Rupture uterus: changing trends in etiology and management.
RS Nagarkatti, VR Ambiye, PR Vaidya
Department of Obstetrics and Gynaecology, L. T. M. G. Hospital, Sion, Bombay, Maharashtra.
R S Nagarkatti
Department of Obstetrics and Gynaecology, L. T. M. G. Hospital, Sion, Bombay, Maharashtra.
Sixty-four cases of rupture uterus which occurred during the period 1980-89 were studied and compared with 70 cases in the preceding decade (1970-79). The changing trends in etiological factors and management of this condition have been demonstrated. While spontaneous rupture continued to account for about two-thirds of the cases (70.3%), the incidence of traumatic rupture uterus has become less than half, from 17.1 to 7.8%, and that of scar rupture has increased to more than double (from 11.4 to 23.4%). As regards management, there are improved results seen with conservative repair of the uterus. It was also seen that a subtotal hysterectomy was more commonly resorted to than total hysterectomy in the later decade. There was a decrease in the overall morbidity from 42.8 to 35.9% and also in the mortality rate from 24.3 to 18.7%.
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Nagarkatti R S, Ambiye V R, Vaidya P R. Rupture uterus: changing trends in etiology and management. J Postgrad Med 1991;37:136-9
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Nagarkatti R S, Ambiye V R, Vaidya P R. Rupture uterus: changing trends in etiology and management. J Postgrad Med [serial online] 1991 [cited 2023 Feb 9 ];37:136-9
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Rupture uterus is a hazardous complication of pregnancy and labour, and carries high risk both to the mother and the fetus. Although its incidence is still high in our country as compared to the developed countries, there has been a definite decline in the resulting morbidity and mortality. This can be attributed to improved antenatal and intrapartum care, better anaesthetic and surgical techniques, availability of higher antibiotics and improved blood transfusion facilities. In this retrospective study, we have tried to analyse and assess the changing trends in the etiological factors and management of rupture uterus over the last 20 years.
Hundred and thirty-four cases of rupture uterus over the last 20 years from 1970 to 1989 were studied. They were divided into two groups, viz. Group I (1970-79) and Group II (1980-89). The incidence, etiological factors, clinical presentation, type of surgery, maternal morbidity and mortality were analysed. We have thus tried to demonstrate the changing trends in the aetiology and management of this condition in recent times.
During 1970-79 (Group I) there were 70 cases of rupture uterus among a total of 51087 deliveries, giving an incidence of 1 in 730 deliveries. During the period 1980-89 of 55360 deliveries there were 64 cases (Group II) of rupture uterus, a slightly decreased incidence (1 in 865 deliveries). In Group I, 74% were emergency cases, while in Group II 69.1% were emergency admissions showing that the importance of antenatal registration is yet not well appreciated by our patients.
[Table:1] shows the changing trends in the aetiology of rupture uterus. The incidence of traumatic vaginal delivery as a cause has considerably declined from 17.1 to 7.8% while that of previous caesarean scar rupture has doubled; from. 11.4 to 23.4%. The total incidence of spontaneous rupture was 71.4% in Group I and 70.3% in Group II. The incidence of rupture uterus in grandmultiparas has shown a decrease.
An analysis of the modes of presentation shows that only 45-60 patients in both groups presented with classical features of rupture uterus, i.e. history of prolonged labour and or intervention, shock and collapse, tenderness over the lower uterine segment and superficial fetal parts. Haematuria, an important sign was seen in only 17.1% cases in Group I, and in 9% cases in Group II. The overall diagnostic features remained the same in both groups. A study of the pathological features showed that the anterior wall of the lower segment continues to be the commonent site of rupture. However the incidence of incomplete ruptures have increased (8.02 to 21.5%) due to an increase in scar ruptures which are usually incomplete.
Analysis of the scar ruptures [Table:2] revealed occurrence in 3 cases during pregnancy, all of which were classical caesarean scars. The rest occurred during labour. A comparative increase of rupture scars in previous lower segment caesarean section was observed, especially in Group II.
[Table:3] shows the type of surgery performed, wherein conservative repair of the uterus was attempted in 22 cases (31.4%) in Group I and 24 cases (37.5%) in Group II. In Group I most of these ruptures had resulted from obstructed labour, while in Group II most of the re-sutured cases were scar ruptures; these ruptures are generally less drastic with lesser haemorrhage and shock, and a relatively clean-cut rent. Hence are the better results of conservative repair in Group II with a lower mortality rate (16.6%) as compared to Group I (mortality rate of 36.2%). Hysterectomy had to be done in cases with extensive tears and uncontrolled bleeding. In these cases, a subtotal hysterectomy was more commonly resorted to than total hysterectomy for Group II as compared to Group I. This preference for subtotal hysterectomy in Group II cases was vindicated by a lower mortality rate (15.6%) as compared to total hysterectomy cases (37.5%). The overall maternal mortality in Group II (18.7%) has also decreased compare to than in the earlier decade (24.3%). The import-ant causes of death were haemorrhage, shock, sepsis, disseminated intravascular coagulation (DIC) and pulmonary embolism.
[Table:4] shows the various complications that were noted, the overall morbidity showing a decrease from 42.8% in Group I to 35.9% in Group II.
Rupture uterus is a serious complication of pregnancy and labour. Its incidence has gradually declined over the years from 1 in 256 in 1962 to 1 in 305 in 1971. Our study confirmed the trend with an incidence of 1 in 730 in Group I and 1 in 865 in Group II. As regards to its aetiology, obstructed labour due to cephalo-pelvic disproportion and malpresentations, continued to be a major causative factor even in the last decade (62.4%). A report of 95 cases of rupture due to obstructed labour in a series of 164 cases (57.9%) has been published. A significant decline however has occurred in the incidence of traumatic vaginal delivery with more than double increase in previous caesarean scar rupture, (from 11.4 to 23.4%). Sinha and Roy also recently reported an incidence of 24.4% scar rupture, while Kulkarni and Kendre reported 56.12% scar rupture in their series on rupture uterus in rural India. This increase in scar rupture is due to an increasing use of caesarean section in the last decade or so, in place of difficult vaginal delivery. Although better alternatives in terms of fetal outcome and decreased maternal morbidity, improved these caesarean sections should not be accompanied by an increase in the rate of scar rupture. All patients with previous caesarean scars should be made aware of the importance of ante-natal care in all Subsequent pregnancies. They also require careful pre-natal supervision, proper selection of cases for vaginal delivery, early hospital admission, and close supervision in labour.
As to the choice of surgery, conservation of the uterus by re- suturing the rent should be attempted wherever possible. With availability of higher antibiotics and better non-steroidal anti- inflammatory drugs, good results have been obtained. However, in cases with severe haemorrhage and shock requiring Hysterectomy, operative time and exposure to anaesthesia are vital factors, and a quick sub total hysterectomy should be resorted to. In our series in Group II, the mortality with sub total hysterectomy was significantly less than that with total hysterectomy.
Thus in conclusion, most cases of rupture uterus are preventable with good ante-natal and intra-partum care, and proper identification of high-risk cases. Our study shows that there has been a decline in the overall morbidity in cases of rupture uterus during last decade (1980-89) and so also the mortality rate (decreased from 24,3 to 18.7%). But we yet have a long way to go to achieve targets comparable to the developed countries. In a Canadian study by Fedorkov et al, the incidence reported was as low as 1 in 2000, with no cases resulting from obstructed labour and no maternal mortality.
We thank the Dean, LTMG Hospital for permitting us to report the hospital data.
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