Rupture of the Uterus*

RUPTURE OF THE UTERUS* HENRY

w. ERVING, M.D., PITTSBURGH, PA.

(From the Department of Obstetrics, University of Pittsburgh School of Medicine and the Elizabeth Steel .i\1agee . Hospital)

RECENT case of spontaneous rupture of the uterus stimulated our interest in this subject. A perusal of the literature and a review of all the cases, spontaneous and traumatic, which have occurred over the past twentysix years at the Elizabeth Steel Magee Hospital, were undertaken in an effort to ascertain how certain questions can best be answered: A

1-\.

1. 2. 3. 4.

Is the incidence increasing or decreasing~ Is a ruptured uterus as lethal as generally considered? "What factors are involved in its occurrence? How can such cases best be handled~

Incidence The reported incidence of ruptured uterus varies from a high of one in 95 dclivcl'ie>f, at the Peking Union Medical College HospitaP 2 to a low of one in :;,17:3 deliveries at the Crawford W. Long Memorial Hospital in Atlanta as reported hy Danie>l and Inman. 7 Considering another aspect of the situation Duggerl(' fuund that 6.6 per cent of the total maternal mortality in Philadelphia over a 10 year span was caused by rupture of the uterus, and Eastman 11 estimated that 5 per cent of all maternal deaths are due to this cause. Table I shO\vs the incidence as reporte>d by various authors. TABLE

I.

REPORTED INCIDENCE OF RUPTURED U'I'~RUS

RATIO TO AUTHOR

\Vhitacre and Fang32 Sallowsky25 Beacham3 Tollefson29 Voogd, Wood, and PowelJ3o Morrison and Douglass23 Brierton5 Fitzgerald14 Posner24 Bill4 Duggerlo Daniel and Inman7

PERIOD

1922-41 1929-38 1913-50 1934-44 1943-55 1920-43 1932-46 1928-47 1935-49 1925-41 1934-44 1946-51

CITY

Peking .Jerusalem New Orleans Los Angeles Cleveland Baltimore New York Chicago New York Cleveland Philadelphia Atlanta

NO. OF CASES

44 13 96 14 12 45 57 42 14 23 105 9

DELIVERIES

1:95 1:698 1:1,328 1:1,370 1 :1;432 1:1,465 1:1,961 1:2,196 1:2,724 1:2,756 1:3,029 1:3,173

At the Elizabeth Steel Magee Hospital during the 26 year period from Jan. 1, 1930, to Jan. 1, 1956, there were 96,153 deliveries. During this time there were 37 instances of ruptured uterus in patients five months or more 1956.

*Presented at a meeting of the Pittsburgh Obstetrical and Gynecological Society, Oct. 1,

251

I
252

Am.

J.

Obst. & Gyner. August, 19 57

pregnant, or an incidenee of one rupture to 2,598 deliveries. 1f this time is divfded into two 8 yeat· periods and the 10 year postwar period, the incidence is as shown in Table II. As can be seen, the incidence in the postwar years has dropped rather sharply in spite of an increase in the number of deliveries. TABLE PERIOD

II.

RUPTURED UTERI AT ELIZABETH STEEL MAGEE HOSPITAL NO.

0~'

1930-37 1938-45 1946-55 1930-55

CASES

~0.

OF DELIVERIES

20,621 26,103 +9,42D 96,15:1

9

12 16 ::!7

RATIO

1 :2.291 1:2,175 1 :3,080 ]:2,598

--

Age and Parity In our series the largest number of cases fall in the age group from 26 to 30. Only 9 patients were under 26, while 2H W<'re over. The oldest was 44. This increased age goes along with increasetl parity, as rupture of the uterus is less frequent in the primigravida and rises as the parity and age increase. For instance, Whitacre and Fang32 reported only 2 primigravidas in 44 cases, Ingram 1 ' one in 13, Sadowsky 25 none in 13, Tollefson 29 one in 14, Posner 24 2 in 14, Bill 4 3 in 23, Gordon 1 '' 7 in 64, and Dugger' 0 16 in 105. Taylcn>, 28 on the other hand, found 8 primigravidas in 33 cases of ruptured uterus. About half of our patients were gravida iv or over·. Increased parity is generally accompanied by a more serious prognosis, and only one of our patients who were gravida vii or over survived while I>ngger 10 harl no survivals among the 16 gravida vii or over in his series. TABLE NO.

AGE

Ill.

;\(a; AN!! CfRAVIDITY GRAVIDI~'Y

NO.

ii iii iv

II

v

4

3

20 21-25 26-30 31-35 36-40

4

6

14

7 6 1

44

vi-xi

4 9

5

Classification Classifications of ruptured uterus are many, such as cesarean and noncesarean, traumatic and spontaneous, complete and incomplete, primary and secondary. The most rational classification seems to us to be : ( 1) ruptured uterus in a previously intact uterus without apparent cause, i.e., spontaneous or idionathic. Table IV shows our cases classified in this way; (2) ruptured uterus following previous uterine surgery, i.e., cesarean section, myomectomy, salpingectomy; (3) ruptured uterus following trauma, i.e., manual dilatation of the cervix, version and extraction, forceps, destructive operations, external violence, Pitocin, etc. TABLE

IV.

CLASSH'ICATION m' RuPTURED UTERI

RUPTURE OF UTERUS

Volume 74Number 2

253

Spontaneous or Idiopathic Rupture.-lt can be seen that spontaneous rupture of a previously intact uterus is an unusual occurrence. Only 2 cases ( 5.5 per cent) have been found at the Magee Hospital over the past 26 years. This is in accord with the findings of Gustafson 16 who called such cases "very rare." Felmus13 in a recent review of the literature was able to find 116 cases to which he added 5. He concluded that there were 6 underlying entities which might be the cause of or a factor in spontaneous rupture of the uterus, namely: (1) history of curettage or manual removal of the placenta; (2) infection; (3) multiparity; (4) infarction of the myometrium; (5) excessive proliferation of chorionic epithelium or deficiency of uterine decidua; ( 6) adenomyosis. One of our uteri showed deep penetration of the chorionic villi at the site of rupture and we presume this to have been the cause. Meyerhardt2 2 reported a spontaneous rupture of the uterus accompanied by placenta accreta while ~.1cCarthy 21 reported one callsed by· placenta percreta. Irving and Hertig 18 in a review of cases of placenta previa found only 4 spontaneous ruptures clue to chorionic villi penetrating the visceral peritoneal surface of the uterus. Our second patient was a 40-year-olcl gravida viii with a breech presentation and a normal-sized baby. After a labor of 9 hours she was brought into the hospital in deep shock and the baby was not delivered until after the mother had died. This elderly multigravida was obese and had an old scarred cervix which tore. Such patients are good candidates for a ruptured uterus. Most cases of spontaneous rupture occur in the last trimester, but they may occur as early as the fourth month. 13 The diagnosis is usually missed or confused with that of abruptio placenta. One of our 2 mothers died but both infants were stillborn. Felmus 13 reported a maternal mortality of 55.9 per cent. Ruphtre Following Previous Uterine S1trgery.-Previous surgery on the uterus accounted for 20, or 54 per cent, of our 37 cases. The average gravidity was 2.4 and the average age 29 years. Table V shows the details of our cases. TABLE AGE (YEARS)

V.

RUPTURE FOLLOWING PREVIOUS UTERINE SURGERY ~'YPE

GRAVIDITY

OF PREVIOUS SURGERY

TERM (MONTHS)

MATERNAL OUTCOME

511£. /~

8 5 8% 7¥2 9 8¥2 8%, 8% 8¥2

Well Well Well Well Well Well Well Well Well Well

\¥ell Stillborn Stillborn Stillborn Stillborn Well Well Stillborn Well Well

9

Well

Stillborn

8¥2 9 814

Well Well Died

Stillborn Stillborn Macerated

9

Well Well Well Well Well

Lived 7 hours Stillborn Stillborn Stillborn Lived 6 hours Atillborn

FETUS

1946-1955.-

iv ii ii ii v ii ii iv ii ii

3 classical sections 1 classical section Salpingo-oophorectomy 1 classical section 2 classical sections 1 low cervical section 1 low cervical section 2 classical sections 1 cla~sical section 1 low cervical section

26

111

26 26 30

iii ii ii

1 classical and 1 cervical section 1 classical section 1 classical section 1 classical section

1930-1937.23

iii

24 30 31 25 39 31 28 30 29 29

'-'

1938-1945.-

23 24 38 34 31

v

vi xi ii iv

1 classical section 2 classical sections 3 classical sections 2 classical sections 1 classical section Myomectomy

8¥2 8 7 61AJ 9

Died

254

ERVING

Am ..J. Obst. & Gynec. August, l9S7

All complete ruptures of the uterus were in patients who had had previous classicaf cesarean section, except for one co~nual rupture following salpingectomy and a complete rupture following a previous myomectomy. There were 4 occult or incomplete ruptures, 3 of which followed low cervical sections. All of these were incidental findings at operation. One patient had 2 successive complete ruptures of classical cesarean scars, and one patient who had previously had both a low cervical and a classical section suffered rupture at the latter site. Thus 14 complete ruptures of the uterus occurred in classical scars and only 3 ruptures, all incomplete, were through low eeevical scars. This is in general accord with the present-clay concept that low cervical sections are safer, particularly in regard to future rupture . .B'itzgerald" reported 2 ruptures after low cervical section as opposed to 9 after classical sections, Bill4 none as opposed to 13, Acken' one as opposed to 7, Beacham 3 3 as opposed to 20. Briet·tou" quoted an incidence ul' 2.8 per cent of rupture of the uterus following cesarean section, with 4.2 per cent following classical section allll 1.9 per cent following low cervical se('tion. LumP\' stated that 90 per cent of 1·uptures of scars follow the classical type of section. This S('('llJS to confirm the view hel
255

RUPTURE OF UTERUS

Volume 74 Number 2

one case which was handled terminally by Braxton Hicks version. Gordon15 reported 20 cases of ruptured uterus caused by version and extraction and 21 by forceps, craniotomy, fundal pressure, Pinard's maneuver, bagging, and Pituitrin. Many reports 4 • 15 ' 19 ' 23 • 27 • 29 of rupture following the latter drug have appeared, as well as a case following an auto accident, 33 and one caused by injuries sustained in falling downstairs while drunk. 14 TABLE VI.

RUPTURE FOLLOWING TRAUMA REASON

TYPE OF 'l'RAUMA

FETUS

1946-1955.-

29

iv

Version and extraction

9

39

vii

9

40

iv

Manual dilatation of the cervix, Pituitrin, Braxton Hicks version Version and extraction

26

iv

Version and extraction

8

9

Neglected transverse presentation Unrecognized rupture. Not delivered Transverse presentation Transverse presen-

Well

Stillborn

Died

Stillborn

Well

Living

Well

Living

tation Version and extraction

8%,

Failed forceps. Persistent occiput posterior

Well

Stillborn

Manual dilatation of the cervix, version and extraction Version and extraction Version and extraction

9

Labor 79 hours

Well

Lived 20 hours

9 9

Died Well

Stillborn Living

Voorhees bag, version and extraction Version and extraction

7¥2

Brow presentation 2 previous versions and extractions ''Tough cervix''

Died

Living

8

Died

Living

31

Version and extraction

9

Died

Living

20

Version and extraction

9

Inertial labor 44 hours Inertial labor 48 hours

Well

Living

Attempted forceps, version and extraction Braxton Hicks version Version and extraction

9

Inertial labor 35 hours Placenta previa Transverse arrest

Died

Stillborn

Died Died

Macerated Stillborn

31

iv

1938-1945.-

24 44 25

iii

20

v

20

v

X

1930-1937.-

26 36 30

iv ii

9

9

Signs and Symptoms These may vary from mild vague discomfort to severe pain and profound shock. Sometimes a patient is not even suspected of having a ruptured uterus, it being discovered at repeat section as an incidental finding. However, one must keep in mind rupture of the uterus if a patient has had previous uterine surgery, if she is in the last trimester of pregnancy, if pituitary extract has been given, or if the duration of labor has been unduly prolonged with failure of descent despite good contractions and a normal presentation. The most common entity is shock. If shock follows external violence or a difficult delivery, the diagnosis is fairly clear. After every difficult vaginal delivery the uterus should be explored to rule out possible rupture. This is especially· true after version and extraction, breech extraction, and mid- or

2.56

Am.]. Obst. & Gynec. August, 1957

ERVING

high midforccps. Again, if the patient in labor suddenly feels a severe tearing pain and utters a sharp cry, the diagnosis of ruptured uterus can be made without the physician's even being in the room. The patient's sensations may give an important clue, as mav otherwise unexnlained matemal tachvearlliH during labor. After rupture, -the labor pains ~case, the fetal heart ·sounds disappear, hemorrhage, external as well as internal, usually occurs, and often then~ is a cumnlaint of sunranubie nain. vV e have not found tenderrwss of the sear to be especially sigu'"ific~mt. ~ 'When the patient is not in labor the diagnosis made is usually separation uf the placenta. 'l'his may cause delay in operation. especially if the hear-t sounds have disappeared, as haprwned in our last fatal rase which occurred in 1948.

Mortality Mortality figures as reported by various authors are listed in Table VII. Maternal mortality varies from 8.4 to 61 per cent, while fetal mortality varies from 33 1/3 to 93 per cent. TABLE

l\fA1'ER~AL A!-;D FETAL MORTALITY

VH.

MATERNA.L MORTALITY

AUTHOR

--Dul.w:erio--

(%) I ___ ----6Lo ___ _

NO. OF CASES ~-I
\Vllitacrea2

44

Fitzgerald14

42

Lynch20 Beacham3

33 96 53 15 45 :lll

Delfss Ackenl l\forrison23

Bill4 Daniel7 Voogdso

9 12

56.8 54.7 53.0 47.9 47.1 46.6 42.2 22.0 11.1 8.4

9 12 16 37

44.4 50.0 6.2 29.7

I

FETAJ, MORTALl'fY (%l ·~---------~---

63.0 93.1

79.0 88.0 79.6 81.1 46.6 77.7 62.0 33.3

58.3

Present Series.1930 .. 37 J 938 .. 45 1946-55 Total

100.0 58.3 56.2

62.2

Three of our patients who died were admitted moribund, or died undelivered, and one died, through an error of judgment, on her way to the operating room for the second time. Nine patients died of shock and 2 of peritonitis. Treatment From analysis of our cases and those of other authors there seems to be no question but that immediate laparotomy combined with blood transfusion is the sine qua non of the treatment of ruptured uterus. This implies that Type 0 Rh-negative blood be available on a few minutes' notice in every delivery room and should be given immediately. Regardless of shock one should then proceed with laparotomy. There is a direct correlation between mortality and the time elapsed from rupture to operation. The amount of blood needed varies. Lund19 felt that 3,500 c.c. is the minimum amount required per patient. It seems to us that the amount must be fitted to the need of the individual patient; it is advisable, however, to have adequate blood available. Many of our patients did not receive sufficient blood.

RUPTURE o:E' UTERUS

Volume 74 Number 2

257

As to choice of l)rocedure, hysterectomy or repair of the laceration can be done, depending -on the natllre of the -laceration, the condition of the patient, the need for speed, the presence of infection, the type of delivery, etc. Laceration through a previous cesarean scar can be repaired, as a general rule. Table VIII shows how our patients were handled. VIII.

TABLE

PROCEDURE

Repair of laceration Hysterectomy Not operated upon

TOTAL CASES --N-0-.-,----:-%;----

13 16 8

35.1 43.2 21.7

I

TREATMENT

1930-37 3 3 3

I 1938-45 I 1946-55 5 3

4

5 10 1

I

MATERNAL MORTALITY

NO. DIED

1

2 8

I

(%)

7.7 12.5 100.0

It is interesting to note that of the 29 patients operated upon, only 3 died, whereas 8 died who were moribund on admission or who did not reach the operating room soon enough. This indicates a human error in either early diagnosis, failure of early transfusion, or delay in operation. Very rarely, following delivery and rupture of the uterus, a patient will go into such profound shock that immediate operation cannot be tolerated. In such instances Dillon9 suggested immediate reflection of the anterior vaginal wall and bladder off the cervix and the placing of straight clamps on each cardinal ligament, :followed by laparotomy when the patient can tolerate it. Also rarely, a case may arise where it would be more expedient to place clamps on the broad ligaments, remove the uterus, get out, and then remove the clamps about the third day.

Summary

At the Elizabeth Steel Magee Hospital over· the past 26 years there have been 96,153 deliveries and 37 cases o:f ruptured uterus. This is an incidenee of one rupture to 2,598 deliveries. In the last 10 years the incidence has fallen to one to 3,089. Most of the patients were over 25 years of age and all but 4 were multiparas. Two ruptures were spontaneous, 15 were traumatic, and 20 followed previous uterine surgery. The gross maternal mortality was 30 per cent and the fetal mortality 62 per cent. Rupture following previous uterine surgery had the lowest maternal mortality rate but the highest fetal mortality. In the last 10 year period the maternal mortality dropped to 6 per cent but the fetal mortality was 56 per cent. This probably can be accounted for on the basis of more conservative obstetrics with fewer difficult vagina.! deliveries and more cesarean sections. In 13 cases the laceration of the uterus v:as repaired; in 16 hysterectomy "\vas performed; and 8 patients never reached the operating room. Only 3 patients of the 23 operated upon died. All 8 of those not operated upon died. Conclusions

1. Rupture of the uterus is becoming less frequent, but still carries a very high fetal mortality and a high maternal mortality. 2. Rupture following previous uterine surgery accounts for the greater percentage of cases, as traumatic deliveries are decreasing in number.

258

ERVING

Am.

J. ObH.

& Gynec. AuguH, 1'157

3. Previous classical cesarean section is adequate reason for repeat cesarean section, especially if the placenta is implanted under the scar. 4. The mortality varies in direct proportion to the elapsed time between diagnosis of the rupture and laparotomy.

References 1. Acken, H. S., Jr.: Am. J. Surg. 49: 423, 1940. 2. Aviles, V. M.: Tr. Interest. & Fourth Am. Congress on Obst. & Gynec. (supp. vol. AM. J. 0BST. & GYNEC.) 61A: 309, 1951.

3. Beacham, W. D., and Beacham, D. W.: AM. J. 0BST. & GYNEC. 61: 824, 1951. 4. Bill, A. H., Barney, W. R., and Melody, G. :F'.: AM. J. 0BST. & GYNEC. 47: 712, 1944. 5. Brierton, .T. F.: AM. J. 0BST. & GYNEC. 59: 113, 1950. 6. Cosgrove, S. A.: Tr. Internat. & F'ourth Am. Congress on Obst. & Gynec. ( supp. vol. AM . .J. 0BS'l'. & GYNEC. 61A: 307, 1951. 7. Daniel, W. W., and Inman, J. 8.: J. Internat. Coli. Surgeons 16: 706, 1951. 8. Delfs, Eleanor, and Eastman, N.J.: Canad. 1\f. A. J. 52: 376, 1945. 9. Dillon, W. F., and Schmitz, H. E.: AM. J. 0BST. & GYNEC. 62: 218, 1951. 10. Dugger, J. H.: S. Clin. North America 25: 1414, 1945. 11. Eastman, N.J.: Williams Obstetrics, eel. 10, New York, 1950, Appleton-Century·Crofts, Inc. 12. Erving, H. W., and Kenwick, A. N.: AM. J. 0BST. & GYNEC. 67: 315, 1954. 13. Felmus, L. B., Pedowitz, P., and Nassberg, S.: Obst. & Gynee. Surv. 8: 155, 1953. 14. Fitzgeralrl, J. E., Webster, Augusta, and Fields, J. E.: Surg., Gynec. & Obst. 88: 652, 1949. 15. Gordon, C. A., and Rosenthal, A. H.: AM. J. OBST. & GYNEC. 58: 117, 1949. 16. Gustafson, G. W., and Crump, W. E.: J. Indiana M.A. 31: 616, 1938. 17. Ingram, James M., Alter, Robert L., and Carter, Bayard: AM. ,J. OBST. & GYNEC. 64: 527. 1952. 18. Irving, :F'. C., and Hertig, A. T.: Surg., Gynec. & Obst. 64: 118, 1937. 10. Lund, C. .T.: .Journal-Lancet 71: 227, 1951. 20. Lynch, F . .J. New England .T. Mec1. 221: 847, 1939. 21. McCarthy, E. G., ana Niehols, E. 0., Jr.: Am .•T. Surg. 80: 485, 1950. ~2. 1\feyerharrlt, 11. H.: J. Missouri M. A. 46: 177, 194~). 23. Morrison, ,T, H., and Douglass, L. H.: AM ..T. OBS'r. & GYNEc. 50: 330, 1945. 2+. Posner, L, B., Smith, D. :E'., and Trambert, H. L.: New York .T. Med. 51: 641, 1051. 25. Sadowsky, A.: Am. J. Surg. 55: 544, 1942. 26. Schmitz, H. E., and Towne, J. E.: Tr. Internat. & Fourth Am. Congress on Obst. & Gynec. (supp. vol. AM. J. OBST. & GYNEC.) 61A: 289, 1951. 27. Sherrill, J. G.: Surg., Gynec. & Obst. 42: 657, 1926. 28. Taylor, J. S.: Pennsylvania M. J. 50: 801, 1947. 29. Tollefson, D. G.: West. J. Surg. 53: 54, 1945. 30. Voogd, L. B., Wood, H. B., and Powell, D. V.: Obst. & Gynec. 7: 70, 1956 31. West, 0. 'r., and Simmons, C. R.: South. M. J. 45: 342, 1952. 32. Whitacre, F. E., and Fang, L. Y.: Arch. Surg. 45: 213, 1942. 33. Woodhull, R. B.: Surgery 12: 615, 1942.