ROTURA UTERINA: DIAGNÓSTICO, MANEJO, TRATAMIENTO, PREVENCIÓN... - Ginecología y Obstetricia -

UTERINE RUPTURE Uterine rupture is a life-threatening pregnancy complication for both mother and fetus. In developed countries, most uterine ruptures occur during labor in patients with a history of previous cesarean section. Uterine rupture without previous scarring is rare and is associated with higher maternal and neonatal morbidity. In resource-limited countries, uterine rupture is associated with prolonged labor, multiparity, misuse of oxytocin, and lack of access to adequate healthcare facilities for childbirth. More videos, podcasts, PDFs, and much more... ALUAGINECOLOGIA.COM (Follow us also on Facebook, Twitter, and Instagram @aulaginecologia). It can occur in 0.3% of patients with a previous cesarean section and much less frequently when there are no previous uterine scars (around 1 in 20,000 pregnancies). RISK FACTORS From highest to lowest: Previous uterine rupture. Available information varies considerably between 0-40%. Previous cesarean section, especially if it was a previous high vertical or fundal hysterotomy (1-12% risk of rupture). Induction of labor with previous cesarean section (1.5% vs. 0.8% of patients without induction), depending on several factors. Induction with Misoprostol (Pg E1): 5-10%. It should not be used to induce labor when there is a previous cesarean section. Prostaglandins E2 in certain regimens, if permitted. Oxytocin: 1.1%. It is not contraindicated for induction. DIAGNOSIS Abnormal fetal heart rate monitoring (FHR) indicating fetal distress, most frequently as fetal bradycardia. There is no pathognomonic pattern for uterine rupture. Continuous monitoring is recommended in patients with a history of cesarean delivery. Abdominal pain: Rupture may be associated with sudden abdominal pain, sometimes masked by epidural analgesia. Vaginal bleeding: May be scant or even absent, despite significant intra-abdominal hemorrhage. Loss of fetal presentation: Because the fetus is extruded through the rupture or due to myometrial relaxation, the fetal presentation may ascend. Hematuria: If the rupture affects the bladder. Sudden hemodynamic instability: Intra-abdominal hemorrhage at the rupture site can cause rapid maternal hemodynamic deterioration (hypotension and tachycardia). Changes in contraction patterns: Both increased contractility and loss of uterine tone have been described. Change in uterine shape: Due to extrusion of part of the fetus or amniotic sac. MANAGEMENT 1. Stabilize the patient: administer fluids and blood transfusion. Simultaneously, prepare the patient for an emergency cesarean section. 2. Notify the Anesthesia Team for management and anesthesia. General anesthesia is preferable to neuraxial anesthesia because maternal hypovolemia, potential coagulopathy, and acute fetal compromise are contraindications for neuraxial anesthesia. In patients with severe bleeding diathesis, the risk of epidural or spinal hematoma increases. 3. Notify the Neonatology Team: they are available for neonatal resuscitation if necessary. 4. Be prepared to encounter unexpected findings during laparotomy. The incision depends on the primary diagnoses, suspected other causes, and the surgeon's preference. SURGICAL TREATMENT Attempt rapid intervention: locate the main source of bleeding and repair it to stop the hemorrhage, reduce maternal blood loss, and prevent progression to DIC. Then decide whether the uterus can be repaired or must be removed. PREVENTION Women with a previous cesarean section: Wait a minimum of 18 months before the next delivery. This should take place in a suitable hospital setting, with sufficient resources to perform a cesarean section. Avoid the use of misoprostol. Shorten the waiting time during the active phase of labor without progression and the expulsive phase. Elective cesarean section in patients with a previous longitudinal or inverted-T cesarean section, with more than two previous cesarean sections, or a history of endometrial cavity rupture in previous surgery. In patients who have already experienced a uterine rupture: elective cesarean section before the onset of labor. Related topics: Liver disease and pregnancy:    • HEPATOPATÍAS del EMBARAZO: colestasis, pre...   Cholestasis of pregnancy:    • COLESTASIS INTRAHEPÁTICA DEL EMBARAZO: cau...   Heart disease and pregnancy:    • CARDIOPATÍAS y EMBARAZO: síntomas, control...   Postpartum depression:    • DEPRESIÓN POSTPARTO: tristeza, causas, dia...   More information, videos, podcasts, and PDFs at AULAGINECOLOGIA.COM