Uterine Rupture: A Literature Review and Case Presentation Highlighting Diagnostic and Clinical Challenges Posed by this Rare and Potentially Catastrophic Obstetric Emergency

Review Article

Austin J Obstet Gynecol. 2024; 11(1): 1224.

Uterine Rupture: A Literature Review and Case Presentation Highlighting Diagnostic and Clinical Challenges Posed by this Rare and Potentially Catastrophic Obstetric Emergency

Aboda A*; Kathawadia K; McCully B

Department of Obstetrics & Gynaecology, Mildura Base Public Hospital, Australia

*Corresponding author: Ayman Aboda Department of Obstetrics & Gynaecology, Mildura Base Public Hospital, Mildura 3500, Victoria, Australia. Email: aymanaboda@hotmail.com; aaboda@mbph.org.au

Received: November 24, 2023 Accepted: December 29, 2023 Published: January 04, 2024

Abstract

Uterine rupture is a rare but life-threatening condition, with incidence ranging from 1 in 5,700 to 1 in 20,000 pregnancies. It is an obstetrical emergency requiring rapid intervention to mitigate harm and allow the best possible chance of survival for mother and baby. While the most frequent antecedent is scar dehiscence associated with previous uterine surgeries such as caesarean section or, less commonly, myomectomy or curettage, other non-iatrogenic aetiologies must also be considered to allow a fully inclusive approach sufficient to spur acute clinical care. This review highlights these factors and the limitations of diagnostic imaging modalities in an acute management setting. It aims to accrue the importance of broad clinical suspicion and pre-emptive action in patients presenting with pain during pregnancy regardless of predisposing risk and the assurances of non-interventional scanning. We offer this review to share an experience of clinical care and improve knowledge and understanding to improve future patient care.

Introduction

Complications during pregnancy and labour present varying degrees of risk to both the mother and fetus. A rare but often catastrophic condition that may occur is a rupture or full-thickness tearing of the gravid uterine wall. This may be complete when the serosal layer is compromised. In this situation, pregnancy contents may be lost or expelled from the uterine cavity. The concept of uterine rupture has been documented in medical literature for centuries, but there are no exact details of the first recorded case. Ancient Mesopotamia, the cradle of civilization, developed a complex understanding of medicine. Clay tablets dating back to around 2000 BCE narrate the story of a woman presenting with severe abdominal pain during labour. The text cryptically mentions "the belly breaking open," suggesting a likely uterine rupture. The Ebers Papyrus, dating back to 1550 BC, contains some of the oldest known medical treatises. Among the many case descriptions is an account of a woman suffering from severe abdominal pain during childbirth, presumed by modern scholars to be a uterine rupture. It describes a woman in distress during the late stages of her delivery. The text mentions "a tearing sensation in her middle" and the realisation of "her life force fleeing.” In the Hippocratic Corpus, a collection of ancient Greek medical texts written in the 5th and 4th centuries BCE, Hippocrates (circa BC 460- 370) made many observations of obstetrics and, tragically, the agonies of complicated childbirth, most notably those of prolonged or arduous labour which according to modern interpretations, may well have included uterine rupture [1]. Soranus of Ephesus circa (AD, year 98 – 138) described a case of a young woman assailed with unbearable pain during her delivery. Soranus felt the protrusion of a fetal limb through a tear in the uterine wall. His account says, "The limb appeared as if attempting to escape, signifying damage to the womb's enclosure” [2].

In the modern world, uterine rupture continues to complicate pregnancy and childbirth. It occurs most often as a complication of obstructed labour, particularly in remote or third-world settings where obstetric or midwifery care is limited or inaccessible, and women with abnormal progress of labour or dystocia may languish without care or intervention [3]. In developed countries, uterine rupture is often due to "scar rupture" in women with previous caesarean section deliveries or, less commonly, following other uterine surgeries such as myomectomy [4]. In the former, studies suggest that women with a single-layer closure are more likely to have thinner residual myometrium than those with a double-layer closure, suggesting greater susceptibility to future dehiscence and rupture [5,6].

Rupture has also been reported as a complication of inadvertent perforation during prior hysteroscopy or curettage [7]. Procedures that entail uterine manipulation, such as an antenatal external cephalic version for breech presentation or an internal podalic version during breech extraction for vaginal delivery of an after-coming second twin, may also be associated with rupture [8,9]. Not surprisingly, rupture is more likely to be seen with difficult deliveries such as those associated with abnormal presentation, foetal macrosomia or assisted instrumental deliveries [3]. It is also more likely to occur when there has been excessive uterine distension, such as with multiple pregnancies or polyhydramnios [8]. Maternal age and parity are also associated with increased risk. The uterine wall may become less pliable with subsequent pregnancies, which may predispose to rupture or tearing. Additionally, abdominal wall laxity, associated with high parity, may permit malpresentation of the presenting part with subsequent dystocia of labour and uterine rupture, particularly in oxytocic stimulation [10,11]. More rarely, uterine adenomyosis, where the inflammatory process may disrupt myometrial fibres, pelvic radiation, connective tissue disorders, and prolonged corticosteroid use, is also associated with increased risk [12,13].

In one case, a 27-year-old primigravida woman at 22 weeks with no known significant history presented to the emergency department with acute abdominal pain. Ultrasound demonstrated normal fetal biometrics and evidence of diffuse adenomyosis in the uterine wall. Soon after admission, her condition deteriorated, and she became pale with tachycardia and hypotension, suggesting hypovolemia. Repeat ultrasound showed the presence of a single still viable foetus in the abdomen associated with free fluid. Laparotomy revealed massive hemoperitoneum and uterine rupture with extravasation of the entire gestational sac. The baby was stillborn at delivery. In other reports, abnormalities of placentation, such as placenta percreta or accrete, have been associated with mid-trimester uterine rupture [12,13].

A recent systematic review of pre-labour uterine rupture between 14 and 34 weeks of gestation using PubMed Google Scholar from 1988 to 2020 showed that nearly half, 36 cases, were associated with previous caesarean deliveries. In a further 6, a classical uterine incision had been performed. Myomectomy was seen in 20 cases, uterine malformations in 13 and 35 cases identified placenta accreta. Paradoxically, studies also show that mothers with pregnancy complications, such as hypertensive and cardiac disorders, antepartum haemorrhage or premature membrane rupture, are less likely to develop uterine rupture. This may well reflect the increased obstetric surveillance in these patients and decreased tolerance for variances of labour that might otherwise conjure an increased risk or predisposition to uterine rupture [14].

Universally, case reports of uterine rupture in the first trimester are rare. They are slightly more common in the second trimester [15,16]. However, they are most often reported in the third trimester, particularly in the setting of labour and delivery, where, in addition to the risks previously noted, they are most commonly linked to uterotonic stimulation for induction or augmentation of poor progress [17]. Spontaneous rupture of the uterus in the early second trimester is a rare and unprecedented event that challenges preconceptions of emergency obstetric presentation and may elude conventional methods of diagnostic delineation. It demands urgent, definitive care to safeguard maternal well-being and to protect future reproductive potential [18]. It is universally associated with grievous maternal outcomes and inevitable pregnancy loss.

Case Presentation

We present the case of a 27-year-old female, 16+6 weeks pregnant, who presented to the Emergency Department with sudden onset of right-side abdomen pain. The pain was unprovoked, constant, and experienced initially as a score of 9/10. It was localised to the Right Iliac Fossae (RIF), epigastrium and right shoulder tip. Apart from nausea and vomiting, there were no other bowel symptoms. There were no urinary symptoms and no history of abnormal vaginal bleeding. She had no shortness of breath or chest pain. Her vital signs were stable on arrival. She was afebrile, her Heart Rate (HR) was 131 bpm, her Blood Pressure (BP) was 148/88 with no postural drop, and her oxygen saturation was 100% on room air. The ED, General Surgery, and Obstetric teams reviewed her. Her abdomen was soft, with localised tenderness in the RIF & RUQ associated with guarding and rebound tenderness. Investigations taken at admission revealed normal FBC with HB 110, WCC 8.3 and PLT 271. Her CRP was 40.9. She had normal Urea and electrolytes, Liver function tests and Lipase. Her serum HCG was 36463. An urgent Ultrasound scan of the abdomen and pelvis showed free fluid around the spleen and in Morrison's pouch and RIF. The appendix could not be visualised. Both ovaries were normal, and a live intrauterine pregnancy consistent with dates was confirmed – Figures 1, 2 and 3. The initial impression was of localised peritonitis with suppuration consistent with suspected acute appendicitis.