OUTLINE

• Uterine rupture
• Uterine prolapse
Definition
Risk factors
Symptom
Diagnosis and degree
Management
Complication

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 Objectives
• At the end of this session the students able to
know:
• Definition of the uterine rupture

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 RUPTURE OF THE UTERUS

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 DEFINITION
➢ Uterine rupture is a tear through the uterine wall
any time beyond 28 weeks of pregnancy is
called rupture of uterus

➢ It can occur during pregnancy or labor.

➢ This condition is considered a serious obstetric
emergency that poses risks to both the mother and
fetus

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 ❑ Silent uterine rupture: Rupture of the uterus before
the onset of labor [uterine scar dehiscence during
pregnancy].
❑It usually occurs in patients with previous uterine
scar involving the upper uterine segment
(e.g. repaired uterine rupture, previous classical C/S).

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 ➢ Uterine rupture has become a rare obstetric
complication due to increasing access of women to
antenatal and skilled intrapartum care in the
developed world.
➢ It is however still prevalent in low-resource settings
where skilled pregnancy care is mostly
unavailable, e.g. sub- Saharan Africa.

➢ Increasing rates of caesarean deliveries also

increase the possibility of a rise in rates of scar
dehiscence in the future

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 Causes

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 A. SPONTANEOUS
➢ DURING PREGNANCY
✓ Mechanical Factors
✓ Grand multiparae
✓ Short interpregnancy interval
✓ Congenital malformation of the uterus
✓ Abruptio placentae
✓ Pacenta percreta

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 B. SCAR RUPTURE
✓ Caesarean section scar
✓ Myomectomy
✓ previous repaired rupture
✓ previous uterine perforation
✓ Hystrotomy
✓ Cassical types of c/s

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 C. IATROGENIC
➢ DURING PREGNANCY
✓ Use of prostaglandins for induction of abortion or labour
✓ Injudicious adminstration of oxytocin
✓ Excessive uterine stimulation
✓ Fall or blow on the abdomen

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 ✓ Internal podalic version
✓ Destructive operation
✓ Manual removal of the placenta
✓ Application of forceps and breech extractions
through incompletely dialated cervix
✓ Injudicious administration of oxytocin for
augmentation of labour
✓ Abdominal massage by a traditional labor attendant

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 Symptoms Diagnosis
Signs Diagnostics
• Severe abdominal pain • Hypovolemia and shock • CTG- abnormal fetal
• Symptoms of hypovolemia • Acute cardio respiratory heart patterns
and shock – dizziness, distress • Hematocrit
weakness, sweating, • Pallor • Blood group and typing
delirium, coma, etc • Dry mucosal surfaces • Cross match of blood
• In labor- cessation of typical • Tender abdomen
labor pains and replacement • Easily palpable fetal parts
with diffuse generalized • Fetal distress or death
abdominal pain • Evidence of fluid in abdomen
• Vaginal bleeding • Features of obstructed labor
• Cessation of fetal on vaginal exam
movement • Bloody vaginal discharge
• Respiratory difficulty • Bloody urine on bladder
• Fever, chills, rigors catheterization
• Offensive vaginal discharge
• Postpartum uterine
exploration in cases of PPH

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 Differential
Diagnsis
✓ Ruptured ectopic pregnancy
✓ Rectus sheath hematoma
✓ Ruptured ovarian cyst
✓ Uterine artery rupture
✓ Abraptio placenta Concealed

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 CLASSIFICATION
➢ Depending on whether peritoneal coat is
involved or not

i. Incomplete- peritoneum remains intact

ii. Complete rupture- occur when peritoneal coat is

involved

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 CLASSIFICATION
❑ On the basis of anatomy
✓ Fundal uterine rupture
✓ Lower segment uterine rupture – transverse;
vertical
✓ Posterior uterine rupture
✓ Uterine rupture with vaginal extension

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 CLASSIFICATION..
❑ Based on timing
✓ Antepartum uterine rupture - before the onset of
labor – usually scar dehiscence
✓ Intrapartum uterine rupture - during labor

❑ Based on presence of scar

✓ Rupture of an unscarred uterus
✓ Rupture of a scarred uterus – “Uterine Scar
Dehiscence”

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 Diagnosis
✓ Clinical finding
✓ Physical examination
✓ Ultrasound trans abdomen/trans vagina
✓ Fetal monitoring
✓ Laboratory test

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 CLINICAL FINDINGS
❑ DURING PREGNANCY
➢ Scar rupture : Classical or hysterotomy
✓ Dull abdominal pain over the scar area with slight
vaginal bleeding

✓ Tenderness on uterine palpation

✓ FHB may be irregular or absent
✓ A sense of something is giving way accompanied by
acute abdominal pain and collapse

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 CLINICAL FINDINGS…
❑DURING LABOR
Spontaneous obstructive rupture
✓ Signs of obstruction
✓ Pain becomes severe in an attempt to overcome
obstruction
✓ Pain becomes sever at the supra pubic region
✓ Dehydrated and exhausted

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 ➢ Spontaneous non obstructive rupture
✓ bruising pain ,relief with cessation of
contraction
✓ Shock, internal haemorrhage, tenderness and vaginal
bleeding

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 CLINICAL FINDINGS…
❑Rupture following manipulative or
instrumental delivery
✓ Sudden deterioration of general condition
➢Clinical finding of incomplete rupture includes:
✓ The fetus remains in the uterus and signs of shock
may be delayed until after delivery.
✓ Rapid maternal pulse
✓ Labor pain may continue
✓ Fetal heart rate abnormalities: the most reliable
warning sign
✓ Vaginal bleeding

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 CLINICAL FINDINGS…
❑The classic signs and symptoms of complete uterine
rupture are:
✓ Sudden onset tearing pain
✓ Cessation of uterine contractions
✓ Easily palpable fetal parts
✓Tender abdomen
✓Absent fetal heart sounds
✓Vaginal bleeding
✓Recession of the presenting part
✓Hemorrhagic shock
✓Bright red blood through the catheter
indicates involvement of the bladder.

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 Complications of Uterine Rupture
✓ Hypovolemic shock
✓ Septic shock
✓ Fetal distress
✓ Stillbirth and early neonatal death
✓ Hysterectomy and loss of fertility
✓ Concomitant bladder injury
✓ Post partum anemia
✓ Maternal mortality
✓ Hospital stay

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 MANAGEMENT

❑ RESUCITATION

❑ LAPAROTOMY
✓ Hysterectomy

✓ Repair

✓ Repair and sterilisation

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 MANAGEMENT…
❑ Emergency management
✓ Secure IV lines bilaterally with large bore cannulae.
✓ Resuscitation with IV fluids and blood products.
✓ Prepare for operative interventions (e.g. determine
hematocrit, blood group and RH, avail cross-matched
blood and organize the OR).
✓ Laparotomy should not be delayed till patient is
resuscitated out of shock.

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 MANAGEMENT …
❑ Surgical intervention
One of the following operative procedures is undertaken to
manage the rupture:
➢ Repair of uterine tear with preservation of fertility:
✓ If preservation of fertility is desired.
✓ Performed for recent tear, not too large, with
accessible and clean (little or no infection) edges.
➢ Repair of uterine tear with bilateral tubal ligation:
✓ For less experienced surgeon, or
✓ If the patient is in critical condition.

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 MANAGEMENT …
❑ Total hysterectomy
✓ Extensive tear,
✓ Necrotic edges,
✓ Tears difficult to stitch (such as posterior tears
and with extension into the vagina),
✓ Grossly infected uterus,
✓ Rupture after prolonged labor,
✓ Future cervical cancer concern.
❑.

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 Subtotal hysterectomy

✓ Similar indications as total hysterectomy.

✓ Relative ease of procedure than
total hysterectomy

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 POSTPARTUM CARE
➢ Intensive resuscitation and monitoring should be
continued till the patient’s condition improves.
➢ Blood transfusion as required.
➢ If hysterectomy/ BTL done: counsel about future
fertility and menstruation.

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 POSTPARTUM CARE …
❑ Repaired uterus
✓ Requires extensive counseling about the increased
risk of rupture with future pregnancies.
✓ Written note should be as given asreferral feedback
to referring health facility.
✓ In future pregnancy, women with prior rupture
should be admitted early to hospital, monitored
closely and offered cesarean delivery at 36-37
weeks of gestation.
✓ For pregnancy with repaired uterus and with
relatively higher risk of silent uterine rupture (e.g.
multiple pregnancies, polyhydramnios, etc),
delivery should be planned earlier.
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 PREVANTION
1. At ANC risky mothers should deliver in the hospital
2. Find out the cause for undue delay in labour in
multiparae
3. Selection of cases with previous LSCS for vaginal delivery
4. Careful watch of patients receiving oxytocin and avoid
IM oxytocin
5. Internal podalic version should not be done in
obstructed labour
6. Avoid forceps delivery or breech extraction in
incompletely dialated cervix
7. Destructive operation should be done by an expert
8. Attempt to remove placenta accreta should be avoided

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• UTERINE
PROLAPSE

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 Introduction
• Pelvic support defects can be classified by
their anatomic location.
Anterior vaginal prolapse
describes an anterior vaginal wall defect
where the bladder is associated with the
prolapse. It is also known as a cystocele

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 Posterior vaginal wall prolapse
describes a posterior vaginal wall defect.
It is also known as a rectocele

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 Apical Prolapse

Uterine prolapse
Vaginal vault prolapse (post hysterectomy)
Enterocele

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 Uterine prolapse

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 Uterine
pr o l a p s e
• Uterine prolapse
is the herniation
of the uterus
into the vaginal
canal.
• It is influenced by
the weakening of
the musculature
(pelvic muscles
and supportive
tissues) that
support the uterus.
 RISK FACTORS
• Age
• Chronic constipation
• Vaginal childbirth
• Those who have jobs that involve heavy lifting
• Chronic cough
• Neurologic disorders
• Genetic
CA USES
• Pregnancy (multiple pregnancies.)
• Vaginal Childbirth
• Obesity
• Fibroids
• Low levels of sex hormones (oestrogen)
after menopause
PATHOPHYSIOLOGY

• Uterine prolapse involves the weakening or

damage to the pelvic floor muscles and
connective tissues that support the uterus.
• There are three components that are responsible for
supporting the position of the uterus and vagina.
A. Ligament and fascia-by suspension from the
pelvic side walls.
B. Levater ani muscles-by constricting and thereby
maintaining organ position.
C. Posterior angulation of the vagina-which
enhanced by rises in abdominal
• Damage to any of these mechanisms will contribute to
prolapse.
• This weakening can occur due to various factors such
as pregnancy, childbirth or aging.

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 DEGREE OF PROLAPSE
A. First Degree (Mild Prolapse)
✓ The uterus is lower than its normal position but does
not reach the vaginal opening.
B. Second Degree (Moderate Prolapse)
✓ The cervix descends to the level of the vaginal
opening (introitus) but does not protrude outside.
.

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C. Third Degree (Severe Prolapse)
✓ The cervix and part of the uterus protrude outside the
vaginal opening.
✓ This is also known as procidentia when most of the
uterus has descended.
D. Fourth Degree (Complete Prolapse)
✓ The entire uterus is completely outside the vaginal ca
✓ This stage is often associated with other pelvic organ
prolapses, such as bladder or rectal prolapse

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 SYMPTOMS
✓ Leakage of urine.
✓ Inability to completely empty bladder.
✓ Feeling of heaviness or fullness in pelvis.
✓ Bulging in vagina.
✓ Lower-back pain.
✓ Aching, or the feeling of pressure, in lower abdomen
or pelvis.
• Constipation.

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 MANAGEMENT
❖Conservative Management
• Conservative methods are preferred for mild prolapse
or when surgery is contraindicated.
a. Lifestyle Modifications
Pelvic floor exercises (Kegel exercises)
- Strengthens the pelvic floor muscles,
- helping to support the uterus.
Weight management: Reduces abdominal pressure on
the pelvic organs.
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Avoid heavy lifting:
Prevents further strain on the pelvic floor.
Manage chronic conditions:
Such as chronic cough or constipation, to reduce intra-
abdominal pressure.
b. Vaginal Pessaries
A vaginal pessary is a device inserted into the vagina to
support the uterus and keep it in place.

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C. Hormonal Therapy
• Topical estrogen creams or vaginal rings can
improve the strength and elasticity of vaginal and
pelvic tissues in postmenopausal women.

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❖Surgical Management
1. Vaginal Hysterectomy:
Removal of the uterus in women who do not desire
fertility.
2. Uterine Suspension Procedures:
For uterine preservation.
3. Colpocleisis:
Vaginal closure for patients who no longer desire sex.
❖Symptom Management:
Manage infections or ulcerations with antibiotics or
topical treatments.

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 COMPLICATION
✓ Urinary Complications
✓ Bowel Complication
✓ Vaginal Complication
✓ Sexual Complications
✓ Emotional and Psychological Impact
✓ Risk of Further Prolapse or Recurrence
✓ Complications from Surgical Treatment

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QUESTION?