Total no of deliveries during this period was 3261 of which 54 were cases of uterine rupture with frequency of 1.6 % . Previous caesarean sections was the leading cause of ruptured uteri in 32 cases ( 59.3 % ). Total no. of patients with prior caesarean deliveries during this period was 1682 .So, the incidence of scar rupture comes out to be 1.9 % ( 32 / 1682 ). Cases with prolonged obstructed labour was the second most common cause in 16 cases ( 29.6 %) ,where 60 % patients gave history of injudicious use of oxytocin in peripheries .
  • 9. RESULTS Cont...... Cases with one caesarean section in past were 24 (44.4%) ,with two sections were 7 ( 12.9%), and one had previous three sections ( 1.8 % ). Lower uterine segment was the most common site of rupture in 38 cases ( 70.8 % ). Majority of women arrived in state of shock and required urgent resuscitative measures. Maternal deaths occurred in 7 cases ( 49 %) and perinatal mortality was 49 ( 90.7%), live birth rate being 9.3%. Hysterectomy was performed in 16 ( 29%) cases.
  • 10. DISCUSSION : RUPTURE UTERUS • Uterine rupture is typically classified as either :  COMPLETE : When all layers of the uterine wall are separated .  INCOMPLETE : When the uterine muscle is separated but visceral peritoneum is intact. • Incomplete rupture is also commonly referred to as uterine dehiscence . • The greatest risk factor for either form of rupture is prior caesarean delivery ( ref: ACOG 1999,2004 )
  • 11. CLASSIFICATION • UTERINE RUPTURE may be classified based on the predisposing factors into the following : RUPTURE OF PREVIOUS SCAR  Myomectomy  Hysterotomy  Caesarean section TRAUMATIC RUPTURE OF UNSCARRED UTERUS  External cephalic version  Blunt trauma
  • 12.     SPONTANEOUS RUPTURE of UNSCARRED UTERUS with UNDERLYING PATHOLOGY Uterine anomalies Previous MROP Curettage with or without perforation SPONTANEOUS RUPTURE OF UNSCARRED NORMAL UTERUS Multiparae : uterus is weakened by rapid and repeated childbearing.Induction of labour in such patients calls for great caution.
  • 13. AETIOLOGY The commonest cause is a previous caesarean section scar, the Classical or the T-shaped incision is more likely to give way in subsequent pregnancy than the low transverse scar. An inter-delivery interval less than 18 months increases the risk of rupture. Any h/o of fever following caesarean raises serious doubts about the integrity of scar. Single layer uterine closure increases the risk. Induction of labour with oxytocin in patients with previous caesarean, has increased rates of rupture.
  • 14. AETIOLOGY Cont ... VERSION IN LABOUR specially internal cephalic is a common cause of uterine rupture. Instrumental delivery like forceps or ventouse application through an incompletely dilated cervix may cause a tear of cervix that extends upwards into the lower uterine segment . Occasionally rupture occurs at the very end of second stage when ‘shortening of cord ‘ occurs due to extrusion of placenta into the abdominal cavity. Uterine rupture may present with primary PPH, that is either concealed intra-abdominally or revealed.
  • 15. PATHOPHYSIOLOGY • Pathologic retraction ring occurs, strong uterine contractions w/o cervical dilatation “tearing sensation” Complete rupture Rupturing of endometrium, myometrium and perimetrium Uterine contraction stops Incomplete rupture Rupturing of endometrium and myometrium Bleeding into peritoneal cavity and tenderness
  • 16. Bleeding into the vagina Decreased blood volume, decreased cardiac output , decreased BP Increased gas exchange ,increased respiratory rate Vasoconstriction of peripheral vessels, increased heart rate , Increased Pulse Uterine perfusion is decreased Decreased perfusion of brain & kidney Fetal distress Decreased LOC , Renal failure Death of mother and fetus
  • 17. DIAGNOSIS SCAR RUPTURE: The patient with prior classical or hysterotomy scar ,complains of a dull aching pain with slight vaginal bleeding .Onset is usually acute,with varying degrees of tenderness and shock.FHS may be absent. The onset is insidious in lower segment scar rupture, a rise in pulse may be a hint..hence called Silent rupture .the sign is therefore highly significant during labour in women with previous LSCS .
  • 18. OBSTRUCTED LABOUR : The patient classically presents with severe pain due to uterine contractions . Patient is dehydrated ,Bandle’s ring formation is seen, the presenting part is jammed in pelvis . There is a sense of something ‘giving way’ or ‘ripped’ at the height of uterine contraction. The contractions may cease ,superficial fetal parts are palpable with abnormal fetal heart rate pattern or absent FHS. A characteristic sign is the loss of presenting part from its former position on P/V exmn..features of shock & vaginal bleeding is associated.
  • 19. Diagramatic representation to show BANDLE’S RING
  • 20. In cases of complete rupture ,the retracted uterus forms a firm swelling to one side of fetus , while in incomplete rupture the bulge of a broad ligament hematoma can often be felt to one side of uterus .
  • 21. Broad ligament hematoma
  • 22. In cases of grand multiparae , the patient at the height of uterine contraction is suddenly seized with an agonising bursting pain followed by relief,and cessation of contractions. Features of shock ,tenderness and varying amount of vaginal bleeding is associated .
  • 23. The Most common and maybe the first sign of uterine rupture is a nonreassuring fetal heart rate pattern with variable decelerations that may evolve into late decelerations , bradycardia and death. So,all women with previous caesarean should have CTG monitoring during labour. And if there is any evidence of abnormal fetal heart rate patterns,delivery should be expedited . In the presence of CTG abnormalities, some have an opinion for fetal blood sampling to detect hypoxia ; however this procedure may incure a delay as we have a maximum time of 30 min before which if we perform surgery , we can save the baby .
  • 24. USG plays an important role in the prenatal examination of a patient with previous caesarean section and to diagnose old ruptures . The use of USG to evaluate the scar thickness from previous caesarean helps to forewarn this potential risk. The Montreal study suggested that the combination of single layer closure and full lower uterine segment thickness < 2.3 mm increases the chances of rupture.
  • 25. UTERINE SCAR DEFECT Arrow indicates a dehiscent myometrium
  • 26. AN OLD UTERINE RUPTURE
  • 27. MANAGEMENT  Initial management consists of resuscitative measures i.e. Management of shock.  Counselling and support to the patient and her attendants , inform them about the situation , the surgery and maternal and fetal probable outcomes.  LAPAROTOMY : HYSTERECTOMY - usually subtotal , best course in extensive rupture. REPAIR OF RUPTURE : in scar rupture where margin is clean. REPAIR OF RUPTURE AND TUBAL LIGATION.
  • 28. CONCLUSION This study concluded that previous caesarean sections is the major cause of uterine rupture in the present day scenario ,followed by obstructed labour as the second most common cause. There is lack of awareness among rural population regarding proper antenatal care and risks of VBAC . Counselling regarding contraception , like PPIUCD insertion is a good option to prevent such casualties. About 75% patients in my study belonged to rural and distant areas, so updating of primary health care providers and stronger referral systems should be stressed upon .
  • 29. ATTEMPTED VAGINAL BIRTH AFTER CAESAREAN SECTIONS.
  • 30. Repeat C-Section or A VBAC ?
  • 31. TAKE HOME MESSAGE A strict criteria to indicate primary caesarean sections. Patients who wish to ; and have a favourable condition should be offered TOL (trial of labour) for VBAC , but under strict vigilance. Contraceptive counselling is a must beginning right from the antenatal care , intranatal ( specially for PPIUCD) and postnatal period. All patients with primary caesarean sections MUST have institutional deliveries .
  • 32. Perhaps we could suggest the inclusion of ‘ minimum three ANC records ‘ as a criteria for provision of benefits under JANANI SURAKSHA YOJNA ,so that more women come for ANC and institutional deliveries. Referrel systems should be strengthened ... Primary health care providers should go a special training to deal with patients with previous caesarean deliveries and to identify the imminent signs of rupture so that they can be referred at the earliest .
  • 33. What We Aim For : A HEALTHY MOTHER & A SMILING BABY
  • 34. Thanks for listening :]