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Rupture uterus: a retrospective analytical study

Uterine rupture is a catastrophic obstetric complication associated with high rates of fetal and maternal morbidity and mortality. In India, it is responsible for 5%-10% cases of all maternal deaths even now. Rupture Uterus can occur at any stage of gestation. Rate of rupture uterus is low in developed countries but while in developing countries like India it’s a still one of the leading cause of maternal mortality. Uterine rupture is defined as a fullthickness separation of the uterine wall and the overlying serosa.


INTRODUCTION
Over 500,000 women die each year due to complications of pregnancy and childbirth, a number that has remained relatively unchanged since 1990, when the first global estimates of the burden of maternal mortality were developed (WHO 2005). 1 Uterine rupture is a catastrophic obstetric complication associated with high rates of fetal and maternal morbidity and mortality. 2 In India, it is responsible for 5%-10% cases of all maternal deaths even now. 3 Rupture Uterus can occur at any stage of gestation. Rate of rupture uterus is low in developed countries but while in developing countries like India it's a still one of the leading cause of maternal mortality. Uterine rupture is defined as a fullthickness separation of the uterine wall and the overlying serosa. 4 predisposing factors for uterine rupture. 5 Consequences of uterine rupture depend on the time between diagnosis of uterine rupture and delivery and can be divided to fetal and maternal. Fetal consequences are admission to neonatal intensive care unit, fetal hypoxia or anoxia, and neonatal death. Maternal consequences are hemorrhage, hypovolemic shock, bladder injury, need for hysterectomy, and a maternal death. On the other hand, morbidity and mortality following rupture of the uterus depend on the level of medical care. 6 The present study was undertaken to evaluate the predisposing factors, clinical presentation, management, maternal outcome of rupture uterus at our hospital. This is a retrospective analytical study that included data collection only. It does not pose any risk to the patients and does not pass any cost to the institute.
On evaluation of predisposing Factors, we have evaluated that prolonged obstructed labor was the main cause of rupture uterus (15 cases-51.72%). Mismanaged second stage of labor was a one of the major contributory factor to it.
Out of 29 cases, in one case rupture was found with transverse lie (3.44%) while in one case injudicious use of oxytocin was found (3.44%). Out of 29 cases of rupture uterus, 16 had undergone obstetric Hysterectomy (55.17%) while in 13 cases repair was done (44.82%). Most common site of rupture was lateral wall of uterus while in cases with scarred uterus lower segment scar rupture was the site of rupture. 10 cases were diagnosed as a rupture uterus at the time of admission in our institute (34.48%) while in rest 19 cases rupture was developed in institute (65.52%). Average Duration of hospital stay was 13 days. All women required blood transfusion.
Associated Bladder injury was found in 2 cases (6.89%) while 8 patients were having wound gap (27.58%). We have found 2 cases of maternal death (6.89%) while study period with rupture uterus.

DISCUSSION
Ruptured uterus still remains one of the serious obstetric complications. Lack of health information, illiteracy, poor antenatal care, poverty, home deliveries by traditional birth attendants and delay in referrals all contribute to uterine rupture. 7 There are two types of uterine rupture, complete and incomplete, distinguished by whether or not the serous coat of the uterus is involved. 8 In the former, the uterine content including fetus and, occasionally, placenta may be discharged into the peritoneal cavity; whereas in the latter, the serous coat is intact, and the fetus and the placenta are inside the uterine cavity. 9 The complete variety is more dangerous of the two varieties. 10,11 Rupture of uterus during labor is more threatening than that occurring in pregnancy, because shock is greater, and infection cannot be avoided. 12,13 The damage to the uterus is sometimes beyond repair, and a hysterectomy is required. Uterine rupture is called as a disarray of the uterine muscle continuing to and including the uterine serosa or disarray of the uterine muscle with extension to the bladder or broad ligament. Uterine Hysterectomy Total dehiscence is defined as disruption of the uterine muscle with intact uterine serosa. 14 In present study we noted that prolonged obstructed labor as a main cause of rupture uterus (15 cases-51.72%) while rupture in scarred uterus was found in 12 cases-41.37% which is comparable to Kidantou HL et al 38% and 33.6% respectively. 15 Appropriate use of the partograph is an important tool for audit and monitoring progress of labour and a warning device to detect deviations from normal labour, preventing obstructed labour and thereby improving maternal and fetal outcome. [16][17][18] The surgical management depended on general condition of the patients, parity, and desire for future fertility, type of rupture and site of rupture.

CONCLUSION
In present retrospective analytical study, we have concluded that most common cause of rupture uterus was neglected prolonged second stage of labor followed by scarred uterus. Hence, we have recommended institutional labor for high risk cases with proper management of labor by experience staff with use of partograph.
Proper antenatal and intrapartum care, identification of high risk factors, reduction in primary caesarean section rates, Promotion of skilled attendance at birth, implications of BEmoc facilities, health education and awareness are key factors in reduction and early diagnosis.