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Fig. 10.24 Postpartum uterine rupture. The right side of
the uterus is ruptured. The right round ligament and uterine artery are intact, making suture repair possible.
(Reproduced with permission from [281])
with suture line reinforcement with adhesives
(eece-coated brin glue) [77, 290] or patches
(Vicryl mesh, Goretex mesh) [291, 292].
Hysterectomy
Hysterectomy should be considered the treatment
of choice in several indications:
• Intractable uterine bleeding,
• UR sites—multiple, longitudinal, or low
lying,
• Placenta percreta,
• Irremediable uterine atony/accrete,
• The probability of cervical cancer,
• Coagulopathy.
The ruptures in unscarred uteri occur most frequently in the corpus uteri and the lateral side and
more frequently extend beyond the cervix. These
rupture types are surgically more challenging to
repair [36].
Total Abdominal Hysterectomy
Total abdominal hysterectomy is a denitive procedure unless cardiovascular decompensation
necessitates subtotal abdominal hysterectomy or
simple suture repair with or without bilateral
tubal ligation [293]. Previously, total hysterectomy was supported because of the probability of
cervical cancer in the cervical stump and the
10 Uterine Rupture andPerforation
Fig. 10.25 Postoperative specimen of the uterus showing
large fundal defect after spontaneous uterine rupture of an
unscarred uterus due to placenta accreta. (Reproduced
with permission from [142] under the CC BY 3.0)
increased rate of bleeding and discharge [294,
295]. The cervical malignancy rate was 0.39–
1.9%. Due to cytological surgery, the rate has
decreased to 0.1–0.15% [296]. The amount of
blood loss, duration of operation, the rate of
maternal deaths, ABO need for blood transfusion, and reoperation are higher with total hysterectomy [296].
Placenta percreta is an additional therapeutic
issue during spontaneous UR.Up to 1966, there
were 33 cases published [297], and in the period
from 1966 to 2000, another 40 cases were
published [298]. Spontaneous UR due to placenta
percreta (Fig.10.25), with partial manual removal
and hysterectomy, has 20% mortality. During
hysterectomy with no attempt at manual removal
results in 100% survival. When the adherent placenta was left in situ, 67% succumbed.
The treatment of choice for the UR with
placenta percreta is a total abdominal hys-
terectomy with no attempt at manual
removal [297, 299, 300].
The fundal hiatus discovered in a presumably
unscarred uterus at emergency CS for other obstetric indications, with the appearance of the brotic
edge of the defect, strongly suggested a chronic
event (rupture or previous perforation) with the
possible expulsion of the previous conception. A
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hysterectomy is recommended. If the defect is
sutured, an intraoperative or denitive biopsy of
the edges of the defect is mandatory [301].
Subtotal Hysterectomy
Subtotal hysterectomy is preferred with the
shorter operation to minimize mortality and morbidity, as in [296]:
• Hemodynamic instability,
• Cardiovascular decompensation.
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These recommendations are for emergency
hysterectomies, not only spontaneous URs representing 10% of cases [296]. Total abdominal hysterectomy for spontaneous UR is done in 14%,
subtotal hysterectomy in 5–22%, uterine repair
with bilateral tubal ligation in 25–45%, and uterine repair without bilateral tubal ligation in 39%
of patients [20, 41].
While performing a subtotal hysterectomy following the dehiscence of a lower segment scar, the
incision may be posterior and circumferentially
from the rupture [22]. In such cases, total hysterectomy carries the risk of ureteric injury. During the
operation, the placenta should be examined and
evacuated. It can be found in the abdominal cavity
or placed intrauterine. The amniotic sac can be
intact (Fig.10.26) [250, 302] or disrupted.
The extent of endometrial activity within the
horn and the degree of separation to the other side
inuence management. However, these factors
are not included in any formal classication. If
the rupture is due to rudimentary horn pregnancy,
separating the placenta from the rudimentary
horn is difcult or impossible. In such cases, the
rudimentary horn of the uterus, along with the
placenta, should be excised (see Chap. 9) [303]
or a subtotal hysterectomy performed.
First andSecond Trimester
Case reports of UR management in the rst or
second trimester are limited [149, 150, 195, 287,
304, 305]. Often, the clinical condition of the
patients requires an emergency hysterectomy. The
most important issues are whether the UR repair
can withhold the tension from the enlarging uterus
Fig. 10.26 Intraoperative photograph shows the uterus
(lower part of the operative eld), the gestational sac (on
the left), and the placenta (upper right) after opening the
abdomen. (Reproduced with permission from [302] under
the CC Attribution License)
and signicant forces developed during labor.
However, there have been reports of the conservation of the uterus. A midgestational UR, repaired
using brin-coated collagen eece, allowed the
successful continuation of the pregnancy [290].
Urinary Bladder Rupture or Injury
See Sect. 28.3.
Elective Cesarean Section
A recurrent UR rate of 4–29% has been noted in
patients with a prior repair [60, 85, 245, 306,
307], although a simple repair of a UR can result
in no cases of recurrent UR [308].
A patient with a previous UR can carry
another pregnancy. The woman with a previous UR should undergo an elective CS as
soon as fetal lung maturity can be demonstrated [66, 282, 285, 309]. CS between 37
and 38weeks is recommended for patients
with a previous ruptured lower uterine scar.
For those with a history of ruptured classical scar or previous UR, the opinion varies
regarding delivery time. Some deliver at
35weeks, while others recommend admission to the hospital 1week before the gestational age at which labor started in the
previous pregnancy [85].
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10 Uterine Rupture andPerforation
10.1.11 Prognosis
The fatality of this dreadful accident to the parturi-
ent female demands our sympathy, and calls for
our utmost exertions to devise some means of
relief, if any can be found, under the circumstances
presenting an almost hopeless condition of our
patient; for an escape from this terrible disaster
may be considered almost miraculous.
(William Jackson, 1845 [148])
Rupture of the uterus is one of the most dangerous
accidents to which the female in the puerperal state
is liable: and one from which recovery is hardly to
be expected, either of the mother or the child.
(Ames RPM, 1881 [5])
Maternal and perinatal mortality vary signicantly between developed and developing countries. Also, these rates are highly variable in the
same country, especially between cities and rural
areas. Due to the rarity of the disease and
improvement in diagnostic and therapeutic
modalities, mortality is decade-dependent and is
continuously decreasing.
10.1.11.1 Maternal Outcome
Repeated Uterine Rupture
In the 1930s, after a simple suture of the tear, several cases in a subsequent pregnancy resulted in a
repeated UR [284, 310]. It is difcult to estimate
the risk of repeated UR due to (1) a high frequency of hysterectomy, (2) pregnancy avoidance after explaining possible similar risks in
further pregnancy, or (3) tubal ligation performed
during UR repair. The women with UR after TOL
have a lower risk for another UR than women
with previous UR during pregnancy. With a history of UR, the recurrence rate ranges from 0% to
33%, which recently decreased to 4–15% [311].
Maternal Morbidity
The maternal morbidity rate ranges from 12% to
46% [15, 248, 312]. Commonly reported maternal morbidity includes hemorrhage and shock,
overall 46%; infection (wound infection, 13.8%;
peritonitis, 10.2%; tubo-ovarian abscess or urinary tract infection, 19.8%; pelvic inammatory
disease, 4.3%; respiratory infections including
pneumonia, 2.2%; and tetanus, 2%); vesicovagi-
nal stula, 6.6%; pelvic hematoma (mostly in the
broad ligament), 19.2%; fever, 21.7%; and paralytic ileus, 18.9%.
Surgical complications include injury to the
bladder and ureter [22], dehiscence, and hernia.
Less commonly, hematuria, renal failure, disseminated intravascular coagulation, atelectasis,
thrombophlebitis, pulmonary and cerebral embolism, and intestinal obstruction are reported. Up
to 58% with UR required ≥5 units of blood [79].
A hysterectomy rate varies from 6% to 83%
[60, 79, 80, 102, 168, 181, 182, 282, 313]. In a
study with a hysterectomy rate of 19%, 68%
were performed because the uterus was not
deemed repairable, 21% for irremediable uterine
atony, and 5% because of placenta accreta [80].
URs outside the lower segment are negatively
associated with healthy mothers [36]. A signicantly higher rate of hysterectomy was (1) before
1980, (2) with an unscarred uterus, (3) parity >3,
(4) postpartum after vaginal delivery, and (5)
URs outside the lower segment (most URs
occurred outside the lower uterine segment in
unscarred uteri (79.3%)) [36, 314]. The hysterectomy rate from complete UR is 21–26% [24, 36,
314].
The increased morbidity in women with unscarred uteri may be due to the increased vascularity at the rupture site and a tendency among
providers to delay treatment due to the low index
of suspicion in the absence of an operative uterine history [36].
Maternal Mortality
Maternal mortality depends on the following:
• Cause,
• Decade of presentation,
• Country development,
• Type and extension of the uterine tear,
• Treatment delay.
Maternal mortality until 1881 was 88%, and
90% of deaths occurred within the rst 10–15min
of the onset of symptoms [5]. In 1966, 29% (2/7)
of patients who underwent repair of a UR later
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presented with another UR in a subsequent pregnancy, and one of these women died [245].
Maternal mortality in general occurs at a rate of
0–1% in developed countries [36, 119, 315], but
in developing countries at the rate of 2–11% [20,
25, 27, 45, 293, 316, 317] and even 30% reported
in Nigeria [43, 47, 318]. UR is an important cause
of maternal mortality in less and less developed
countries, accounting for 9.3% of maternal deaths
[319]. In the Second Report on Condential
Enquiries into Maternal Deaths in South Africa
1999–2001, UR caused 6.2% of deaths due to
direct causes and 3.7% of all deaths (1.9% due to
rupture of an unscarred uterus and 1.8% due to
rupture of a scarred uterus) [320, 321]. UR was
the only cause other than sepsis to have increased
since the previous report, possibly due to the
widespread use of misoprostol in uncontrolled
dosages for labor induction [73, 322, 323].
In a South African study from 1976, with a
mortality rate of 8.5% due to the rupture of an
unscarred uterus, deaths could be subdivided into
mortality for women with longitudinal uterine
tears (8.2%), transverse tears (4%), posterior wall
tears (13%), and multiple uterine tears (25%).
Golan etal. reported no deaths among 32 mothers
who experienced a rupture of a scarred uterus
compared with 15% of women with an intact
uterus [60]. The maternal mortality rate associated with UR largely depends on whether the
diagnosis is established before (4.5%) or after
delivery (10.4%) [313]. The incidence of twin
pregnancy is 5% of rudimentary horn pregnancies, and the overall survival rate is 2.4% [315].
The mortality associated with hysterectomy was
higher than for suture repair. Patients with more
extensive, multiple, or infected tears were unsuitable for repair and tended to be much more acutely
ill, contributing to the high mortality rate [43, 72].
10.1.11.2 Fetal Outcome
Fetal Morbidity
Signicant neonatal morbidity occurs in women
with UR when more than 10–37 min elapses
between the onset of prolonged decelerations and
successful CS [80, 102, 269]. Many decades ago,
it was 29%, mainly causing nervous system dam-
age or pulmonary disease [146]. Most surviving
mothers had a mean blood loss of more than
2000 mL [149, 165]. Maternal hemorrhagic
shock is a risk factor for fetal mortality and
morbidity.
Fetal Hypoxia
Leung etal. found that 5% of neonates born to
women with URs developed neonatal asphyxia
(dened as umbilical artery pH <7 with seizures
and multiorgan dysfunction). No clinically signicant perinatal morbidity is present when the
delivery is accomplished within 17min of an isolated and prolonged fetal heart rate deceleration.
If severe, late decelerations preceded prolonged
deceleration, perinatal asphyxia is observed at
10min from the onset of the prolonged deceleration to delivery [80]. Also, 55% of fetuses born
after UR had bradycardias between 18 and
37min before delivery. Although the rate of fetal
acidosis was high (91%), no permanent neurological injuries or neonatal deaths occurred [269].
Even with rapid (<18min) intervention between
prolonged fetal heart rate deceleration and delivery, 5–10% of neonates developed hypoxic–ischemic encephalopathies with impaired motor
development [88, 121]. Although the rapid intervention did not always prevent severe metabolic
acidosis and severe neonatal disease, it probably
did limit neonatal death.
In 99 cases of UR, 43% had an umbilical
artery pH <7, and 58% of these newborns had a
pH <6.8. Regarding these pH levels, 39% had
5-min Apgar scores of <7, and 12% had 5-min
Apgar scores of <3 [80]. Around 91% born after
UR had an umbilical artery cord pH level <7.0,
and 45% had 5-min Apgar scores <7 [269].
The most important factor for the develop-
ment of fetal acidosis is the complete extru-
sion of the fetus and placenta into the
maternal abdomen [269].
Hypoxic–Ischemic Encephalopathy
Descriptive neonatal consequences (fetal acidosis, Apgar scores, need for resuscitation, and
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10 Uterine Rupture andPerforation
intensive care unit admissions) are poor predictors of neonatal morbidity. UR is associated with
a signicant increase in the risk of neonatal
encephalopathy compared with a nonreassuring
fetal status [324]. UR can result in acute and profound asphyxia, which might explain the predominant basal ganglia and thalamic injury
pattern observed in newborn babies [325, 326].
One-third of delivered infants after a UR showed
hypoxic–ischemic encephalopathy, and in 19%,
it was moderate or severe [324]. The prevalence
of hypoxic–ischemic encephalopathy is expected
to increase due to decreased fetal mortality.
However, hypoxic–ischemic encephalopathy is
rare, and most recover without sequelae [37].
Fetal Mortality
The highest risk of intrapartum/infant death
was when UR is associated with placental
separation or fetal extrusion [37, 80, 327],
regardless of time to delivery [37, 327].
Up to the year 1848, almost all fetuses died.
One-day survival of delivered fetuses was 37%,
but mortality of the survived fetuses after 24h
was 46% [3]. The initial mortality of undelivered
fetuses was 23%. Mortality after 24h was 73%
[3]. Fetal mortality is highly variable. The most
developed countries have a fetal mortality rate of
4.7–26.2% [37, 62, 66, 327, 328]; less developed
countries claim 54.3–81.7% [15, 25, 27, 41, 293,
316], with up to 91–93% in Pakistan, Uganda,
and Nigeria [20, 40, 43, 44]. Risk factors for fetal
mortality are presented in Table10.3.
The decade of analysis is prognostic. The
complete UR with infant death in Norway was
present in 51.6% during 1967–1977, while
dropped to 15.0% from 2000 to 2008 [37].
Older studies claimed two to three times lower
fetal mortality in the scarred UR group [65, 146],
although newer studies did not nd a difference
[37]. The explanation is that many unscarred URs
are detected postpartum, indicating that UR
occurred shortly before delivery, with a short duration of hypoxia [37]. The UR was three times more
likely to result in the death of the infant if the
Table 10.3 Risk factors for fetal mortality from complete UR are [37, 65]
Obstetric Maternal Other
Unscarred
uterus?
Sudden loss of
contraction
Placental
separation
Infant extrusion Occurrence outside
Parity ≥3
Hemorrhagic
shock
Decade
The time from
rupture to delivery
>30min
Delivery after
midnight
the hospital
delivery took place in a hospital with <3000 births
a year (1/1300) compared to hospitals with >3000
births a year (1/4700) [329]. The differences exist
if preterm infants and different populations are
included (all women in labor vs. women undergoing a trial of labor after a previous CS) [88].
Time intervals <20min had the least intrapartum/infant deaths. For every additional minute,
there was a 10% increase in intrapartum/infant
deaths and a 5% decrease in delivering a healthy
infant [37].
Between 1990 and 2000, newborn survivors’
average gestational age and weight were
32weeks and 1770 g, respectively [315]. Fetal
mortality after UR with the previous salpingectomy as a possible cause is 67% [238].
There are no comparisons of the type and the
location of UR and fetal mortality and morbidity.
In six cases of posterior UR after the previous
CS, in only the last case, both mother and fetus
survived [33]. Scars outside the lower segment
were associated with a higher percentage of catastrophic prelabor UR than scars in the lower segment, resulting in a high perinatal death rate [37].
There are cases of delivery of a live fetus from
abdominal pregnancy due to unrecognized UR
[330, 331].
10.2 Traumatic Uterine Rupture
10.2.1 Historical Perspective
For a historical perspective of spontaneous UR, see
Sect. 10.1.1. First, Baisch then De Lee [332] divided
URs into spontaneous and traumatic. Lazard and
Kliman, in 1936, proposed a classication of trau-
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matic URs [333]. Traumatic URs are due to criminal abortion (better termed “instrumental” trauma)
or a result of blunt abdominal trauma, complicating
about 0.6% of traumas during pregnancy [334].
The rst two cases are from 1706 and 1709,
resulting from a fall at the sixth and seventh months
of gestation. One fetus was expelled through the
anus and another through the navel [335, 336].
Joseph. B.De Lee, in 1904, described the eighth
month pregnant woman falling through a broken
stair, the body falling till the protuberant abdomen
was arrested by the narrow opening. Complete UR
was at the fundus resulting in fetal death [332].
Cases by Ley in 1919 and Hosking in 1923 followed. The rst cases of fetal death due to traumatic UR from MVA were by Woodhull in 1942
[337] and Elias (boat collision) in 1950 [338].
10.2.2 Incidence
Up to and including 1929, Estor and Pueck
(referred to by Jaroschka, Medizinische Klinik,
1929) collected 40 cases. Additional cases in the
1930s were collected by Orthner [339], Lazard
and Kliman [333], and Ruder and Moore [340].
During the last 50 years, motor vehicle use
increased blunt abdominal trauma resulting in
traumatic UR [341–343]. Over 100 cases of traumatic rupture of the pregnant uterus have been
reported until 1975, with only three [338, 344,
345] with the avulsion of the uterus. The overall
incidence of all-cause UR signicantly varies. In
patients hospitalized for assault during pregnancy, the incidence of UR reached 0.71%, with
an odds ratio of 46 compared with women with
no history of assault [346]. Traumatic placental
abruption is the most common injury after blunt
maternal abdominal trauma, and traumatic UR in
the 1980s was present in 10% of cases [347].
10.2.3 Etiopathogenesis
See Sect. 25.3.3.3. While a trauma of sufcient
force may cause a rupture in a healthy uterus, the
presence of a weakened point caused by preceding disease, such as hyaline degeneration of mus-
cle bers resulting from multiparity, previous
curettages, placenta previa, intramural broids,
etc., would undoubtedly increase the probability
of UR resulting from external violence. Orthner
gives the following explanation of the mechanics
of the injury [339]: as to whether the blow or the
resultant fall is the principal factor, one can
assume that whichever is of the greater intensity
is the chief factor, i.e., with a slight blow and a
fall from a great height, the latter is the main factor; with a severe blow and a shortfall to the oor,
the blow in all probability is to blame. It is not
possible, as a rule, to determine the kind and
direction of the force from the location of the UR,
as this usually occurs by countercoup.
The rupture is always the result of a sudden
increase in the intrauterine pressure caused by
the sudden compression of the abdominal contents. By the laws of hydrodynamics, this pressure spreads equally in all directions in the
uterine cavity lled with amniotic uid. The tear
occurs at the weakest point of the uterine wall.
At the end of pregnancy, the point is at the fundus [333], which lacks the protection of the
bony pelvis. In many cases, the placental site is
especially weak because of the increased vascularity. It is unknown whether uterine scar from
previous CS indicated due to myomectomies is
prone to rupture. The rupture site directly relates
to the site where direct traumatic or countercoup
forces are applied, mainly involving the uterine
fundus (Fig.10.27a). However, other locations
and degrees of UR from other causes have been
reported (Fig.10.27b) [334, 349–351]. This is
because amniotic uid transmits high pressures
efciently; “blast injuries” can follow blunt
trauma, resulting in rupture of the uterine fundus in 75% of cases. During the rst trimester,
the pelvis protects the uterus, and uterine avulsion can likely occur solely in combination with
a pelvic ring fracture [345]. Even cases with the
seatbelt as the proposed etiologic factor exist
[352].
The extent of the UR can be variable. Such an
injury may result in serosal hemorrhage or abrasions, avulsion of the uterine vasculature with
bleeding, complete disruption of the myometrial
wall with extrusion of the fetus, placenta, or
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Fig. 10.27 Ruptured uterus. (a) The most common location is the uterine fundus [348], but other locations (b) can rup-
ture depending on the mechanism of trauma. (Reproduced with permission from [349] under the CC Attribution License)
10 Uterine Rupture andPerforation
umbilical cord into the abdominal cavity; or complete uterine avulsion [353].
10.2.4 Clinical Presentation
The seatbelt sign is a strong predictor of traumatic
UR [350, 354]. Clinical presentation varies from
subtle ndings (e.g., uterine tenderness, nonreassuring fetal heart rate patterns) to a rapid onset of
maternal hypovolemic shock. The classic description of UR includes the following: severe uterine
pain and tenderness, profound shock, palpation of
fetal parts outside the uterus, and vaginal bleeding.
The examination can reveal a (moderately) distended abdomen with suprapubic tenderness and
guarding. The uterus can be difcult to palpate.
Pelvic examination conrms normal external genitalia and closed rm cervix. Fullness in the pouch
of Douglas can be found with the examining nger
stained with blood. The presence of maternal hypotension is a late and ominous sign. These complex
ndings, however, often are not present [15, 355,
356]. Consequently, the diagnosis is often delayed
or not considered at all. The hemodynamic stability
of the mother is maintained at the expense of uterine blood ow, putting the fetus at risk [357, 358].
Consequently, fetal distress may be the rst indicator of unsuspected maternal hemorrhage.
Fig. 10.28 Abdominal CT shows the fetus in the abdominal cavity and hemoperitoneum, ndings consistent with
complete uterine rupture [348]
10.2.5 Diagnosis
The diagnostic modalities used depend on the
severity of the maternal injury. The fetus can be
palpated in the abdomen outside the uterus in
severe abdominal trauma with UR.Alternatively,
abdominal CT can conrm this condition
(Fig. 10.28). On plain (abdominal) X-rays, the
fetus can be found in abnormal positions, such as
in the mother’s thigh (Fig.10.29).
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Table 10.4 (Pregnant) uterus injury scale
AIS-
GradeaDescription of injury
I Contusion or hematoma (without
placental abruption)
II Supercial laceration (<1cm) or partial
placental abruption <25%
III
Deep laceration (≥1cm) in second
trimester or placental abruption
25–50%
Deep laceration (≥1cm) in third
trimester
IV Laceration involving uterine artery 4
Deep laceration (≥1cm) with >50%
placental abruption
V Uterine rupture
• Second trimester 4
• Third trimester 5
Complete placental abruption 4–5
Reproduced with permission from [360]
a
Advance one grade for multiple injuries up to grade III
90
2
3
3
4
4
passed out under the skin of the right thigh
along the line of least resistance.
287
Fig. 10.29 The fetus was found lying just under the skin
and supercial fat on the upper anterior surface of the
right thigh. (Reproduced with permission from [359])
Coutts explained two possible mechanisms
[359]:
1. The bus struck the woman on her left side,
throwing her on the ground, and went over
her; the pressure of the tires and counterpressure of the ground ruptured the uterus, and the
pressure continuing downward and to the
right forced the fetus down into the thigh (the
fetus was about 23weeks old, so the uterus
would be above the brim and nearing the level
of the umbilicus),
2. The original blow and pressure were on the
right side and stripped the skin and supercial
fascia of the thigh, detaching the inguinal ligament from its attachments and the abdominal
muscles from the anterior third of the iliac
crest; the same force continued to act, tore the
peritoneum, and ruptured the uterus. On the
release of the pressure, the uterus rebounded
forward and squeezed out the fetus, which
10.2.6 Treatment
The diagnosis of UR warrants immediate obstetric intervention. As to therapeutic procedure,
much depends on the location of the rupture and
the degree of injury (Table10.4).
Total abdominal hysterectomy is considered
the operative intervention of choice, although
subtotal hysterectomy or simple suture repair
may be reasonable alternatives [15, 356]. If it
occurs in the fundus, a laceration repair is quick
and is done with less shock. If the tear is in the
lower segment, transverse hysterectomy is indicated. Palliative measures must be considered
and might be lifesaving, such as applying the
Momberg belt or clamping the uterine arteries
through the cervix until the patient can be relieved
of shock and prepared for surgery.
10.2.7 Prognosis
UR tends to occur only in the most severe accidents involving direct abdominal trauma. This
event can be catastrophic for both the mother and
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10 Uterine Rupture andPerforation
her unborn fetus, especially when there is a delay
in the diagnosis since initial symptoms may be
variable. With traumatic UR, fetal mortality
approaches 100% and maternal mortality is close
to 10%, with most maternal deaths due to concurrent injuries [334, 361, 362]. Maternal survival
results from blood vessel constriction when the
bleeding rapidly diminishes or even stops. The
uterine contents (the placenta, the amniotic sac,
etc.) are immediately emptied into the abdominal
cavity. After that, the uterus contracts as it would
following CS.Since the blood supply at the midline (where the rupture usually occurs) is scanty,
the uterine muscle contractions practically stop
the bleeding. This suggests that when the placenta is inserted more toward the parametrial
region, with lower contractibility and larger
blood vessels, the trauma will result in fatal
exsanguination.
More than 50% require ≥5 units of blood after
UR, and hysterectomy rates are 26–83% [342].
10.3 Uterine Perforation
10.3.1 Traumatic
See Sect. 25.4.
10.3.2 Iatrogenic
10.3.2.1 Incidence
Uterine injury or perforation can be from serosato- mucosa or mucosa to serosa. Serosa-tomucosa injury occurs during open [363] or
laparoscopic [364–367] procedures. Mucosa to
serosa injury occurs during instrumental transvaginal procedures, like curettage (see Sect.
18.3). The most common emergent surgical oper-
ations during pregnancy are appendectomy and
cholecystectomy. Therefore, iatrogenic uterine
injuries most commonly occur during these procedures, mainly by laparoscopic access from a
blind Veress needle or trocar insertion [363–367].
Due to the similarity with fetoscopy, this inadvertent uterine perforation is termed incidental
fetoscopy [366].
10.3.2.2 Pathophysiology
andPresentation
Incision or perforation through the full thickness
of the uterine wall can lead to the following complications: (1) bleeding from the incision site, (2)
leakage of amniotic uid, (3) the contamination
of amniotic uid with the purulent or feculent
material, (4) CO2 insufation into uterine wall or
intrauterine cavity [368, 369], which can lead
CO2 embolism, and (5) pneumoamnion [367].
Most cases are discovered during the initial
operation.
10.3.2.3 Diagnosis andTreatment
The knowledge about this issue arises from the
operative fetoscopy. It involves inserting a 1.2- to
3-mm trocar under US guidance through the
maternal abdomen and uterus into the amniotic
cavity to access the fetus, placenta, or umbilical
cord. After the procedure is completed, the
trocar(s) are removed from the abdomen. The
sites of uterine perforation from the trocars generally do not require repair [366].
Accidental perforation of the pregnant uterus
during laparoscopy necessitates intraoperative
obstetric consultation. Conversion to laparotomy
is unnecessary if adequate inspection and potential repair of the uterus can be obtained by laparoscopy. When the uterine injury is recognized
during the operation, rst, the operator should
verify whether the amniotic sac is intact. The US
should be performed to determine a fetal heart
rate and residual amniotic uid volume [366].
The gestation could continue with a live fetus and
enough amniotic uid and no signicant bleeding. If the defect is minimal, from a Veress needle
or 5mm trocar puncture, there is no indication to
suture the defect [368]. Larger lacerations should
be repaired with 2-0 absorbable sutures in a single layer [366]. Additional suturing could potentially cause more harm by increasing the risk of
membrane rupture. If signicant leakage occurs
or there is a dilemma about fetal vitality, the baby
should be delivered by CS during the same operation. If the advanced gestation continues with a
viable fetus, postoperative corticosteroids should
be considered due to the risk of preterm labor
[366]. Fetal middle cerebral artery Doppler
References
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289
assessment evaluates fetal anemia, especially
when placental perforation is suspected. Anti-D
immunoglobulin should be administered to any
Rh-negative patient, and a Kleihauer-Betke test
should be obtained [366]. Before hospital discharge, fetal and amniotic uid status should be
checked with US [366].
CO2 embolism should be suspected when
maternal hypotension occurs after CO2 insufation through the Veress needle [369]. In the early
postpartum surgery, or after the termination of
pregnancy, the Veress needle insertion into the
uterine cavity results in the gas escaping through
the cervical os [369].
The use of perioperative broad-spectrum antibiotics prevents the risk of chorioamnionitis.
WBC and CRP should be measured once or twice
daily to detect chorioamnionitis early.
Cardiotocography should be performed daily.
The immediate risk of preterm labor is addressed
by using indomethacin (see Chap. 4). However, a
calcium channel blocker is also an option and
would not affect the amniotic uid volume or
potentially mask an infection.
If the injury is unrecognized during the operation, pneumoamnion causes increasing maternal
abdominal pain. An abdominal CT shows pneumoamnion (Fig.10.30).
10.3.2.4 Prognosis
The risks of operative fetoscopy include PPROM,
oligohydramnios, preterm delivery, chorioamnionitis, fetal injury, and pregnancy loss.
Additionally, there are concerns about the potential risk of fetal anemia, placental abruption, and
fetomaternal hemorrhage when the trocar perforates the placenta [370]. However, some studies
did not nd signicant differences in rates of
PPROM, placental abruption, miscarriage, or
perinatal survival [371].
Despite the rarity of publications on the subject, similar complications and outcomes can be
expected for operative fetoscopy. There is an
increased rate of preterm labor after iatrogenic
uterine injuries [366]. Although some recommend CS before the onset of labor to minimize
the risk of spontaneous UR [372], small defects
that were not sutured during the initial operation
heal without evidence of prior uterine injury
[366]. Therefore, with small punctures, vaginal
delivery should be preferred. A single case of
pneumoamnion resulted in the spontaneous rupture of membranes with the delivery of a stillborn
[367].
References
Fig. 10.30 Postoperative abdominal CT shows an air-
uid level (pneumoamnion) within the amniotic cavity
(large arrow) and subcutaneous air from the laparoscopic
trocar insertion site (small arrows). (Reproduced with
permission from [364])
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