Uterine Rupture

Definition

Uterine rupture is a full-thickness perforation (disruption) of the uterine wall during late pregnancy or labor. It ranges in severity from simple scar dehiscence to complete fetal extrusion into the abdominal cavity. - ROSEN's Emergency Medicine, p. 3077

Incidence: approximately 1:1,000-3,000 deliveries overall, but rises to ~1% in VBAC (vaginal birth after cesarean) deliveries following a single prior cesarean. - Morgan & Mikhail's Clinical Anesthesiology, p. 3391

Types

Type	Description
Incomplete (scar dehiscence)	Partial disruption; visceral peritoneum intact; usually asymptomatic
Complete rupture	Full-thickness breach; fetus ± placenta may extrude into peritoneal cavity
Traumatic rupture	From blunt abdominal trauma (e.g. motor vehicle collision); accounts for 17.5% of MVC-related perinatal deaths

Risk Factors

Primary risk factor: Previous cesarean section (especially classic vertical incision)

Additional risk factors:

Single-layer uterine closure at prior C-section
Fetal size >3,500 g
Labor augmentation (oxytocin, prostaglandins)
Extensive myomectomy or uterine reconstruction
Intrauterine manipulations / forceps use
Prolonged obstructed labor / fetopelvic disproportion
Grand multiparity
Multiple gestation
Uterine structural anomalies (e.g. bicornuate uterus)
Connective tissue disorders (e.g. Ehlers-Danlos syndrome)
Oxytocin infusion causing hypertonic contractions
Tintinalli's Emergency Medicine, p. 2146; Morgan & Mikhail, p. 3391

Clinical Features

Presentation is variable - the diagnosis can be subtle or dramatic:

Sign/Symptom	Notes
Persistent abdominal pain	Even with epidural in place; abrupt onset of continuous pain is a key herald
Abnormal fetal heart rate	Prolonged decelerations / bradycardia - the most reliable sign of fetal compromise
Vaginal bleeding	Can be severe; significant hemorrhage in ~1/3 of cases
Loss of fetal station	Fetal presenting part recedes on exam
Loss of uterine contour	Fetal parts palpable through abdomen
Hypovolemic shock	Hypotension with occult intra-abdominal bleeding
Loss of uterine tone	Uterus may become soft/non-contracted

The clinical spectrum runs from subtle FHR changes to frank maternal hemorrhagic shock. Pain is not always present. - ROSEN's Emergency Medicine, p. 3082

Diagnosis

Clinical diagnosis is primary - high index of suspicion is essential
CTG/EFM: Prolonged fetal heart rate deceleration is the most reliable sign
Ultrasound: May reveal hemoperitoneum, protruding amniotic sac, or myometrial defect - sensitivity data are limited
A transvaginal ultrasound assessment of cesarean scar characteristics (residual myometrial thickness) can predict risk antenatally (2026 systematic review, PMID: 41213428)

Maternal and Fetal Mortality

Scenario	Mortality
Minimal fetal extrusion	Perinatal mortality <1%
Complete fetal extrusion	Perinatal mortality 10-20%
Maternal death	Rare but maternal mortality risk up to 10% in traumatic rupture
Hemorrhage complicating rupture	~1/3 of cases

ROSEN's Emergency Medicine, p. 3077; Mulholland & Greenfield's Surgery, p. 1295

Management

This is an obstetric emergency.

Immediate Steps

Activate emergency response - call for OB, anesthesia, neonatology, blood bank
Resuscitate - large-bore IV access, aggressive volume replacement, blood products
Emergency cesarean delivery - hastens delivery and allows uterine repair; the ACOG-identified 30-minute decision-to-delivery window maximizes fetal outcome
Laparotomy under general anesthesia is usually required

Contraindications

Uterotonic agents (oxytocin, prostaglandins) are CONTRAINDICATED as they can exacerbate the rupture. - ROSEN's Emergency Medicine, p. 3087

Surgical Options

Uterine repair (primary closure) - if rupture is clean and patient desires future fertility
Ligation of the internal iliac (hypogastric) arteries - to control hemorrhage
Emergency hysterectomy - if hemorrhage is uncontrollable or rupture is extensive
Morgan & Mikhail's Clinical Anesthesiology, p. 3391

Key Points Summary

Prior C-section scar is the #1 risk factor; ~1% rupture rate in VBAC
FHR decelerations are the most reliable clinical sign
Pain may be absent; always maintain a high index of suspicion
Do NOT give uterotonics if rupture is suspected
30-minute window from diagnosis to delivery is the target
Emergency laparotomy +/- hysterectomy may be required to control hemorrhage

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