Rupture of the unscarred uterus
- James F Smith, MD, MA
James F Smith, MD, MA
- Professor and Chair
- Department of Obstetrics and Gynecology
- Creighton University School of Medicine
- Joseph R Wax, MD
Joseph R Wax, MD
- Professor of Obstetrics and Gynecology
- Tufts University School of Medicine
Rupture of the pregnant uterus, similar to rupture of any internal organ, can be life-threatening for the mother and fetus. Most ruptures occur in women who have had a previous transmyometrial surgical incision, typically for cesarean delivery. Rupture of the unscarred uterus is rare, but the incidence is increasing. It is associated with higher major maternal and neonatal morbidity than cases of rupture of the scarred uterus .
This topic will review issues related to rupture of the unscarred uterus. Rupture of the scarred uterus is discussed separately. (See "Uterine rupture after previous cesarean delivery".)
Rupture of the unscarred pregnant uterus is a rare event, estimated to occur in 1/5700 to 1/20,000 pregnancies [2-5]. In a study of uterine ruptures in The Netherlands, the incidence of rupture in unscarred and scarred uteri was 0.7 and 5.1 per 10,000 deliveries, respectively; ruptures of unscarred uteri accounted for 13 percent of all ruptures . A study from the United States reported rupture of the unscarred uterus in 4.54 per 100,000 deliveries, or about 1 in 22,000 deliveries . The incidence of rupture in both scarred and unscarred uteri has increased in recent decades .
Rupture of the unscarred uterus occurs more frequently in resource-limited countries where prompt access to cesarean and instrument-assisted vaginal delivery is not widely available for management of obstructed labor [7-10]. Higher parity and frequency of contracted pelvises may also play a role.
Rupture of an unscarred uterus may be caused by trauma or congenital or acquired weakness of the myometrium. Sources of trauma include motor vehicle accidents and obstetric maneuvers (eg, internal or external version). The myometrium may be inherently weak because of a congenital disorder, such as Ehlers-Danlos type IV [11-14], or it may become weakened from protracted labor or use of strong uterotonic drugs (eg, misoprostol), which place prolonged stress on the myometrium [15,16]. Overdistension of the uterine cavity, whether absolute or relative to the size of the cavity, may be the major physical factor provoking rupture when the myometrium is weakened for any reason.
- Gibbins KJ, Weber T, Holmgren CM, et al. Maternal and fetal morbidity associated with uterine rupture of the unscarred uterus. Am J Obstet Gynecol 2015; 213:382.e1.
- Dow M, Wax JR, Pinette MG, et al. Third-trimester uterine rupture without previous cesarean: a case series and review of the literature. Am J Perinatol 2009; 26:739.
- Porreco RP, Clark SL, Belfort MA, et al. The changing specter of uterine rupture. Am J Obstet Gynecol 2009; 200:269.e1.
- Miller DA, Goodwin TM, Gherman RB, Paul RH. Intrapartum rupture of the unscarred uterus. Obstet Gynecol 1997; 89:671.
- Zwart JJ, Richters JM, Ory F, et al. Uterine rupture in The Netherlands: a nationwide population-based cohort study. BJOG 2009; 116:1069.
- Al-Zirqi I, Stray-Pedersen B, Forsén L, et al. Uterine rupture: trends over 40 years. BJOG 2016; 123:780.
- Hofmeyr GJ. Obstructed labor: using better technologies to reduce mortality. Int J Gynaecol Obstet 2004; 85 Suppl 1:S62.
- Hofmeyr GJ, Say L, Gülmezoglu AM. WHO systematic review of maternal mortality and morbidity: the prevalence of uterine rupture. BJOG 2005; 112:1221.
- Ekpo EE. Uterine rupture as seen in the University of Calabar Teaching Hospital, Nigeria: a five-year review. J Obstet Gynaecol 2000; 20:154.
- Batra K, Gaikwad HS, Gutgutia I, et al. Determinants of rupture of the unscarred uterus and the related feto-maternal outcome: current scenario in a low-income country. Trop Doct 2016; 46:69.
- Pepin M, Schwarze U, Superti-Furga A, Byers PH. Clinical and genetic features of Ehlers-Danlos syndrome type IV, the vascular type. N Engl J Med 2000; 342:673.
- Walsh CA, Reardon W, Foley ME. Unexplained prelabor uterine rupture in a term primigravida. Obstet Gynecol 2007; 109:455.
- Taylor DJ, Wilcox I, Russell JK. Ehlers-Danlos syndrome during pregnancy: a case report and review of the literature. Obstet Gynecol Surv 1981; 36:277.
- Rudd NL, Nimrod C, Holbrook KA, Byers PH. Pregnancy complications in type IV Ehlers-Danlos Syndrome. Lancet 1983; 1:50.
- Sakr R, Berkane N, Barranger E, et al. Unscarred uterine rupture--case report and literature review. Clin Exp Obstet Gynecol 2007; 34:190.
- Khabbaz AY, Usta IM, El-Hajj MI, et al. Rupture of an unscarred uterus with misoprostol induction: case report and review of the literature. J Matern Fetal Med 2001; 10:141.
- Jones DE, Mitler LK. Rupture of a gravid bicornuate uterus in a primigravida associated with clostridial and bacteroides infection. J Reprod Med 1978; 21:185.
- Samuels TA, Awonuga A. Second-trimester rudimentary uterine horn pregnancy: rupture after labor induction with misoprostol. Obstet Gynecol 2005; 106:1160.
- Nahum GG. Uterine anomalies. How common are they, and what is their distribution among subtypes? J Reprod Med 1998; 43:877.
- Walsh CA, Baxi LV. Rupture of the primigravid uterus: a review of the literature. Obstet Gynecol Surv 2007; 62:327.
- LeMaire WJ, Louisy C, Dalessandri K, Muschenheim F. Placenta percreta with spontaneous rupture of an unscarred uterus in the second trimester. Obstet Gynecol 2001; 98:927.
- Tarney CM, Whitecar P, Sewell M, et al. Rupture of an unscarred uterus in a quadruplet pregnancy. Obstet Gynecol 2013; 121:483.
- Mizutamari E, Honda T, Ohba T, Katabuchi H. Spontaneous rupture of an unscarred gravid uterus in a primigravid woman at 32 weeks of gestation. Case Rep Obstet Gynecol 2014; 2014:209585.
- Henderson CE, Hana RG, Woroch R, Reilly KD. Short interpregnancy interval and misoprostol as additive risks for uterine rupture: a case report. J Reprod Med 2010; 55:362.
- Palmer JM, Indermaur MD, Tebes CC, Spellacy WN. Placenta increta and cocaine abuse in a grand multipara leading to a second trimester rupture of an unscarred uterus: a case report. South Med J 2008; 101:834.
- Noh JJ, Park CH, Jo MH, Kwon JY. Rupture of an unscarred uterus in a woman with long-term steroid treatment for systemic lupus erythematosus. Obstet Gynecol 2013; 122:472.
- Sweeten KM, Graves WK, Athanassiou A. Spontaneous rupture of the unscarred uterus. Am J Obstet Gynecol 1995; 172:1851.
- Bagga R, Chaudhary N, Kalra J. Rupture in an unscarred uterus during second trimester pregnancy termination with mifepristone and misoprostol. Int J Gynaecol Obstet 2004; 87:42.
- Akhan SE, Iyibozkurt AC, Turfanda A. Unscarred uterine rupture after induction of labor with misoprostol: a case report. Clin Exp Obstet Gynecol 2001; 28:118.
- Bique C, Bugalho A, Bergström S. Labor induction by vaginal misoprostol in grand multiparous women. Acta Obstet Gynecol Scand 1999; 78:198.
- Zeteroglu S, Sahin HG, Sahin HA. Induction of labor with misoprostol in grand multiparous patients. Int J Gynaecol Obstet 2004; 87:155.
- Jozwiak M, Bloemenkamp KW, Kelly AJ, et al. Mechanical methods for induction of labour. Cochrane Database Syst Rev 2012; :CD001233.
- Budden A, Chen LJ, Henry A. High-dose versus low-dose oxytocin infusion regimens for induction of labour at term. Cochrane Database Syst Rev 2014; :CD009701.
- Ofir K, Sheiner E, Levy A, et al. Uterine rupture: differences between a scarred and an unscarred uterus. Am J Obstet Gynecol 2004; 191:425.
- Ozdemir I, Yucel N, Yucel O. Rupture of the pregnant uterus: a 9-year review. Arch Gynecol Obstet 2005; 272:229.
- Rodriguez MH, Masaki DI, Phelan JP, Diaz FG. Uterine rupture: are intrauterine pressure catheters useful in the diagnosis? Am J Obstet Gynecol 1989; 161:666.
- Ridgeway JJ, Weyrich DL, Benedetti TJ. Fetal heart rate changes associated with uterine rupture. Obstet Gynecol 2004; 103:506.
- Attarde VY, Patil P, Chaudhari R, et al. Sonographic findings of uterine rupture with expulsion of the fetus into broad ligament. J Clin Ultrasound 2009; 37:50.
- Wylie BJ, Gilbert S, Landon MB, et al. Comparison of transverse and vertical skin incision for emergency cesarean delivery. Obstet Gynecol 2010; 115:1134.
- Kapoor DS, Sharma SD, Alfirevic Z. Management of unscarred ruptured uterus. J Perinat Med 2003; 31:337.
- Chauhan SP, Martin JN Jr, Henrichs CE, et al. Maternal and perinatal complications with uterine rupture in 142,075 patients who attempted vaginal birth after cesarean delivery: A review of the literature. Am J Obstet Gynecol 2003; 189:408.
- Kwee A, Bots ML, Visser GH, Bruinse HW. Uterine rupture and its complications in the Netherlands: a prospective study. Eur J Obstet Gynecol Reprod Biol 2006; 128:257.
- Phelan JP, Korst LM, Martin GI. Causation--fetal brain injury and uterine rupture. Clin Perinatol 2007; 34:409.
- Chibber R, El-Saleh E, Al Fadhli R, et al. Uterine rupture and subsequent pregnancy outcome--how safe is it? A 25-year study. J Matern Fetal Neonatal Med 2010; 23:421.
- Usta IM, Hamdi MA, Musa AA, Nassar AH. Pregnancy outcome in patients with previous uterine rupture. Acta Obstet Gynecol Scand 2007; 86:172.
- Lim AC, Kwee A, Bruinse HW. Pregnancy after uterine rupture: a report of 5 cases and a review of the literature. Obstet Gynecol Surv 2005; 60:613.
- Jastrow N, Chaillet N, Roberge S, et al. Sonographic lower uterine segment thickness and risk of uterine scar defect: a systematic review. J Obstet Gynaecol Can 2010; 32:321.
- Cheung VY. Sonographic measurement of the lower uterine segment thickness: is it truly predictive of uterine rupture? J Obstet Gynaecol Can 2008; 30:148.
- RISK FACTORS
- Use of uterotonic drugs
- CLINICAL MANIFESTATIONS
- - Fetal heart rate changes
- - Loss of station
- - Abdominal pain with/without hemodynamic changes
- - Uterine tenderness, cessation of contractions, change in uterine shape
- - Vaginal bleeding
- - Hematuria
- DIAGNOSTIC IMAGING AND LABORATORY TESTS
- Intrapartum differential diagnosis
- Postpartum differential diagnosis
- Initial approach to intrapartum uterine rupture
- - Category III tracing and hemodynamically unstable mother
- - Category II or III tracing and hemodynamically stable mother
- Uterine repair versus hysterectomy
- MORBIDITY AND MORTALITY
- PREGNANCY AFTER UTERINE RUPTURE
- Risk of recurrent rupture
- Predicting recurrent rupture
- Timing of delivery
- SUMMARY AND RECOMMENDATIONS