Uterine rupture

Introduction to uterine rupture The rupture of the uterus or the lower uterus during pregnancy or childbirth is called rupture of uterus (ruptureofuterus), which occurs mostly during childbirth, with obstructive labor, inappropriate dystocia surgery, abuse of uterine contractions, pregnancy uterine trauma and uterine surgery scars. It is related to factors such as poor healing. Individuals occur in late pregnancy, and uterine rupture is one of the most serious complications of obstetrics, often causing death in mothers and children. The incidence rate is one of the quality standards for obstetrics in a region. In recent years, with the increase in the quantity and quality of obstetric workers in China, the establishment and gradual improvement of the tertiary health care network for urban and rural maternal and child health has significantly decreased. basic knowledge The proportion of illness: 0.03% Susceptible population: pregnant women Mode of infection: non-infectious Complications: fetal death, hemorrhagic shock, fetal distress

Cause of uterine rupture

1, the cause:

Obstructive dystocia (10%):

Obvious pelvic stenosis, head basin not called, soft birth canal malformation, pelvic tumor and abnormal fetal position and other factors hinder the decline of the first exposure of the fetus, the uterus overcomes the resistance to strengthen the contraction, the lower uterus is forced to stretch and thin, and finally the uterus rupture, this kind of Uterine rupture is the most common type of uterine rupture, and rupture occurs mostly in the lower uterus.

Uterine scar rupture (20%):

The main causes of uterine scar are cesarean section, uterine fibroids removal, uterine rupture or perforation repair, uterine deformity orthopedics, etc.; the cause of rupture is the mechanical traction of the uterus in the pregnancy leading to rupture of the scar or the uterus The intima of the scar is damaged, the placenta is implanted, the penetrating placenta causes spontaneous rupture of the uterus, and the cesarean section is rapidly increased in recent years. The uterine body longitudinal incision cesarean section is easy to be complicated with uterine rupture. The anatomical nature of the longitudinal incision and the lower transverse incision are also different, and the effect of the infectious factor should also be considered, because the current cesarean section of the uterus with a longitudinal incision usually undergoes a long period of labor, multiple vaginal examinations, and the chance of infection increases.

Abuse of uterine contractions (10%):

The uterotonics here should include a variety of substances that stimulate uterine contractions, including the most commonly used oxytocin (oxytocin) and misoprostol, which has been used in recent years. The reported cases of uterine rupture caused by misoprostol More and more, the main reasons include excessive drug dosage or drug delivery rate, immature cervical cervix, malposition of the fetal position, obstructive dystocia, and careful observation of the labor during the medication.

Vaginal midwifery surgery injury (10%):

The cervix is not open, forcibly producing forceps or hip traction, causing severe cervical laceration and extending to the lower uterus, neglecting transverse reversal, destructive surgery, partial artificial exfoliation, etc. due to improper operation, Can cause uterine rupture.

The disease of the uterus itself (20%):

Multi-partum, multiple curettage history, history of infectious abortion, history of intrauterine infection, history of artificially stripped placenta, history of hydatidiform mole, etc., due to the above factors, damage to the endometrium or even the muscle wall, placenta implantation or penetration after pregnancy, Eventually the uterus ruptures.

2, classification

The classification of uterine rupture is mainly classified as follows according to factors such as rupture, rupture time, rupture site and degree of rupture.

(1) Classification by cause of rupture:

1 spontaneous uterine rupture occurs mostly in prenatal, common in scar uterus and uterine dysplasia such as double-horned uterus.

2 Traumatic uterine rupture occurs mostly at birth.

(2) Classification according to the time of occurrence of the rupture:

1 uterine rupture during pregnancy is common in scar uterus and uterine dysplasia.

2 uterine rupture during childbirth is more common in the mother, the cause is mostly obstructive dystocia or surgical trauma or oxytocin (oxytocin) improper use, most uterine rupture occurred in this period.

(3) Classification according to the location of uterine rupture:

1 uterine body rupture is more common in the body part of the scar, placental implantation and uterine dysplasia.

2 rupture of the lower uterus is more common in obstructive dystocia, inappropriate vaginal midwifery leads to cervical laceration and uplift.

(4) Classification according to the degree of uterine rupture:

1 Complete uterine rupture: the uterine wall is completely ruptured, the uterine cavity communicates with the abdominal cavity, the fetus and placenta can be invaded at the uterine rupture, and can also enter the abdominal cavity. If the gestational age is small, the placenta and amniotic sac encapsulate the fetus completely. Abdominal cavity.

2 incomplete uterine rupture: part of the uterine muscle wall or full-thickness rupture, the serosa layer is intact, the common uterine segment is ruptured, forming a wide ligament intrahepatic hematoma, also known as uterine rupture in the broad ligament.

Pathogenesis

The effects of uterine rupture include:

1, bleeding

Uterine rupture usually manifests as massive hemorrhage. Hemorrhage is divided into internal hemorrhage, external hemorrhage or mixed hemorrhage. Internal hemorrhage indicates that blood accumulates in the broad ligament or in the abdominal cavity, resulting in a broad ligament hematoma or hemorrhage in the abdominal cavity; external bleeding indicates that blood is discharged from the vagina.

The site of bleeding of the uterus rupture usually includes uterine and soft birth canal rupture and placental septal bleeding; uterine and soft birth canal bleeding usually requires large blood vessels at the site of injury, if the soft birth canal injury does not damage the large blood vessels usually does not show major bleeding or activity Hemorrhage, the bleeding of the placenta exfoliation surface is related to the degree of placental dissection and the intensity of uterine contraction. If the placenta is not completely peeled off or exfoliated, the uterine cavity is not discharged, which affects the contraction of the uterus, which is characterized by massive hemorrhage; otherwise, if the placenta is completely stripped and has been discharged from the uterine cavity, The uterus contraction is very good, and there is a small amount of active bleeding on the placenta peeling surface.

The above-mentioned bleeding refers to preoperative hemorrhage, and hemorrhage after surgery. The main cause is wound or DIC hemorrhage after clearing of the broad ligament hematoma, or conservative treatment of uterine bleeding.

In addition to causing hemorrhagic shock, bleeding also occurs due to hypercoagulability of the mother, excessive bleeding, and excessive shock time, resulting in DIC.

2, infection

After the uterus rupture, the parts that are prone to infection mainly include pelvic cavity, abdominal cavity, pelvic retroperitoneum and soft birth canal. The main causes of infection are: the pelvic cavity or the broad ligament is connected with the uterine cavity and the vagina. After the communication, bacteria enter; the uterus ruptures. After hemorrhage, severe anemia or DIC, decreased resistance, easy to infection; hemorrhage or extraperitoneal hemorrhage in the abdominal cavity or pelvic cavity, easy to infect; hysterectomy or repair after uterine rupture, under the conditions of bacteria; There may be more vaginal operations during the diagnosis after rupture; longer uterine ruptures are more likely to cause multiple infections in multiple sites.

In addition, the infection that is worth mentioning is a respiratory infection. There are many factors that cause infection. The shock time is too long. The drainage and defense mechanisms of the normal respiratory tract are damaged, and the factors such as aspiration cannot be excluded.

3, leading to birth canal and other abdominal and pelvic organ damage

Injury of uterine rupture includes injury before and after surgical intervention. The damage before surgery intervention includes various damages of uterus, lower uterus, cervix and vagina, and may also have primary bladder due to fetal head compression. Injury, uterine rupture patients have many injuries during the diagnosis process and surgical treatment, sometimes even more than the primary injury, excessive unnecessary vaginal operation or examination during the diagnosis process, resulting in increased birth canal injury; open exploration, clearing blood Or clean the fetus, placenta and fetal membranes, improper operation, leading to intestinal or omental damage; clearing the wide ligament hematoma, causing pelvic floor blood vessels, ureter and bladder injury; uterine rupture time is too long, the damage to the abdominal organs is heavier.

4, the impact on the fetus

The impact on the fetus after uterine rupture is mainly caused by bleeding at different times and varying degrees of bleeding. Most fetuses die, the perinatal morbidity and mortality of surviving fetuses are significantly increased, and long-term complications are also significantly increased.

Uterine rupture prevention

The uterine rupture is a serious threat to the mother and child, and most uterine rupture can be avoided, so prevention is extremely important.

Strengthen family planning publicity and implementation, reduce maternality; change the concept of childbirth, promote natural childbirth, reduce cesarean section rate; strengthen prenatal checkup, correct fetal position, estimate possible childbirth, or have a history of dystocia, or have a cesarean section History of production, should be hospitalized early delivery, close observation of the progress of labor, according to obstetric indications and the previous surgery to determine the mode of delivery, strict control of the application of oxytocin indications, usage, dosage, and should be guarded by someone; Scars, uterine malformation of maternal trial production, we must closely observe the labor process and relax the indications of cesarean section; close observation of the labor process, for the first exposed high, pregnant women with abnormal fetal position should be carefully observed; avoid damaging vaginal midwifery And operation, such as the middle and high position forceps, the cervix is not open, that is, midwifery, neglecting the shoulder first dew in the line, forcible excavation when the placenta is implanted.

Uterine rupture complications Complications, fetal death, intrauterine hemorrhagic shock, fetal distress

Can cause fetal stillbirth.

Symptoms of uterine rupture Common symptoms Precursor uterine rupture Irritability Unstable uterine rupture signs Lower abdominal pain Cold sweat Shortness of breath Internal vaginal bleeding Blood pressure drop Abdominal pain with shock

Uterine rupture can occur in the third trimester of pregnancy, but most of them occur when labor is difficult during labor, and the labor process is prolonged. The fetal head or the first exposed part cannot enter the basin or be blocked in the plane or above the ischial spine. Most can be divided into two stages: aura uterus rupture and uterine rupture.

1. Aura uterus rupture

In the process of labor, when the fetal first exposed part is blocked, the strong constriction makes the lower part of the uterus gradually thinner and the uterus is thicker and shorter, forming a distinct annular depression between the two, and the depression will gradually rise up. Above the umbilical or umbilical, called pathologic retraction ring, maternal self-reported lower abdomen pain, irritability, shortness of breath, difficulty urinating, increased pulse, due to uterus over-frequency contraction, fetal blood supply blocked, The fetal heart changes or can't be heard clearly. Check the abdomen, and a obvious depression can be seen on the abdominal wall. The lower part of the uterus is raised, the tenderness is obvious, the uterine round ligament is extremely tense, and it can be touched and tender. The fetus incarcerated at the entrance of the pelvis is exposed. Compression of the bladder, damage to the bladder mucosa, hematuria can be seen during catheterization. If this condition is not immediately relieved, the uterus will soon rupture at and below the pathological constriction ring.

2

According to the degree of rupture, it can be divided into complete uterine rupture and incomplete uterine rupture.

(1) Complete uterine rupture:

Refers to the full-thickness rupture of the uterine wall, so that the uterine cavity and the abdominal cavity are connected, the uterus is completely ruptured for a moment, the maternal often feels tearing severe abdominal pain, followed by the disappearance of the uterus, the pain is relieved, but with the blood, amniotic fluid and fetus into the abdominal cavity, Sustained total abdominal pain, maternal appearance pale, cold sweat, superficial breathing, pulse breakdown, blood pressure drop and other signs of shock symptoms, examination of total abdominal tenderness and rebound tenderness, clear carcass under the abdominal wall The uterus shrinks to the side of the fetus, the fetal heart disappears, the vagina may have blood flowing out, the amount may be more or less, the first exposed part of the dew or falling disappears (the fetus enters the abdominal cavity), and the expanded cervix can be retracted When the anterior wall of the uterus ruptures, the rupture can extend forward to cause the bladder to rupture. If there is more bleeding in the abdominal cavity, the mobile dullness can be removed. If the uterine rupture has been diagnosed, the uterine rupture is not necessary to be examined by vaginal vaginal injection. In the case of uterine rupture, the mother feels strong contraction of the uterus after injection, and suddenly it is severely painful. The first exposed part then rises and disappears, and the abdominal examination is as seen above.

(2) Incomplete uterine rupture:

Refers to the uterine muscle layer completely or partially ruptured, the serosal layer has not been worn, the uterine cavity and the abdominal cavity are not connected, the fetus and its appendages are still in the uterine cavity, the abdominal examination, there is tenderness in the incomplete rupture of the uterus, if the rupture occurs in Between the two lobes of the uterine wall broad ligament, hematoma can be formed in the broad ligament. At this time, the gradual enlargement and tenderness of the mass can be touched on the side of the uterus, and the fetal heart sound is irregular, such as the uterine artery being torn. Can cause severe extraperitoneal hemorrhage and shock, abdominal examination of the uterus still maintains its original shape, tenderness after rupture is obvious, and can gradually increase the hematoma on the side of the abdomen, the wide ligament hematoma can also extend upwards to become a retroperitoneal hematoma, such as Hemorrhage is not limited, the hematoma can penetrate the serosa layer and form a complete uterine rupture.

Uterine rupture caused by uterine scar can occur in the late pregnancy, but most of the general aura is not obvious after labor, only mild abdominal pain, tenderness in the uterine scar, at this time should be alert to the possibility of scarring, but due to the membrane Not yet ruptured, so the fetal position can be found clearly, the fetal heart is good, if it can be found and treated in time, the prognosis of mother and baby is good, because the symptoms are light, easy to be ignored, when the gap is enlarged, amniotic fluid, fetus and blood enter the abdominal cavity to have a similar complete rupture Symptoms and signs appear, but no tear-like pain, some scar rupture and bleeding, maternal feeling that the contraction stops, fetal movement disappears, no other discomfort, after 2 to 3 days can occur abdominal distension, abdominal pain and other symptoms of peritoneal inflammation, application The uterine rupture caused by improper oxytocin, the uterus strongly contracted after administration, the sudden sensation of tear-like abdominal pain, and the abdominal examination showed signs of uterine rupture.

Examination of uterine rupture

Dynamic observation of changes in blood routine can also assist in the diagnosis of uterine rupture in some cases, especially uterine rupture in the broad ligament and atypical uterine rupture. For the uterine rupture in the suspected broad ligament, dynamic monitoring of blood changes can assist in diagnosis, and The blood loss can be roughly estimated. The precautions are as follows: immediate hemoglobin and red blood cells are compared with those at admission; timed review of dynamic changes in hemoglobin and red blood cells; blood routine reduction of 10/L (1 g/dl) of hemoglobin is equivalent to about 500 ml of blood loss. Note that early shock, blood concentration, estimated blood loss may be less than the actual blood loss; comprehensive analysis with vaginal blood loss; pay attention to the progressive decline of platelets; if possible, dynamic monitoring of coagulation function and dynamic changes of D-dimer.

1. Abdominal puncture or posterior iliac puncture: It can be confirmed whether there is bleeding in the abdominal cavity, and the abdominal percussion is positive for mobile dullness. Combined with medical history and physical signs, it is not necessary to perform this examination.

2, B-mode ultrasound examination: the fetus is in the abdominal cavity, the fetal movement, the fetal heart disappears; the uterus shrinks and has a crack, and the abdomen has free liquid.

3, vaginal examination: the decline of the first dew, the enlarged uterine mouth shrink, visible blood outflow.

Diagnosis of uterine rupture

diagnosis

Comprehensive analysis should be carried out according to the medical history, clinical manifestations and physical signs. The diagnosis is generally not difficult. Anyone who observes the maternal after careful labor can clearly diagnose the uterus when the uterus is ruptured. If the rupture has occurred, it is often inappropriate. Using a history of oxytocin, severe pain occurs during labor, patients have shock and obvious abdominal signs, the diagnosis can be immediately clear, the diagnosis of rupture of the posterior wall of the uterus is difficult, vaginal examination can be done, if necessary, by abdominal puncture, where the original There is a history of cesarean section. This time, from the vaginal trial production, the original incision is found to have tenderness in the labor process, and the possibility of warning of rupture of the aura should be raised.

Very few, although the fetus is delivered from the vagina, but the uterus is still broken, this can be used for abdominal puncture and B-assisted examination, if necessary, laparoscopy can be used to clarify.

In short, the diagnosis of uterine rupture and the type, degree, location, nature of internal bleeding, the presence or absence of fetal heart rate, the complete or partial discharge of the placenta are closely related, light or atypical is easy to be ignored, such as uterine posterior wall rupture symptoms The signs and signs are often atypical and mild; the uterine rupture of the cesarean section in the lower uterus is usually located in the thin layer of the muscle layer, and there is no obvious symptoms and signs when there is no vascular area. Because of less bleeding, the uterine contractions often cover up. Symptoms of abdominal pain are only found during re-cesarean section or during routine vaginal exploration of the uterine cavity.

Differential diagnosis

1. Differentiation from other causes of acute lower abdominal pain: 1 intra-abdominal hemorrhage: such as ectopic pregnancy; 2 tumor pedicle torsion, rupture or degeneration; 3 acute infection of pelvic organs; 4 blocked by blood discharge: such as congenital genital malformation or Postoperative cervix, intrauterine adhesions, etc.; 5 abnormal uterine contractions: such as dysmenorrhea, adenomyosis and so on.

2, dystocia concurrent infection: individual dystocia cases, after multiple vaginal infections, found symptoms of abdominal pain and peritonitis stimulating signs, similar to uterine rupture signs, vaginal examination due to long labor, the lower part of the uterus is thin, double check the fingers touch, Just like only the abdominal wall, it is easy to be misdiagnosed as uterine rupture, but in such cases, the cervix will not retract, the fetus will not rise first, and the carcass is not in the abdominal cavity, and the uterus will not shrink.

3, early exfoliation of the placenta: often due to acute onset, severe pain, internal bleeding, shock and other symptoms are confused.

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