Rupture of the uterine body or lower segment during pregnancy or labor is called uterine rupture. It often occurs during labor and is related to factors such as obstructed labor, inappropriate difficult childbirth surgery, misuse of uterine contraction agents, uterine trauma during pregnancy, and poor healing of uterine surgical scars. Some cases occur in the late stage of pregnancy. Uterine rupture is one of the most serious complications in obstetrics, often leading to maternal and fetal death. Its incidence rate is one of the criteria for judging the quality of obstetric care in a region. In recent years, with the improvement in the quantity and quality of obstetric workers in China, and the establishment and gradual improvement of the three-level maternal and child health care network in urban and rural areas, its incidence rate has significantly decreased.
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Uterine rupture
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1. What are the causes of uterine rupture
2. What complications can uterine rupture lead to
3. What are the typical symptoms of uterine rupture
4. How to prevent uterine rupture
5. What laboratory tests are needed for uterine rupture
6. Diet taboos for patients with uterine rupture
7. Conventional methods of Western medicine for treating uterine rupture
1. What are the causes of uterine rupture
Uterine rupture often occurs in difficult labor, elderly multiparous women, and women with a history of surgery or injury to the uterus. According to the cause of rupture, it can be divided into scarless uterine rupture and scarred uterine rupture.
1. Obstructed labor
Obvious pelvic narrowness, malpresentation, deformity of the soft birth canal, pelvic tumors, and abnormal fetal position, etc., hinder the descent of the presenting part of the fetus. To overcome the resistance, the uterus strengthens its contractions, and the lower uterine segment is forced to elongate and become thin, ultimately leading to uterine rupture. This type of uterine rupture is the most common type of uterine rupture, and the rupture site often occurs in the lower uterine segment.
2. Uterine scar rupture
The main causes of uterine scar formation include cesarean section, resection of uterine fibroids, repair of uterine rupture or perforation, and correction of uterine malformation. The cause of rupture is the mechanical traction of the pregnant uterus, leading to rupture at the scar site or damage to the endometrium at the uterine scar, placental implantation, and penetrating placenta causing spontaneous uterine rupture. In recent years, the rapid increase in cesarean sections has led to an increased incidence of uterine rupture in subsequent pregnancies with a longitudinal incision in the uterine body. The analysis of the reasons includes not only the difference in the anatomical nature of the longitudinal incision in the uterine body and the transverse incision in the lower segment, but also the role of infection factors, because patients who undergo cesarean section with a longitudinal incision in the uterine body usually have a long labor process, multiple vaginal examinations, and an increased risk of infection.
3. Abuse of uterotonic agents
The uterotonic agents here should include various substances that stimulate uterine contraction, including the most commonly used oxytocin (pitocin) and misoprostol, which has been applied in recent years. There are increasing reports of misoprostol causing uterine rupture. The main reasons include excessive drug dosage or rapid administration speed, immature cervix, malpresentation, obstructed labor, and not observing the labor process carefully during medication.
4. Injury from vaginal obstetric surgery
Incomplete cervical os, forced forceps delivery or breech extraction, leading to severe cervical laceration and extension to the lower uterine segment. Negligent transverse version, destruction of the fetus, and partial artificial placental stripping due to improper operation can all cause uterine rupture.
5. Uterine malformation and uterine wall hypoplasia
The most common is bicornuate uterus or unicorne uterus.
6. Uterine itself lesions
Multiparous women, history of multiple dilatation, history of infectious abortion, history of uterine cavity infection, history of artificial placental stripping, history of hydatid mole, and so on. Due to the above factors, the endometrium and even the muscular wall may be damaged, leading to placental implantation or penetration after pregnancy, and ultimately resulting in uterine rupture.
2. What complications can uterine rupture easily lead to
One of the manifestations of the harm of uterine rupture is the harm to the fetus. Experts say that once the fetus breaks out of the uterus and enters the abdominal cavity, the sudden disappearance of uterine contraction pressure, the change in the shape of the uterus, and the change in the position of the fetus may result in the inability to hear the fetal heart sound or irregular late diastolic deceleration of the fetal heart sound, even causing early placental abruption, leading to fetal distress and the possibility of stillbirth. The harm of uterine rupture also manifests in the harm to the mother. After uterine rupture, severe internal bleeding may occur, resulting in symptoms such as severe abdominal pain, rebound pain, and extreme bloating. In severe cases, it can lead to hemorrhagic shock and other conditions.
3. What are the typical symptoms of uterine rupture
Uterine rupture can occur in the late pregnancy period before labor, but most cases occur during labor when there are difficulties in delivery, manifested by prolonged labor, the inability of the fetal head or presenting part to enter the pelvis or to be obstructed at the level of the ischial spines or above. Most uterine ruptures can be divided into two stages: predisposition to uterine rupture and uterine rupture.
I. Predisposition to uterine rupture
During the process of labor, when the presenting part of the fetus is obstructed from descending, strong uterine contractions gradually thin the lower segment of the uterus while making the body thicker and shorter, forming a distinct annular concavity between the two. This concavity gradually rises to the level of the umbilicus or above it, and is called pathological contraction ring. The mother may complain of severe lower abdominal pain that is difficult to bear, restlessness, rapid breathing, difficulty in urination, and an increased heart rate. Due to the frequent contractions of the uterus, the blood supply to the fetus is obstructed, resulting in a change in fetal heart sound or difficulty in hearing it. During examination of the abdomen, a distinct concavity can be seen on the abdominal wall, the lower segment of the uterus is prominent, and there is marked tenderness. The round ligament of the uterus is extremely tense, and it can be palpated clearly with tenderness. Due to the compression of the presenting part of the fetus that is stuck in the pelvis entrance, which damages the mucosa of the bladder, hematuria can be seen during catheterization. If this situation is not resolved immediately, the uterus will soon rupture at the pathological contraction ring and below it.
II. Uterine rupture
According to the degree of rupture, it can be divided into complete uterine rupture and incomplete uterine rupture.
1. Complete uterine rupture
Complete rupture of the uterine wall, allowing communication between the uterine cavity and the abdominal cavity. In an instant of complete uterine rupture, the mother often feels a tearing-like severe abdominal pain, followed by the disappearance of uterine contractions and pain relief. However, as blood, amniotic fluid, and the fetus enter the abdominal cavity, persistent abdominal pain occurs. The mother may exhibit symptoms of shock, such as pale complexion, cold sweat, shallow breathing, rapid, thin pulse, and decreasing blood pressure. During examination, there may be tenderness and rebound pain in the entire abdomen. The fetus can be palpated clearly below the abdominal wall, the uterus has shrunk and is located on the side of the fetus, the fetal heart sound has disappeared, and there may be fresh blood discharge from the vagina, which can be either abundant or scarce. The presenting part of the fetus, which was exposed or descending, has disappeared (the fetus has entered the abdominal cavity), and the previously dilated cervix may retract. When the anterior wall of the uterus ruptures, the rupture may extend forward to cause bladder rupture. If there is a lot of bleeding in the abdominal cavity, a mobile dullness can be percussion. If it has been diagnosed as a uterine rupture, there is no need for further vaginal examination of the rupture site. If the uterine rupture is caused by oxytocin injection, the mother may feel strong uterine contractions and sudden severe pain after medication, followed by the upward and disappearance of the presenting part. Abdominal examination shows the aforementioned findings.
2. Incomplete uterine rupture
It refers to the complete or partial rupture of the uterine muscle layer, with the serosal layer not yet pierced, and the uterine cavity not communicating with the abdominal cavity. The fetus and its附属物 are still in the uterine cavity. Abdominal examination shows tenderness at the site of incomplete uterine rupture. If the rupture occurs between the two leaves of the broad ligament on the lateral wall of the uterus, a hematoma within the broad ligament can form. At this time, a gradually increasing and tender mass can be felt on one side of the uterus, and the fetal heart sound is often irregular. If the uterine artery is torn, it can cause severe extraperitoneal hemorrhage and shock. Abdominal examination shows that the uterus still maintains its original shape, with marked tenderness after rupture, and a gradually increasing hematoma can be felt on one side of the abdomen. The hematoma in the broad ligament can also extend upwards to become a retroperitoneal hematoma. If bleeding does not stop, the hematoma can penetrate the serosal layer, forming a complete uterine rupture.
Although uterine rupture caused by uterine scar can occur in the later stages of pregnancy, most cases occur during labor. The prodromal symptoms are usually not obvious, only with slight abdominal pain. There is tenderness at the site of the uterine scar, and at this time, one should be vigilant for the possibility of scar rupture. However, since the amniotic membrane has not ruptured, the fetal position can be clearly felt and the fetal heart is good. If it can be detected and treated in time, the prognosis for both mother and child is good. Due to the mild symptoms, it is easy to be overlooked. When the incision expands, symptoms and signs similar to complete rupture appear when amniotic fluid, fetus, and blood enter the abdominal cavity, but there is no tearing pain. Some scars rupture with little bleeding, and apart from the cessation of uterine contractions and the disappearance of fetal movement, there are no other discomforts. Abdominal distension and abdominal pain, symptoms of peritonitis, may appear 2-3 days later. Uterine rupture caused by improper use of oxytocin is characterized by intense uterine contractions and a sudden tearing-like abdominal pain after medication, with signs of uterine rupture on abdominal examination.
4. How to prevent uterine rupture
To prevent uterine rupture, it is necessary to strengthen the publicity and implementation of family planning, reduce the number of multiparas; change the concept of childbirth, advocate for natural childbirth, and reduce the rate of cesarean sections; strengthen prenatal examinations, correct malpresentation, and for those with potential difficulties in childbirth, a history of dystocia, or a history of cesarean section, early hospitalization for childbirth should be arranged, and the progress of labor should be closely observed. The mode of delivery should be decided based on obstetric indications and the previous surgical history. Strict control should be exercised in the application of oxytocin, including indications, methods, and dosage, and there should be a dedicated guardian. For women with uterine scar or malformation who attempt labor, close observation of the labor process and relaxation of the indication for cesarean section should be made. Close observation of the labor process is particularly important for women with high presentation and abnormal fetal position who attempt labor; avoid large-scale vaginal assistance and operations, such as mid-high forceps, assistance before the cervix is fully dilated, internal version for shoulder presentation, and forced extraction of the placenta when it is implanted.
5. What laboratory tests are needed for uterine rupture
Observing the changes in blood routine dynamically can also assist in the diagnosis of uterine rupture in some cases, especially in broad ligament uterine rupture and atypical uterine rupture. For suspected broad ligament uterine rupture, dynamic monitoring of blood routine changes can assist in diagnosis and can roughly estimate the amount of blood loss. Precautions include: comparing the immediate hemoglobin and red blood cells with those at admission; regularly reviewing the dynamic changes of hemoglobin and red blood cells; a decrease of 10g/L (1g/dl) in hemoglobin is equivalent to approximately 500ml of blood loss, and attention should be paid to the early stage of shock, where blood is concentrated, and the estimated blood loss may be less than the actual blood loss; comprehensive analysis with vaginal bleeding; attention should be paid to the progressive decrease in platelets; if possible, dynamic monitoring of coagulation function and the dynamic changes of D-dimer.
1. Abdominal puncture or cul-de-sac puncture
It can clearly determine whether there is bleeding in the abdominal cavity, mobile dullness positive on abdominal percussion, combined with medical history and signs, and in most cases, this examination is not necessary for diagnosis.
2. B-ultrasound examination
Fetus is in the abdominal cavity, fetal movement and heartbeat have disappeared; the uterus has shrunken with a tear, and there is free fluid in the abdomen.
3. Vaginal examination
The presenting part retracts, the dilated cervix shrinks, and fresh blood can be seen flowing out.
6. Dietary taboos for patients with uterine rupture
In terms of diet, it is recommended to eat less chili peppers, and avoid eating chili peppers before labor or when constipated, as chili peppers can cause constipation and increase blood flow, among other adverse effects. During pregnancy, due to the compression of the enlarged uterus on the digestive tract, pregnant women are prone to constipation. If chili peppers, especially too much dried chili peppers, are eaten, it is easier to exacerbate constipation. If constipation occurs, one has to strain and hold their breath, which increases abdominal pressure, thereby compressing the uterus, fetus, and local blood vessels, leading to insufficient blood supply. This can easily cause adverse phenomena such as increased blood pressure, abortion, preterm birth, or fetal malformation. If a pregnant woman eats chili peppers during labor, it can indirectly cause uterine rupture or eclampsia.
7. Conventional methods of Western medicine for treating uterine rupture
When there is a sign of uterine rupture, effective measures should be taken immediately to suppress uterine contractions to alleviate the progression of uterine rupture. It is best to perform cesarean section as soon as possible, and pay attention to check whether the uterus has ruptured during the operation. The purpose of treating uterine rupture is to correct shock, prevent and treat infection, and perform laparotomy. The surgical principle strives for simplicity and speed, and aims to achieve hemostasis. Different surgical methods are determined according to the degree and location of uterine rupture, the time from the occurrence of rupture to the operation, and whether there is severe infection.
First, general treatment
Uterine rupture is often accompanied by severe bleeding and infection, and preoperative blood transfusion, fluid infusion, sodium lactate administration, and active anti-shock treatment should be performed. Intraoperative and postoperative administration of large doses of broad-spectrum antibiotics is required to control infection.
Second, Surgical Treatment
1. Early Signs of Uterine Rupture:When the early signs of uterine rupture are detected, drugs to suppress uterine contractions should be administered immediately, such as inhalation or intravenous general anesthesia, intramuscular or intravenous injection of sedatives, such as pethidine 100mg, and cesarean section should be performed as soon as possible. If the fetal heart sound exists, cesarean section should be performed as soon as possible, and it is possible to obtain a living baby.
2. Surgical Treatment of Uterine Rupture
(1) For patients with uterine rupture within 12 hours, with整齐的 incision edges and no obvious infection, and who need to retain reproductive function, it can be considered to repair and suture the rupture.
(2) For cases with a large rupture or irregular tearing and a possible infection, consider a subtotal hysterectomy.
(3) If the uterine incision extends not only to the lower segment but also to the cervical os, consider a total hysterectomy.
(4) If the scar of a previous cesarean section ruptures, including the corpus or lower segment of the uterus, and the mother has a living baby, the incision should be sutured, and bilateral tubal ligation should be performed at the same time.
(5) When there is a large hematoma in the broad ligament, to avoid injury to surrounding organs, it is necessary to open the broad ligament, isolate the ascending branch of the uterine artery and its accompanying veins, and push the ureter and bladder away from the tissue to be clamped to avoid injury to the ureter or bladder. If there is active bleeding during the operation, the ipsilateral internal iliac artery ligation can be performed first to control the bleeding.
(6) In addition to paying attention to the site of uterine rupture during laparotomy exploration, the bladder, ureter, cervix, and vagina should be carefully examined. If there is injury, simultaneous repair of these organs should be performed.
(7) For individual cases that have been overlooked, have a long labor, and are severely infected, to save the life of the mother, the operation time should be minimized as much as possible, and the operation should be as simple and rapid as possible to achieve hemostasis. Whether to perform a total hysterectomy or a subtotal hysterectomy or only incision suture combined with bilateral tubal ligation depends on the specific situation. Effective antibiotics should be used before and after the operation to prevent and treat infection.
(8) For patients with uterine rupture and shock, first-aid treatment should be provided on the spot as much as possible to avoid exacerbating shock and bleeding due to transportation. However, if it is necessary to transfer to a hospital due to local conditions, the transfer should also be carried out after massive fluid resuscitation, blood transfusion to counteract shock, and abdominal bandaging.
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