International Journal of Reproduction, Contraception, Obstetrics and Gynecology

Kalewad PS et al. Int J Reprod Contracept Obstet Gynecol. 2016 Sept;5(9):3098-3102

www.ijrcog.org pISSN 2320-1770 | eISSN 2320-1789

DOI: http://dx.doi.org/10.18203/2320-1770.ijrcog20162993
Research Article

Pregnancy outcome in cases of rupture uterus: a clinical study

Pallavi S. Kalewad*, Amarjeet Bava, Y. S. Nandanwar

Department of Obstetrics and Gynaecology, Lokmanya Tilak Municipal Medical College and Hospital, Sion, Mumbai,
Maharashtra

Received: 14 July 2016

Accepted: 09 August 2016

*Correspondence:
Dr. Pallavi S. Kalewad,
E-mail: pallavi.kalewad@gmail.com

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: The aim of the study was to evaluate and analyze the risk factors, maternal and perinatal outcome in
cases of ruptured uterus.
Methods: It is retrospective observational study was designed from January 2015 to December 2015. A total of 69
patients diagnosed with ruptured uterus during the study period were included.
Results: The incidence of uterine rupture was 0.64%. The uterine rupture in scarred uterus seen in 66 (95.6%) cases
and unscarred uterus 3 (4.4%) cases. Forty five (65.3%) patients did not receive any antenatal care. Sixty six (49.1%)
of the cases underwent previous uterine surgery due to cesarean. Other observed predisposing factors were
induced/augmented labor seen in 39 cases (29.1%), prolonged labor in 8 (6%), macrosomic fetus 8 (11.6%), grand
multiparous 10 (7.5%), multiple pregnancies 4 (3%) and malformed baby 2 (1.5%), cephalopelvic disproportion 2
(1.5%), instrumental deliveries 1 (0.7%) respectively. Primary repair of uterus was performed in 52 (75.2%) of the
patients. Subtotal abdominal hysterectomy was performed in 10 patients (15.2%). There were seven fetal deaths and
two maternal deaths recorded during the study period.
Conclusions: Uterine rupture is a major contributing factor for maternal and perinatal morbidity and mortality.
Proper antenatal care and early referral of women at risk to tertiary center will significantly improve maternal and
perinatal outcome. Uterine rupture is amongst the preventable obstetric complication that carries severe risks both to
the mother as well as the baby. Health education of people, training and supervision of health personal will reduce
incidence especially in remote areas.

Keywords: Uterine rupture, Scar rupture, Pregnancy outcome

INTRODUCTION Uterine rupture typically is classified as either: 1)

Complete uterine rupture was defined as complete when
Uterine rupture is a major obstetric hazard. Gravid all layers of the uterine wall are separated, with or
uterine rupture is associated with high maternal and without expulsion of the fetus or 2) Incomplete uterine
perinatal mortality-morbidity rates and loss of future rupture was defined as incomplete when the uterine
fertility. Despite advances in modern obstetric practice, muscle is separated but the visceral peritoneum is intact.
rupture of gravid uterus still remains as a fetal and
maternal life threatening complication especially in Uterine rupture is also classified on the basis of previous
developing countries; the incidence is high due to a surgery into 1) Rupture of scarred uterus 2) Rupture of
greater number of unbooked obstetric emergencies, often unscarred uterus.
originating from rural areas with poor antenatal care. In
India it still accounts for 5-10% of all maternal deaths. 1 As there is increase in the incidence of previous cesarean
The perinatal mortality ranges from 80 to 95 %. section deliveries or VBAC in teaching and referral
hospitals.1,2 Most common cause of uterine rupture seen

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in these centers are those involving a previous uterine and 0.023% in Ireland study conducted by Gardiel F,
scar rupture during labor. Daly S et al.6,7

Rupture of an unscarred uterus may be either traumatic or Table 1: Incidence.

spontaneous. Traumatic factors include instrumental
deliveries, internal podalic version, assisted breech Total number of delivery 10734
delivery, abdominal trauma, labor induction, and in Total number of rupture 69
particular the unmonitored usage of oxytocin or Incidence 0.64%
prostaglandins. Fundal pressure during third stage of
labor also has been linked to traumatic rupture. The uterine rupture was classified as scarred in 66
Spontaneous rupture is usually observed with (95.6%) patients and unscarred in 03 (4.4%) patients
cephalopelvic disproportion, delivery of a macrosomic or depend on previous surgical history. Scarred uterine
a grossly anomalous fetus, malpresentation. Rupture may rupture is again classified into complete uterine rupture in
also develop spontaneously in grand multiparas, 7 (10.6%) patients and incomplete uterine rupture in 59
congenitally abnormal uteri (e.g. Unicornuate or (85%) patients according to the surgical finding. As
bicornuate), abnormal placental implantation, previous shown in the above table Incidence of rupture in scarred
history of uterine perforation and in women with a uterus was much higher than in unscarred uterus.
history of invasive mole in previous pregnancy. Uterine
rupture occurs in 1: 200 to 1: 3000 deliveries depending Table 2: Type of uterine rupture.
upon standard of obstetric care and the population dealt
with.2,3 Type of uterine rupture Number Percentage
Scarred 66 95.6
This obstetrics complication is also associated with short Complete 7 10.6
term maternal morbidities such as vesicovaginal fistula, Incomplete 59 85
rectovaginal fistula, bladder rupture, foot drop, Unscarred 03 4.4
psychological trauma, anemia and in the long term
because of the surgical intervention, the woman may be
In study conducted by Ibha K, Poonam G, Sehgal A et al
sterilized which can lead to divorce and loss of economic
49.1% uterine rupture occurred at the previous lower
support.4 segment cesarean section (LSCS) scar and our
An early diagnosis, their timely referral from gross route observation is similar to that of others.3,11
level and prompt treatment of the condition is the most
Table 3: Incidence of uterine rupture with regard to
important factor in improving the maternal and perinatal
demographic variables.
outcome. This retrospective study was undertaken to
evaluate and analyse various aspects of uterine rupture. Variables Number Percentage
Age
METHODS
<20 0 0
21-25 19 27
It is a retrospective observational study done over one
year. 26-30 41 60
31-35 7 10
All cases of rupture of uterus treated in the Lokmanya >35 2 3
Tilak Municipal Medical College and Hospital, Sion, Booking status
Mumbai during period from Jan 2015 to Dec 2015. Booked 24 34.7
Unbooked 45 65.3
Patients diagnosed with the rupture uterus, with previous Parity
scarred or unscarred uterus during latent phase or active Para 0 1 1.5
phase were included in our study. Para 1 23 33
Para 2 35 51
RESULTS >/=Para 3 10 14.5
Birth weight
Incidence of uterine rupture in our study is 0.64%. <2.5kg 9 13
2.6-3.5kg 52 75.4
In developing countries like Nigeria it is higher i.e. >3.6kg 8 11.6
1.69% according to study conducted by Ibrahim SM,
Umar NI et al.5 The incidence in developed countries is 60% of the cases were in the 26-30 year age group
at least ten times lower i.e. 0.086% in Australia study whereas 27% were in 21-25 years age group. 45 (65.3%)
conducted by Lynch JC, Pardy JP et al cases were unbooked and 24 (34.7%) were booked cases.
Most of the booked cases were post caesarean, which

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came to the hospital long after onset of labor pains at In Nigerian study uterine repair done in 67.9% of cases
their homes. Majority of the unbooked patients came and subtotal hysterectomy done in 24% cases and total
from rural areas and most of them had irregular antenatal hysterectomy done in 7.5% cases incidence is near to
check-ups. 90% of the women belonged to the low socio similar with our study.5
economic group.
Common complications seen in our study is anemia that
Table 4: Etiology of uterine rupture. required blood transfusion is 10 (14.5%), PPH 4 (5.8%)
and febrile morbidities seen in 13 (18.9%) cases. ICU
Etiology Number Percentage Study conducted in Rawalpindi medical college by Ara J
Previous LSCS 66 49.2 et al, incidence of rupture in scarred uterus was 86.7%,
Previous 1 LSCS 39 29 obstructed labor 23.3%, prolonged labor 33.3% and in
Previous 2 LSCS 10 7.5 induced labor was 26%.8
VBAC after 1 LSCS 17 12.7
Induction and/or Primary repair of uterus was performed in 52 (75.2%) of
39 29.1 the patients with bilateral tubal ligation in 46 (66.6%)
augmentation of labour
Grand multiparity 10 7.5 patients and without tubal ligation in 6 (8.6%) patients.
Prolong labour 8 6 Subtotal abdominal hysterectomy was performed in 10
patients (15.2%). Total hysterectomy was performed in 4
Twins/multiple
4 3 (5.8%) patients. Bladder repair was done in two patients
pregnancy
(3%) and colporrhexis in 1 (0.8%).
Cephalopelvic
disproportion 1.5
2 Table 6: Maternal and fetal outcome.
(borderline)
Spontaneous rupture 2 1.5 Outcome Number Percentage
Malformed baby 2 1.5 Maternal morbidity
Instrumental delivery 1 0.7 Anemia (required
Previous 10 14.5
blood transfusion)
myomectomy/other 0 0 Postpartum hemorrhage 4 5.8
surgery Febrile morbidity 13 18.9
ICU admission 4 5.8
Study conducted in Nigeria by Ibrahim SM, Umar NI et Maternal mortality 2 2.9
al uterine rupture seen most commonly in 25 to 35 age of
Perinatal outcome
age group 45%, incidence was higher in parous women
Normal fetus 46 66.6
95% and incidence in unbooked patients was 93.7%.5
Hypoxic injury 16 23.2
Table 5: Surgical management. Malformed baby 2 2.9
Perinatal mortality 7 10.1
Surgery Number Percentage
Scar repaired 52 75.2 admission required in 4 (5.8%) cases.
With sterilization 46 66.6
Without sterilization 6 8.6 2 patients with rupture uterus expired in spite of all the
Hysterectomy 14 21 efforts taken and there were 7 neonatal deaths in our
Total 4 5.8 study.
Subtotal 10 15.2
In study conducted in Nigeria maternal mortality rate was
Bladder repaired 2 3
Colporrhexis 1 0.8 1.1% and perinatal mortality rate was 87.4%.5 In our
study perinatal mortality rate 0.7 per 1000 live birth was
very low because of early diagnosis and prompt
In our study average fetal weight at which uterine rupture management of uterine rupture.
occurred were between 2.6kg-3.5kg which was 52
(75.4%).
DISCUSSION
Sixty six (49.1%) of the cases had previous caesarean
Rupture of the gravid uterus is an unexpected obstetric
section. Other observed predisposing factors were
emergency with high maternal and perinatal morbidity-
induced/augmented labor seen in 39 cases (29.1%),
mortality rates. The frequency of uterine rupture in the
prolonged labor in 8 (6%), macrosomic fetus 8 (11.6%),
presented study was 0.64%. This is due to increase in
grand multiparous 10 (7.5%), multiple pregnancies 4
number of referrals from peripheral hospitals. Our
(3%), malformed baby 2 (1.5%), cephalopelvic
hospital caters to rural as well as urban areas and is one
disproportion 2 (1.5%), and instrumental deliveries 1
of the referral centers for complicated cases in and
(0.7%).
around the city. In developing countries like Ethiopia and

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 Kalewad PS et al. Int J Reprod Contracept Obstet Gynecol. 2016 Sept;5(9):3098-3102

Nigeria it is 0.03% and 0.83% respectively. 6,9 The management. This incidence was similar to other study
incidence in developed countries is at least ten times performed in india.15
lower i.e. 0.086% in Australia and 0.023% in Ireland. 6,7
In our study perinatal mortality was 0.7 per 1000 live
Higher incidence in developing countries is attributable birth, in study conducted in Nigeria maternal mortality
to neglected and obstructed labor, inadequate access to rate was 1.1% and perinatal mortality rate was 87.4%. 5
medical care, injudicious use of oxytocin by untrained In our study perinatal mortality rate is very low because
people, poor monitoring of patients with previous CS, of early detection, prompt treatment of uterine rupture
several shortcoming in health care system as Lack of and this is due to higher number of incomplete scarred
antenatal booking, lack of specialist staff, failure of uterine ruptures.
referral and transport system between health care
centers.10 CONCLUSION

In our study incidence of rupture in previous LSCS was Rupture uteri is a serious life-threatening obstetric
66%. In study conducted by Ibha K, Poonam G, Sehgal A complication. The high maternal and fetal morbidity and
et al 49.1% uterine rupture occurred at the previous lower mortality rates that follow uterine rupture calls for an
segment cesarean section (LSCS) scar and our integrated effort to prevent its causes. Good ANC,
observation is similar to that of others 3, 11. Rupture of Family planning services, prompt referral of obstructed
LSCS scar most often takes place when the women are labor, availability of transportation and obstetric care are
allowed to labor. There is a lack of awareness in our the essential factors to prevent complications and to
population about the need for antenatal care and decrease the maternal mortality, fetal mortality and
supervised hospital delivery, especially in those women maternal morbidity rates associated with it. At the same
who have had previous cesarean section. Incidence of time, there is a significant rise in rupture of previous
uterine rupture in induced/augmented labor was 29.1% in cesarean scars. Reducing the primary cesarean section
our study. Women with previous LSCS and induction of rate and optimizing care for women with previous scarred
labor are more prone to rupture than those who undergo uterus will go a long way in decreasing the incidence of
spontaneous labor.12 rupture uterus. Educating women who have undergone
cesarean section once or twice before, about risks and
Other most common cause of spontaneous uterine rupture consequences will help to reduce complications in these
in our study was grand-multipara which was 7.5%. Dare patients, especially in those who insist on VBAC and
and Oboro reported rupture in grand multiparas was avoid going to hospitals as Labor pains begin.
12.7/1000 deliveries, and rupture in paras 1-4 in 3.1/1000
deliveries.13 In Ezechi et al series 50.8 % were grand Funding: No funding sources
multiparas and in Ibha et al series 32% were grand Conflict of interest: None declared
multiparas.11,14 Ethical approval: The study was approved by the
Institutional Ethics Committee
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Cite this article as: Kalewad PS, Bava A,

Nandanwar YS. Pregnancy outcome in cases
of rupture uterus: a clinical study. Int J Reprod
Contracept Obstet Gynecol 2016;5:3098-102.

International Journal of Reproduction, Contraception, Obstetrics and Gynecology Volume 5 · Issue 9 Page 3102