Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 220 - файл
.pdf
270
https://t.me/medicina_free
10 Uterine Rupture andPerforation
for UR. One trial of second-trimester abortion
using misoprostol in 720 women with one or
more previous CS concluded that misoprostol
was not associated with an excess of complications compared with women with unscarred uteri
[233].
Uterine Curettage
See Sect. 18.3.
Salpingectomy
The ectopic pregnancy site, type, and quality of
suture material, suturing technique, mono- or
bipolar electrocautery, and the gynecologist’s
experience inuence outcomes after laparoscopic
Fallopian tube resection [234, 235].
To decrease the risk of long-term complications from a ruptured tubal pregnancy localized
near the cornual region, using additional reinforcing sutures during laparoscopy appears to be
more appropriate management than electrosurgery alone since cautery-induced thermal injury
may compromise the myometrial tissue [236].
However, additional sutures in the cornual region
may be associated with a risk of myometrial ischemia. Therefore extensive suturing should be
avoided. For unruptured tubal pregnancy, conservative therapy with methotrexate or laparoscopic
salpingostomy is the methods of choice (see Sect.
9.1.7.3) that can prevent severe complications in
subsequent gestations [237].
Apart from the surgical approach, the time
between the surgical removal of a Fallopian tube
and conception is important. It was <12months
in 67% of the analyzed URs in the group of nonectopic pregnancies. Interstitial pregnancy was
the cause in all cases. However, it is impossible to
determine the safe interval between conception
and salpingectomy with a high degree of certainty, and the risk of UR during subsequent
pregnancy cannot be excluded entirely after several years [238].
Uterine Artery Embolization
Except for uterine artery embolization, described
cases with UR had additional risk factors for
which uterine artery embolization was indicated.
Most include (resected) uterine myomas or
abnormal placentation during pregnancy with
UR [239–241].
10.1.6 Prevention
10.1.6.1 Scarred Uterus
The most direct prevention strategy for minimizing the risk of pregnancy-related UR after CS is
to minimize the number of patients at the highest
risk. The salient variable is the threshold for a tolerable risk. Although this choice is arbitrary, the
safety threshold is 0.5% (1/200). Therefore, the
categories of patients that exceed this critical
value are those with previous:
• Multiple CS,
• Classic midline CS,
• Low-vertical CS,
• Low-transverse CS with a single-layer hysterotomy closure,
• CS with an interdelivery interval of <2years,
• Low-transverse CS with a congenitally abnormal uterus,
• CS without a previous history of a successful
vaginal birth,
• CS with either labor induction or
augmentation,
• CS in a woman carrying a macrosomic fetus
weighing >4000g,
• Uterine myomectomy.
Accurate prediction of UR would be extremely
valuable, as it would allow women at low risk to
proceed with a TOL, whereas women at high risk
for UR could undergo a planned CS.Thinning in
the lower uterine segment measured by US predicts UR’s complete rupture or scar dehiscence at
birth during TOLAC.A full lower uterine segment
thickness cutoff of 3.1–5.1mm and a myometrium
thickness cutoff of 2.1–4.0mm provided a strong
negative predictive value for the occurrence of a
defect during TOLAC.A myometrium thickness
cutoff between 0.6 and 2.0mm provided a strong
positive predictive value for the occurrence of a
defect [242]. The interobserver agreement is that
the lower uterine segment thickness should be
measured by transvaginal US [243].
10.1 Spontaneous Uterine Rupture
https://t.me/medicina_free
271
10.1.7 Clinical Presentation
The prevalence of Müllerian duct malformations
in the general population and the population of
fertile women is estimated to be 4.3%, and in
infertile patients, approximately 25%. The septate uterus is the most common anomaly (35%),
followed by the bicornuate uterus (25%) and the
arcuate uterus (20%) [244]. These malformations
remain asymptomatic until the patient reaches
reproductive age. Such anomalies result in an
increased rate of infertility, miscarriage, recurrent pregnancy loss, preterm labor, and other
obstetric complications. Clinical presentation
varies from asymptomatic to vague complaints of
mild lower abdominal pain with gastrointestinal
upset and its severest form of acute abdomen
with hemorrhagic shock. Women with a noncommunicating uterine horn may present after menarche with progressive abdominal pain caused by
hematometra, hematosalpinx, and endometriosis.
However, many women remain asymptomatic.
10.1.7.1 Symptoms
The symptoms and signs of UR largely depend
on [22] the following:
• Time of occurrence (pregnancy, early or
late labor),
• Cause,
• Duration,
• Site,
• Type,
• Degree,
• Extent,
• The amount of intraperitoneal spill,
• The size of the blood vessels involved,
• Complete or partial extrusion of the
fetus and placenta,
• The intensity of retraction of the uterine
muscle.
Sudden, severe, shearing abdominal pain with
the absence of fetal heart sounds, cessation of
uterine contractions, and recession of a present-
ing part, combined with vaginal bleeding and
shock, is a classical presentation [154]. Overall,
only 45% of the cases reviewed have typical
symptoms and signs of UR [39, 45, 54, 154, 159,
245–248]. The most common presentation is
fetal distress, mainly as a nonreassuring fetal
heart rate pattern with variable deceleration at a
time in labor when they are not characteristically
seen [82, 154]. Fetal distress occurs in 81%
before abdominal pain or vaginal bleeding [182].
Pregnancy
Common symptoms and signs are abdominal pain
and tenderness, shock (faintness, pallor, and tachycardia), vaginal bleeding, fetal distress, manifested
by fetal bradycardia, absence of fetal movement,
undetectable fetal heartbeat, palpable fetal body
parts, cessation of contractions, and signs of intraperitoneal bleeding. Severe abdominal pain is
present in 14% of patients, shock in 10–21.3%,
bleeding in 16.8%, the disappearance of fetal heart
sounds in 8.9%, and cessation of contractions in
5.6% [149, 247]. Epigastric pain, shoulder pain
(right-sided or bilateral), abdominal distention and
paralytic ileus, hypertonic uterus, altered uterine
contour, and uid thrill are less commonly associated with UR. Hematuria and vernixuria (vernix
caseosa in urine) are additional signs resulting
from a rupture extension to the bladder [249].
Labor andPostpartum
UR during labor is associated with cessation of
labor pain, the recession of presenting fetal body
parts, cervical lacerations, and vaginally palpable
uterine defects. One of the pathognomonic signs
of constriction–ring dystocia is that, despite a
painful, colicky contraction originating and felt
in the upper part of the uterus, no impulse of
descent or pressure is imparted to the presenting
fetal head below. Downward contractile impulse
is cut off by the gap in the continuity of the muscle bers at the rupture site. After rupture, the
uterus continues to contract above, but the fetal
head below remains immobile to the examining
nger during a contraction [22]. This phenomenon partly depends on the degree and extension
of UR and the associated partial or complete
expulsion of the fetus in the peritoneal cavity.
272
https://t.me/medicina_free
10 Uterine Rupture andPerforation
The most common sign is the sudden appearance of fetal distress during labor. Up to 81% of
patients with UR during labor have evidence of
fetal distress before bleeding or abdominal pain
[182] and fetal heart abnormalities in 43.5% [57].
The observation of sudden fetal heart irregularity
in laboring women is a dangerous sign [70].
Postpartum bleeding is present in 24%, while
postpartum abdominal pain, distention, and ileus
are present in 14% [149]. A large blood clot evacuated with the spontaneous exit of the placenta,
especially in patients on uterotonics or prostaglandins for induction of labor, should raise the
suspicion of UR [109]. Another suspicious sign is
bloodstained liquor after the rupture of membranes [187].
Scarred Uterus
The symptoms and signs of UR in patients with
scarred uterus differ from patients without a uterine scar [246]. UR at a previous uterine scar site
is typically less violent and dramatic than a spontaneous or traumatic UR because of its relatively
reduced vascularity. Hypogastric tenderness is
the most common sign in women with a previous
uterine scar. In women without a scar, shock is
the most common sign, followed by uterine
bleeding, severe abdominal pain, and easily palpable fetal parts. Severe abdominal pain is common in both groups of women with and without a
uterine scar.
present in 4.5% [247]. Cases that presented as
puerperal sepsis have shown to be unrecognized
UR.
Silent antepartum UR is usually associated
with a previous uterine scar from CS, myomectomy, or uterus perforation at the time of curettage. Antenatal spontaneous silent rupture of the
intact uterus is exceptionally rare [162, 169, 250,
251], without predilection of UR location. High
parity is common.
Delayed Presentation
Delayed presentation with abdominal pain and
minimal or absent other symptoms and signs is
possible if the UR is “covered.” The rupture site
may be covered from the outside by the small
[252] or large intestine [253] or from the inside
by fetal legs [254], preventing massive bleeding.
Therefore, vital signs and laboratory data could
be stable. The external covering of UR may prevent amniotic rupture or amniotic cavity protrusion, explaining the initial absence of a fetal heart
rate pattern indicative of cord issues (Fig.10.11).
Another delayed presentation is during early
postpartum. The condition is not suspected or
diagnosed until the patient has become established upon slow but progressive postpartum
bleeding. The UR, which does not cause symptoms until the early postpartum period, is impor-
Incomplete andSilent Rupture
At rst, quiet, silent, or occult rupture occurs
without the symptoms and signs ordinarily associated with UR. Diagnosis may be difcult or
unduly delayed, and unless the possibility of UR
is suspected, it may be missed. In quiet rupture,
there is the uncomplaining multipara in labor or
the patient whose CS scar is stretching and nally
yields in either pregnancy or labor. Nothing dramatic happens, but an increase in the pulse rate,
pallor, perhaps slight vaginal bleeding, and the
patient complains of some pain is present.
Contractions may continue unaltered, but the cervix fails to dilate further—an essential sign [22].
Uterine tenderness on internal examination is
present [250]. UR as the incidental nding is
Fig. 10.11 Defect of the posterior wall of the uterus
adhered to the sigmoid colon, hematoma on mesentery,
and active bleeding on the rupture site. (Reproduced with
permission from [253] under the CC BY 4.0)
10.1 Spontaneous Uterine Rupture
https://t.me/medicina_free
273
tant because traumatic bleeding may be attributed
to atony of the uterus and collapse to so-called
obstetrical shock [22].
Epidural/Spinal Anesthesia
Epidural analgesia rarely masks the symptoms
and signs of UR [60, 182, 255]. The sudden
development of “breakthrough pain” under epidural analgesia may improve the specicity of
abdominal pain as a symptom of UR in patients
attempting vaginal birth after previous uterine
surgery [82].
10.1.7.2 Physical Examination
A physical examination reveals tenderness in the
middle of the lower abdomen with or without
guarding. Vaginal bleeding can be present. Blood
pressure depends on the severity of uterine bleeding, and the patient can be hypotensive with an
increased pulse rate. A lump (expelled fetus)
could be palpated in a hospitalized patient with
new-onset UR without the presenting part [154].
Shoulder pain (Kehr’s sign) is a valuable sign of
intraperitoneal blood in the subdiaphragmatic
region. Even a small amount can cause this symptom, but it is important to realize that it may be
24 h or longer after the bleeding has occurred
before blood will track up under the diaphragm.
Also, some acute massive intraperitoneal bleeding may not initially have shoulder pain. Sooner
or later, however, shoulder pain will usually
appear. In doubtful cases with slow intraperitoneal bleeding for 2 or 3days, such referred pain
has great diagnostic value.
With sufcient cervical dilation, a vaginal
examination may reveal intestinal loops, parts of
the greater omentum in the uterine cavity, or a
defect of the (lower) uterine segment [109, 256].
Considerable abdominal distension compressing
the thoracic cavity results in dyspnea. Postpartum
fever ≥38 °C after CS is associated with an
increased risk of UR during a subsequent trial of
labor [257]. Antepartum hemorrhage (APH)
often indicates UR [33] and may be associated
with shoulder tip pain due to hemoperitoneum.
APH is present in 33% of posterior URs [32].
With posterior UR, bleeding may be concealed,
where signs of hypovolemia develop, with a
large, concealed hemoperitoneum [29, 30].
Maternal pulse and blood pressure could remain
within normal limits despite massive UR, demonstrating the potentially misleading capacity for
compensation in an otherwise t patient. Women
reported persistent abdominal pain in 33% of
posterior URs [29, 32]. A hard mass can be palpated if the fetus is partly or entirely outside the
ruptured uterus, especially if the UR is on the
anterior wall [8].
10.1.8 Diagnosis
It is a worthy subject of an obstetrical truism- that is,
if a multiparous patient, in pregnancy, in labour, or in
the early postpartum period, should develop constitutional or local (abdomino-pelvic) signs and symptoms for which there is no ready explanation, then
rupture of the uterus should at least be suspected.
(John Kevin Feeney, 1956 [22])
10.1.8.1 Laboratory Findings
Only 30% of patients are diagnosed with UR preoperatively [70, 158]. Laboratory ndings show
lowered serum hemoglobin levels, and the exact
value and dynamics of its decrease depend on the
intensity of uterine wall bleeding. Suspicion of
placenta accreta/percreta arises in the case of an
unexplained elevation of alpha-fetoprotein [258].
10.1.8.2 Abdominal Ultrasound
A transvaginal and transabdominal US is helpful
for the direct and indirect ndings of UR.Direct
signs are a thin wall with bulging of fetal parts
(Fig.10.12) or visualization of the rupture. The
fetus can be partly (Fig.10.13) or entirely out of
the uterus (Fig.10.14). Indirect signs include free
peritoneal uid (blood), especially in the pouch
of Douglas, extraperitoneal hematoma, intrauterine blood, empty uterus, and gestational sac
above the uterus (Fig.10.15), and large uterine
mass with gas bubbles [8, 259, 260]. Congenital
uterine anomalies or acquired uterine changes
raise the suspicion of UR.
10.1.8.3 Abdominal CT
An abdominal CT is indicated in uncertain cases
such as intestinal adhesions over UR, delaying
274
https://t.me/medicina_free
Fig. 10.12 An abdominal ultrasound of the uterine wall
and the minor fetal part. A small arrow indicates a thin
uterine wall, which is slightly bulging. Beneath the thin
uterine wall, a minor fetal part (large arrow) is visible and
palpable mass through the abdomen. (Reproduced with
permission from [8] under the CC BY 2.0)
10 Uterine Rupture andPerforation
diagnosis. It is seen as a focal disruption of the
myometrium with the hemoperitoneum. Other
signs, as found on US (see Sect. 10.1.8.2), such
as fetal parts or hemoperitoneum outside the
uterus, can be visualized (Figs.10.16, 10.17, and
10.18).
10.1.8.4 Abdominal MRI
US diagnosis relies on nonspecic, secondary
signs such as free uid or hematoma formation,
while MRI allows the visualization of the uterine
wall defect or tear with higher accuracy [262].
MRI may also be less uncomfortable for the
patient with a tender abdomen.
Fig. 10.13 Unrecognized edge of the uterine rupture
(diagnosed initially as synechiae (arrow) due to the history of uterine curettage) and the fetal head already
extruded through the uterine defect. (Reproduced with
permission from [165])
Fig. 10.14 Abdominal ultrasound shows a contracted
uterus with fetal extremities and amniotic sac outside the
uterus. (Reproduced with permission from [259])
Fig. 10.15 Abdominal ultrasound shows a contracted
uterus, endometrial stripe, and no intrauterine gestation,
with the placental tissue above and bladder to the right.
(Reproduced with permission from [259])
Fig. 10.16 Contrast-enhanced abdominopelvic CT
shows a defect in the anterior wall of the uterus (arrow)
and uid collection with wall enhancement and adjacent
uid collection 2weeks after elective Cesarean section.
(Reproduced with permission from [261])
10.1 Spontaneous Uterine Rupture
https://t.me/medicina_free
Fig. 10.17 Axial CT of the abdomen (the same patient as
in Fig.10.16) shows uid collection anterior to the uterus
(arrow). (Reproduced with permission from [261])
275
Fig. 10.18 Abdominal CT shows an empty uterus
(arrow) and the fetus (F) outside of the uterus, denoting
uterine rupture. (Reproduced with permission from [165])
The MRI appearance consists of a focal myometrial defect: (1) lled with hematoma and an
associated hemoperitoneum (Fig.10.19) and (2)
protruding amniotic cavity (Fig. 10.20) or protruding placenta [264]. The characteristic sign is
the shower cap sign [264]. UR is a surgical emer-
Fig. 10.19 A female in the third trimester with prior
cesarean delivery. Sagittal T2WI shows a focal disruption
at the uterine fundus (arrows) with associated hematoma.
No part of the fetus protruded into the abdominal cavity
[263]
gency, and MRI should only be considered when
the diagnosis is inconclusive, and the patient is
hemodynamically stable [265].
Scar dehiscence results in an extensive uid
collection with air bubbles in the bladder ap as a
sign of local infection. The differential diagnosis
includes bladder ap hematoma, endometritis,
and regular CS incision changes, better depicted
with MRI than CT.MRI may provide a preoperative diagnosis of uterine sacculation [176] or
uterine diverticulum [177].
10.1.8.5 Cardiotocography
CTG abnormalities are associated with 55–87%
of URs [266]. Other recognized signs of UR
include loss of station of presenting part and new
inefcient contractility [267].
276
https://t.me/medicina_free
Fig. 10.20 Abdominopelvic MRI (T2WI, coronal section) reveals a bulging amniotic cavity protruding through
the defect in the uterine wall (arrows). Neither peritoneal
uid nor hemoperitoneum was observed. (Reproduced
with permission from [11] under the CC Attribution
License). The intraoperative nding is presented in
Fig.10.4
10 Uterine Rupture andPerforation
CTG is mandatory in patients with clinical
suspicion of UR because fetal distress is
the most common sign or symptom of UR
and frequently precedes any other clinical
manifestations of this complication [154].
External monitoring (external tocodynamometer) demonstrates the classic sign of complete
loss of uterine tone. In contrast, internal monitoring (internal pressure transducer) demonstrates
increased uterine resting tone. Both techniques
reveal a stepwise gradual decrease in contraction
amplitude followed by a sudden onset of profound and prolonged fetal bradycardia in patients
with rupture of an unscarred uterus at the term—
staircase sign (Fig.10.21). With internal moni-
toring, the intrauterine pressure catheter does not
show a complete loss of resting tone (Fig.10.22).
Internal monitoring has better sensitivity for
detecting fetal heart rate and uterine contractions.
UR shows the persistence of uterine contractions
and increased resting tone, monitored by an intrauterine catheter—ndings not observed with
external monitoring [12, 182]. However, few
Fig. 10.21 Uterine contraction pattern during rupture of
an unscarred uterus at term. External cardiotocography
was used for the tracing. Black arrows show the gradual
decrease in the amplitude of uterine contractions (stair-
case sign). A black arrowhead with a dashed body indicates prolonged fetal bradycardia. (Reproduced with
permission from [268])
10.1 Spontaneous Uterine Rupture
https://t.me/medicina_free
277
Fig. 10.22 Uterine contraction pattern during term rupture of an unscarred uterus. An intrauterine pressure catheter was used for the tracing. The black arrow shows the
gradual decrease in the amplitude of uterine contractions
papers in the literature documented the type of
uterine monitoring used. Furthermore, the uterine
contraction pattern may differ depending upon
the presence or absence of a uterine scar or the
site and direction of rupture. Bradycardia is the
most common fetal heart rate abnormality with
UR [182, 269]. It may occur due to cord compression within the UR, loss of uterine perfusion,
or placental abruption. This staircase pattern
appears to be a unique combination of fetal heart
rate pattern and uterine contraction pattern that
may be of value in diagnosing UR.Fetal bradycardia starts right after or several minutes after
the staircase sign [268]. Intermittent fetal heart
tone auscultation is mandatory while the patient
is off continuous monitoring.
10.1.9 Dierential Diagnosis
Differential diagnoses in the third trimester and
during delivery include placenta previa, placental abruption, uterine atony, and uterine inversion. Moreover, any condition unrelated to
pregnancy that may cause hemoperitoneum
should be considered in the differential diagnosis. Acute pubic symphysis rupture will be discussed in detail.
10.1.9.1 Acute Pubic Symphysis
Rupture
Incidence
The incidence of acute pubic symphysis rupture
caused by pregnancy varies greatly between
(staircase sign). Black arrowheads with a dashed body
indicate prolonged fetal bradycardia. The gray arrow
shows an increased resting tone. (Reproduced with permission from [268])
1/600–1/800 [270, 271] and 1/30,000 (older and
probably underdiagnosed studies). Risk factors
include large fetal birth weight, prolonged labor,
epidural anesthesia, nulliparity, shoulder dystocia [272], forceps delivery, and maternal developmental hip dysplasia. Even with these conditions,
there is a low risk of a pubic symphysis rupture
during or after labor.
Pathophysiology
The nonpregnant woman’s symphysis pubis gap
is 4–5mm, and it is normal to widen 2–3mm,
without discomfort, during the last trimester of
pregnancy. Widening over 10mm is considered
pathologic.
Mechanically, acute pubic symphysis rupture
occurs when the fetus descends rapidly into the
birth canal during stage 2 of labor, and the head
drives into the true pelvis [271]. Despite physiologic laxity during pregnancy, the pelvis cannot
adjust quickly enough in rare cases, and the pelvic ring begins to fail at its weakest point—the
pubic symphysis.
Clinical Presentation
Acute frank pubic symphysis rupture often presents as a sudden onset of severe tearing pain and
a sensation of separation directly over the symphysis at delivery or early postpartum. Pain is
often immediate and preceded by a “popping” or
“snapping” sensation. Other symptoms include
tenderness, instability, allodynia, hyperesthesia,
or hyperalgesia at and around the joint site. In
addition, many women will have difculty walking. The gait is described as waddling or painful
278
https://t.me/medicina_free
10 Uterine Rupture andPerforation
with the inability to stand or walk. Sometimes, it
is possible to hear a clicking sound when the
patient walks.
The examination may reveal (1) a palpable
gap with edema or hematoma on the soft tissue
overlying the symphysis pubis [273, 274], (2)
anteroposterior or superoinferior displacement
of the upper border of the pubic symphysis or
pubic tubercle, or (3) pain during lateral to
medial compression of the iliac wings or greater
trochanters. One or both SI joints may be tender
to palpation. The less acute presentation
includes pain, weight- bearing difculty, and a
waddling or wide-based gait. The patient may
have a positive Patrick test—pain at the sacroil-
iac joint with exion, abduction, and external
rotation of the hip (with one iliac spine held in a
xed position by the examiner, the woman lies
in a supine position, placing her opposite heel
on the ipsilateral knee with the leg falling passively outward) [275].
Injuries associated with pubic symphysis rupture include massive bleeding, resulting in hemodynamic instability [276], sacroiliac dislocation
[275], sacral fracture, lumbosacral plexopathy
[277], and urinary bladder injury.
Diagnosis
A plain pelvic X-ray is diagnostic. Severe palpatory tenderness of the sacroiliac joint or plain
X-ray ndings suggests a widening of the sacroiliac joint or sacral fracture. A pelvic CT denes
the extent of the injury and posterior ring involvement [275]. According to the clinical presentation, soft tissues are evaluated with MR of the
abdomen and pelvis [272].
Treatment
The rst-line treatment is a closed reduction and
application of a pelvic binder. Internal surgical
xation is indicated if a gap of the pubic symphysis is >40 mm [272, 277]. Even a gap
>40mm can be treated conservatively, but postpartum pelvic pain persists in most patients
[277, 278]. Associated injuries are treated
accordingly—sacroiliac joint disruption, vaginal tears, etc. Implants are removed after
6months [278].
Prognosis
The prognosis is good to excellent in most cases.
All fusions heal, and symptoms improve.
Radiographic loosening of implants is observed
in subacute cases [279].
10.1.10 Treatment
The patient with threatened UR should be examined gently but thoroughly, under anesthesia, by
someone experienced enough to carry out whatever treatment method may be indicated. If UR is
not diagnosed until after delivery, the procedure
depends on the extent of the laceration. The complete UR mandates laparotomy; a cautious plugging from below may be employed in partial UR.
10.1.10.1 Anesthetic
andPerioperative
Management
See Chap. 2.
10.1.10.2 Operative Treatment
The uniformly fatal termination in a very short
space of time, of every case of rupture of the uterus
that had come to my knowledge in the practice of
my friends, or of my own, induced me seriously to
reect what could be done, or what might be rationally attempted, in these deplorable cases
(William Jackson, 1845 [148])
Around 1845, maternal and fetal mortality
was near 100%, and William Jackson (an anatomist and physiologist at the Medical Institution,
Shefeld, UK) advocated surgical exploration
when UR was suspected [148]. Despite this conclusion, in 1932, Mahfouz still urged conservative treatment whenever possible [280], but today
the key to successful treatment is early surgical
intervention.
The time available for successful interven-
tion after a frank UR and before the onset
of major fetal morbidity is only 10–37min
from fetal distress on the electronic fetal
heart rate monitor [80, 102, 269].
10.1 Spontaneous Uterine Rupture
https://t.me/medicina_free
279
After the fetus is successfully delivered, the
type of surgical treatment should depend on the
following factors:
• Type of UR,
• Location of UR,
• The extent of UR,
• The degree of bleeding,
• The condition of the mother,
• Future childbearing.
Suture Repair
Before deciding on the type of surgical management, all rupture locations should be dened. Most
URs are at the single site, but anterior and posterior UR (10.7%), bladder, and vaginal involvements (9% and 5%, respectively) are present [43].
Uterine bleeding is more profuse when the uterine
tear is longitudinal rather than transverse.
“Conservative surgical management” involving
uterine suture repair (Figs. 10.23 and 10.24) is
reserved for the following ndings [149, 250]:
• The desire for future childbearing,
• Low-transverse UR,
• Fundal UR,
• No extension to the broad ligament, cervix, or paracolpos,
• Easily controllable uterine hemorrhage,
• Good general condition,
• No coagulopathy.
Suture repair is not contraindicated in the congenitally malformed uterus [172]. Repair of a UR
is achieved in 13–74% of cases [43, 60, 79, 181,
182, 282]. Suture repair carries a recurrence risk
of 4–19% in a subsequent pregnancy [14, 283,
284]. Therefore, the women with a previous
suture repair of UR should undergo an elective
CS when fetal lung maturity is demonstrated
[285], or the patient is hospitalized and monitored until 37 weeks. Then CS is performed
[286]. Recommendations are not strong because
there are no prospective studies.
The type and location of UR dictate the type
of uterine repair. When the lower anterior uterine wall ruptures, the primary repair is accompanied by hemostatic techniques such as
hypogastric artery ligation [149]. The percentage of patients with the simple repair of the
uterus is signicantly higher in the scarred
(90.2%) than in the unscarred uterus group
(57.5%). Hysterectomy is performed in 25% of
the patients with a previously unscarred uterus,
signicantly higher than the 9.8% in patients
with a scarred uterus [65].
However, if an obvious cause is detected during surgery, and the multiparous woman does
not desire future pregnancy, or the future conception may be dangerous, suture repair of the
rupture with tubal ligation for sterilization could
be performed instead of hysterectomy [287,
288].
In most cases, simple repair of the uterine tear
is repaired with a double-layer closure using continuous absorbable sutures [289]. There are cases
a
Fig. 10.23 (a) The ruptured and contracted uterus during emergent exploration. (b) The uterine rupture, extending
inferiorly from the left side of the previous lower segment scar. (Reproduced with permission from [259])
b
Соседние файлы в папке @xirurgi_2025