eISSN: 2377-4304

Obstetrics & Gynecology International Journal

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Received: January 01, 1970 | Published: ,

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Abstract

40 cases of uterine rupture that occurred at Durgapur sub divisional hospital during 5 years period from January 1995 to December 1999 were analyzed for clinical observations. The incidence was 1:273; 77.5% were spontaneous, 15 were traumatic, and 7.5 % has scar rupture. It was complete in 92.5% cases disproportion was responsible in 40 cases and mal presentation in 27.5% cases. Total hysterectomy was done in 30% cases, subtotal in 27.5% cases and rent repair in 42.5% cases. Overall maternal mortality was 30% of which highest (41.2%) found in rent repair and lowest (16.6%) in total hystechtomy.

Keywords: uterine rupture, maternal mortality and morbidity, prenatal mortality, type of surgery

Introduction

In modern obstetrics, rupture of the uterus at one suggests a badly manage labour. But in sub-divisional hospital like at Durgapur catering to all referring cases, it is not rare but a frequent occurrence. The commonest cause of rupture was prolonged obstructed labour and trauma. Even in this era of jets and rockets, women are brought in this hospital in state of shock from miles away either in a bullock cart or other slow moving vehicles, hours after rupture had set in. Hence, rupture is still a life threatening problem to the medical fraternity particularly the obstructions.

Material and methods

Present study compromises 40 cases of uterine rupture attained during 5 years period from January 1995 to December 1999 at Durgapur Sub divisional Hospital, West Bengal. The patients were evaluated with special reference to incidence, aetiological factors, and clinical features type off surgery to be undertaken, maternal mortality and its relationship to type of surgery.

Observations

During the period of study there were 10,920 deliveries, the incidents being 1:273 deliveries majority of the patients were between the ages 25 and 35 years. Average parity was 3.8. Most of the cases (77.5%) had spontaneous rupture. This proportion was the major aetiological factors in 40% of the cases (Table 1). Malpresentations like mentoposterior, persistent occipitoposterior and transverse lie were responsible in 27.5% of the cases. Traumatic rupture were seen in 15% of the cases, either following internal podalic version, injudicious used of oxytocin or forceps extraction. Scare rupture was found in 7.5& of the cases, two were dehiscence of lower segment of scar and one was classical caesarean section scar rupture.

Aetiology	No of Cases (%)
Disproportion	16(40%)
Malpresentations	11 (27.5%)
Traumatic Rupture	6 (15%)
Grand Multiparity	4 (10%)
Scar Rupture	3 (7.5%)
Total	40 (100%)

Table 1 Aetologywise distribution of cases of uterine rupture

In this study 37 cases (92.5%) had complete rupture only three (7.5%) had incomplete rupture. Transverse tear of bladder was the commonest variety of rupture. Out of 37 cases of complete rupture, 35 were in lower segment and only two had upper segment rupture. Lateral wall tear with cervical extension was present in three cases of incomplete rupture. Most of the cases had typical diagnostic features as described in Table 2.

Clinical Features	No of Cases (%)
Prolonged Labour	25
Superficial foetal parts	12
Loss of uterine contour	18
Absence of foetal heart sound	34
Shock	30
Vaginal Bleeding	20
Haematuria	7
Inability to trace cervical rim	3

Table 2 Distribution of cases according to clinical features

Suturing of the tear was done in 17 cases. In 15 of them sterilization was done. Total hysterectomy was done in 12 cases where suturing of tear was impossible, tear being extensively ragged and extending into broad ligament on both the sides associated with hematoma. Subtotal; hysterectomy was done in 11 cases (Table 3). Majority of the cases were operated under spinal anesthesia. Only in 2 cases the operation was done in general anesthesia. As shown in Table 3, there were 12 cases (30%) of maternal death. The causes of death were haemorrhage and shock in 8 cases, peritonitis and endotoxic shock in 4 cases.

Type of surgery	No of cases (%)	No. of maternal deaths (%)
Total Hysterectomy	12	2(16.7%)
Subtotal Hysterectomy	11	3 (27.3%)
Rent Repair	17	7 (41.2%)
Total	40	12 (30.0%)

Table 3 Distribution of cases according to type of surgery undertaken and maternal death

Maternal morbidity was also high. About 60% of the patients had suffered from ill effects of either haemorrhage or sepsis. Two patients developed vesicovaginal fistula. Maternal mortality was highest in cases with rent repair that total hysterectomy and subtotal hysterectomy.

Discussion

Spontaneous rupture of the uterus occurred in 77.5 % cases in this series and disproportion accounted for 40% of the cases. Similar observation was made by Sinha & Roy¹ and Kulkarni & Kendre,² such ruptures are more catastrophic than scare ruptures . The clinical picture varied from non symptoms at all to complete collapse, classical picture was present in about 80% of the cases. Transverse tear on anterior wall with lateral extension was the commonest variety in all cases of spontaneous rupture. Similar observations have been made by previous studies.^1,2 Mortality rate was 30%, highest (41.2&%) following rent repair and lowest (16.7%) following total hysterectomy. All the cases had peritonitis and endotoxic shocks following rent repair. Hence, total hysterectomy should be treatment of choice as has also been observed by Eden et al.³ Rent repair may be performed only in cases of scare rupture or if the condition of the patient is too poor to withstand hysterectomy or to preserve child bearing function. Total hysterectomy was performed in 12 and subtotal in 11 cases. Although it is advisable to do total hysterectomy than subtotal , here in this study subtotal hysterectomy and rent repair were done in majority of the cases because most cases were already in a state of shock where operating time, blood loss and exposure to anesthesia were vital factors.