Uterine rupture - threatened or accomplished - what to do if you are at risk?

Uterine rupture (UR) during childbirth is a complication that can lead to massive bleeding, being the most dramatic cause of maternal and perinatal mortality. Violation of the integrity of the wall of the unoperated uterus is considered one of the indicators of improper management of labor and poor quality obstetric care in general.

In Russia R.M. According to pathogenesis, they are divided into mechanical, histopathic, mechano-histopathic and violent [1]. In foreign literature, the dominant cause of RM was considered to be the presence of a scar on the uterus after previous interventions. As a conditional analogue of mechanical RM, one can consider the rupture of an unoperated (unscarred or unattached uterus), and histopathic - a previously operated uterus (scarred uterus). There is no complete identity between the concepts of “histopathic uterine rupture” and “rupture of a previously operated uterus,” since damage to the myometrium may be associated with other causes, i.e., the absence of a scar on the uterus does not guarantee the impossibility of its rupture.

According to WHO, the overall incidence of RM is 5.3 per 10,000 births, rupture of the operated uterus is 100 per 10,000, and rupture of the unoperated uterus is 0.6 per 10,000 births (Table 1).

Table 1. Frequency of uterine rupture and accompanying maternal and perinatal mortality, according to various authors

According to Rosstat in the Russian Federation, the incidence of RM in 2014 was 1.4 per 10,000 births. In Moscow, according to the organizational and methodological department of the Department of Health (DZ) of Moscow, the frequency of RM for the past 2014 was 2.7 per 10,000 births. According to the Center for Family Planning and Reproduction D.Z. Moscow, the overall incidence of uterine rupture was 3 per 10,000 births, and rupture of an unoperated uterus was 0.9 per 10,000 births.

Maternal mortality from uterine rupture in Russia, according to Rosstat, in 2013 was 0.42 per 100,000 live births.

Presented in table. 1 data show wide variability in the incidence of rupture of the operated uterus from 5 per 10,000 in Saudi Arabia to 740 per 10,000 births in India. Unoperated uterine rupture represents a relatively low rate of 0.3–0.7 per 10,000 births or 11.5–13% of all RMs.

According to some authors [10], decreased interest in managing vaginal delivery in patients with a uterine scar after cesarean section may lead to a change in the ratio and a relative increase in the number of ruptures of the unoperated uterus.

Currently, rupture of the unoperated uterus occurs more often in countries with less developed economies, which are characterized by high birth rates and a lack of emergency obstetric care. According to authors from Nigeria, 94% of patients with RM had no scar on the uterus; in India, such patients also made up the majority - 77.4% [11, 12]. Such ruptures lead to more severe complications in the mother and fetus (compared to uterine ruptures along the scar) and can be a direct cause of maternal mortality [2, 6, 9].

Rupture of the unoperated uterus often occurs due to overstretching of the myometrium of the lower uterine segment due to obstruction of the fetus being born (mechanical factor). Sometimes trauma to the uterus can be associated with obstetric manipulations: internal rotation and extraction of the fetus by the pelvic end, application of abdominal obstetric forceps with a high-standing head. In the literature, congenital or acquired inferiority of the myometrium, disorders of the collagen matrix and abnormal architecture of the uterine cavity (bicornuate and complete duplication of the uterus, uterus with a blind uterine horn) are considered as putative causes of RM [13, 14].

In the 35th chapter of Williams Obstetrics, devoted to obstetric hemorrhage, uterine curettage is mentioned first among the provoking moments [15].

Risk factors for rupture of the unoperated uterus during childbirth include a large number of births and overstretching of the myometrium during multiple pregnancies. Drug induction and stimulation of labor with mifepristone, misoprostol, and oxytocin are described as an iatrogenic cause of uterine rupture [16].

The purpose of the study was to use an in-depth retrospective analysis of observations of patients with an unoperated uterus who experienced RM during childbirth, to identify the causes of RM and offer recommendations to reduce their frequency; confirm the feasibility of performing organ-preserving operations for uterine ruptures during childbirth.

Risk factors and main causes

There are several theories that try to explain the origin of the injury. The creator of one of them is Bandle, who explained the pathology by mechanical reasons. He described this process as excessive distension of the lower part of the uterus due to the large size of the fetus and the narrow pelvis of the mother. But this theory cannot explain why trauma occurs when the child is small.

This theory was supplemented by the research of Ya. F. Verbov, who believed that pathologically altered tissues are necessary for the formation of a wall defect. This disease occurs against the background of chronic endometritis, after multiple abortions and curettage, endometriosis or scar changes.

Currently, the causes of uterine rupture have expanded significantly. It is believed that histological changes in the wall predispose to cavity formation, and this process is triggered by mechanical or violent action.

Histological causes include the following:

• Scars after operations (caesarean section, plastic surgery of congenital defects, removal of myomatous node, perforation);
• chronic inflammatory process;
• tight fit of the placenta;
• dystrophic changes after frequent curettage;
• Infantilism and birth defects;
• biochemical changes during prolonged labor.

The defect can occur not only at the site of a scar or altered wall, but the injury occurs around the prostate horn. In this case, the rupture occurs at 16-20 weeks of pregnancy, provided that the fetus is attached to the area of ​​the prostate horn. Clinical manifestations of the pathology resemble tubular abortion.

Mechanical causes combine cases that cause discrepancies in the size of the fetus and the female pelvis:

• Clinically or anatomically narrow pelvis;
• hydrocephalus;
• Large fruit;
• Frontal or posterior presentation;
• incorrect head position;
• transverse or oblique position of the fetus;
• myometrial tumors;
• birth canal with cicatricial changes;
• unevenness or deformation of the bones in the pelvis.

The occurrence of this complication can be caused by sudden actions resulting from improper use of surgical or obstetric manipulations:

• obstetric forceps;
• vacuum extraction of the fetus;
• Kristeller Extraction;
• extraction of the fetus through the end of the pelvis;
• internal rotation;
• Removal of the head according to Morisseau-Levre;
• release the retracted lever when presenting the lock;
• fetal demolition operations.

Causes of violence include accidental injuries that may occur outside of childbirth.

Truths and lies about the treatment of cervical deformities

Gynecologists at the Diana Clinic commented on common statements about methods of treating cervical deformities and divided them into truth and speculation.

“If the pathology does not bother you, it does not need to be treated.” It is a myth!

Deformation of the cervix is ​​accompanied by eversion of the inner mucous membrane of the cervical canal outward into the vaginal area. As a result, differences in microflora and pH environment (acidity) lead to damage to cervical tissue and an increased risk of infection - microbes easily penetrate into tissues through cracks and erosion. If treatment is not started on time, the woman will face acute infectious and inflammatory diseases.

In addition, postpartum injuries and cervical ruptures transform into scars during healing. Scars interfere with the normal movement of sperm, reducing the likelihood of conception. Also, scar formations and erosions due to deformation of the cervix can degenerate into oncology. Due to the risks to a woman’s health, treatment of cervical deformities is a mandatory measure.

“Treatment of cervical deformity requires surgery.” This is true!

Pills and physiotherapeutic procedures are not able to return the cervix to its normal physiological state. To restore its original position, the injured area is removed and the normal anatomy of the organ is restored.

This can only be achieved by surgical intervention, which is carried out using classical surgical or minimally invasive methods. At the same time, modern methods of removing areas of cervical deformity are easier to tolerate by patients and do not require long postoperative recovery.

“Classical surgical operations are outdated, and it is always better to replace them with hardware methods.” It is a myth!

Modern hardware techniques are a safety standard for women. These methods are also called destructive, since they are based not on cutting out tissues, but on their destruction - with current, acid, laser.

However, gynecologists still perform classical surgery if it is necessary to take tissue for histological examination to exclude or confirm oncology.

In addition, only classical cervical plastic surgery will return the normal condition and position of a highly modified organ. Destructive methods are the priority solution for treating primary changes - for example, small scars.

“Radio wave conization of the cervix is ​​a safe way to treat deformities.” This is true!

Excision of damaged cervical tissue with a radio wave knife allows you to simultaneously get rid of deformations and scars and prevent further growth of connective tissues.

This effectiveness is achieved by exposure to radio wave radiation on the cervical tissue. During the procedure, growth cells, like vessels, are cauterized and soldered together, eliminating the development of bleeding and further deformation of the organ.

In addition to the effectiveness of radio wave conization of the cervix, the advantages of the method also lie in the painlessness and safety of the technique. The likelihood of developing complications after using a radio wave knife is minimal, and the recovery period lasts several days.

“Laser correction of cervical deformity leads to infertility.” It is a myth!

There are many ridiculous comments on the Internet regarding laser treatment. In fact, this technique is safe and effective in eliminating small areas of deformed cervix. In this case, the laser beam acts specifically on the site of damage, evaporating scars and not touching healthy tissue.

“After treatment for cervical deformity, pregnancy is impossible.” It is a myth!

If an operation to eliminate cervical deformities is performed by an experienced gynecologist, it is possible to achieve complete restoration of the physiology and functional activity of the mucous membranes. This allows the patient to become pregnant and bear children.

Doctors at the gynecological department of the Diana Clinic are ready to perform a range of measures to treat cervical deformity, guaranteeing the patient’s safety and preservation of reproductive function.

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Features of the mechanism

One of the common causes of this complication is an inconsistent method of delivery. This condition develops as a result of stimulation of labor, for which there is no indication, or due to the individual characteristics of the body (more about the indications and contraindications for stimulation of labor). These include imbalances in the autonomic nervous system with a predominant influence of the parasympathetic department. Such disorders occur during childbirth against the background of increased myometrial tone. Stimulation contractions become more frequent and do not decrease.

The pressure in the uterus changes rapidly, and instead of the muscle fibers gradually spreading, they quickly stretch. In the presence of pathological changes, a crack forms.

A fracture that occurs primarily due to mechanical obstruction occurs by a different mechanism. The fetus cannot move along the birth canal, so the myometrium moves to the bottom, and the lower segment is stretched. The baby's head presses the cervix against the pelvic bones, causing hyperemia and swelling. The minimum thickness of the uterine wall with the probability of rupture in this condition is several millimeters. When the fabric no longer stretches, the following process begins:

• Rupture of the vessel wall;
• formation of hematomas;
• formation of cracks;
• Eventually the uterus becomes incomplete or completely ruptured.

The mechanism of violent rupture during childbirth is associated with an additional impact on the uterus, which is already in a critical condition. Excessive stretching of the lower segment in a clinically narrow pelvis and pressure on the fundus of the uterus cause increased tissue tension and a defect.

It is generally accepted that healthy myometrium is not prone to cracking. If a healthy woman experiences a discrepancy between the size of the fetal head and the birth canal, labor is usually stopped. Pathologically changed tissues after abortion, curettage and inflammation are characterized by the presence of connective tissue and impaired blood supply. Histological changes occur at the cellular level, so sometimes they cannot be noticed during examination.

This modified wall is capable of stretching during pregnancy and can withstand contractions during normal childbirth, but cannot withstand additional load.

After each operation on the internal genital organs, which was accompanied by cutting the wall, some of the muscle cells at the edge of the wound are lost. During healing, the wound surface is filled with new myocytes and connective tissue, but the structure is not restored. If not enough time has passed from the formation of the scar to the onset of pregnancy, imperfection of its tissue can lead to rupture of the uterus along the length of the scar.

Why do severe postpartum cervical ruptures and deformation occur?

The content of the article

Mild cervical ruptures are normal during childbirth; they heal quickly and therefore do not require treatment. Severe ruptures are the result of incorrect behavior of the woman in labor (early pushing), illiterate or traumatic obstetric care with the use of obstetric forceps or a vacuum extractor, rapid or late labor.

The cervix ruptures for other reasons, for example, if a woman has already had a childbirth with stitches.

When several factors combine, severe cervical ruptures occur that are difficult to stitch. Inexperienced gynecologists apply rough or uneven sutures. And if childbirth occurs suddenly, in unsuitable conditions, the woman is left without medical care at all. As a result, the cervix becomes deformed - it thickens, shortens and bends, and the internal mucous membrane turns outward.

Options for birth trauma

There are several different variants of uterine rupture, which have become the basis for different approaches to the classification of this pathological condition. Based on the characteristics of the formation mechanism, they distinguish:

• Spontaneous - occurs without the influence of external factors as a result of pathological changes in the wall and disturbances in professional activity;
• Violent - when performing manipulations and obstetric operations.

The stage of advancement is determined by the clinical course:

• threatening;
• in the early stages;
• accomplished.

The nature of the damage may vary:

1. A rupture is a small break in a piece of the uterine wall.
2. An incomplete fracture consists of the appearance of a defect only in the mucous membrane and muscles. The outer layer of the serous membrane remains intact. This type of injury is more common on the lateral surfaces of the lower segment or along the rib of the uterus. The injury is accompanied by internal bleeding with the formation of a huge hematoma between the ligaments of the uterus.
3. Complete loss is the most common. It is characterized by damage to all layers of masonry.

Uterine rupture: Fig. 1 - through the scar after cesarean section; Dig. 2 - incomplete, in the lower segment with the formation of a hematoma

Most often, the crack occurs in the lower segment. This area is most rarely seen during childbirth. But another arrangement is possible:

• at the bottom of the uterus;
• along the side walls;
• in organism;
• detachment of the uterus from the vaginal vault.

Uterine rupture is a condition associated with the period of labor of the fetus. Therefore, it is impossible to consider the causes of rupture outside pregnancy from this point of view. Violation of the integrity of the wall in non-pregnant women is more often called perforation.

Sources

• Turan OM., Driscoll C., Cetinkaya-Demir B., Gabbay-Benziv R., Turan S., Kopelman JN., Harman C. Prolonged early antenatal indomethacin exposure is safe for fetus and neonate. // J Matern Fetal Neonatal Med - 2021 - Vol34 - N2 - p.167-176; PMID:30905227
• Wallstrom T., Bjorklund J., Frykman J., Jarnbert-Pettersson H., Akerud H., Darj E., Gemzell-Danielsson K., Wiberg-Itzel E. Induction of labor after one previous Cesarean section in women with an unfavorable cervix: A retrospective cohort study. // PLoS One - 2021 - Vol13 - N7 - p.e0200024; PMID:29965989
• Vogel JP., Osoti AO., Kelly AJ., Livio S., Norman JE., Alfirevic Z. Pharmacological and mechanical interventions for labor induction in outpatient settings. // Cochrane Database Syst Rev - 2021 - Vol9 - NNULL - p.CD007701; PMID:28901007
• Sarreau M., Leufflen L., Monceau E., Tariel D., Villemonteix P., Morel O., Pierre F. . // J Gynecol Obstet Biol Reprod (Paris) - 2014 - Vol43 - N1 - p.46-55; PMID:23972769
• Epee-Bekima M., Overton C. Diagnosis and treatment of ectopic pregnancy. // Practitioner - 2013 - Vol257 - N1759 - p.15-7, 2; PMID:23634634
• Charach R., Sheiner E. Risk factors for peripartum hysterectomy following uterine rupture. // J Matern Fetal Neonatal Med - 2013 - Vol26 - N12 - p.1196-200; PMID:23356737

Clinical manifestations of different stages of the process

Symptoms of uterine rupture are varied and depend on the stage of the process. The mechanism and timing of injury have important implications for clinical symptoms. Sometimes, with obvious changes in the wall, symptoms at the initial stage are minimal, and gradual tissue growth is observed, which is difficult to diagnose.

Threatening

If there is persistent scarring or tissue inflammation, this may occur after 30 weeks of pregnancy. Myometrial stretch reaches its maximum during this period. The woman has the following symptoms:

• A nagging pain in the lower abdomen and lower back that cannot be clearly defined;
• low blood pressure;
• scanty bleeding from the genital tract;
• increased uterine tone;
• decrease in vital parameters of the fetus.

During childbirth, rapid rupture is manifested by various symptoms:

• quick birth;
• overload of the lower segment and change in the shape of the abdomen;
• sharp pain when touching the uterus;
• severe swelling of the vagina and swelling of the genitals;
• persistent leakage of amniotic fluid.

Symptoms of birth trauma may be more subtle due to frequent use of pain medications.

Started

The next stage is characterized by all of the above symptoms, but they can appear in various combinations and be more serious.

Contractions become sharp, painful, sometimes accompanied by convulsions. Sharp pain in the lower abdomen in the uterine area persists even after contractions. The woman's state is excited, her pupils are dilated, and a feeling of fear appears. Vaginal bleeding is light, and there may be urinary retention or small amounts of blood in the urine. The fetal head stops moving along the birth canal, and pronounced swelling appears above the uterus.

The fetal condition is deteriorating. It can become overactive. CTG examination shows increased or rapid heart rate and muffled sounds. If this stage is not treated, fetal death occurs in 80% of cases.

Accomplished

The symptoms of what is happening correspond to the clinical signs of massive bleeding. But first there is a sharp pain in the lower abdomen. A woman may feel like something has broken inside her. In this case, the contractions stop abruptly, the fetus rolls down and dies. The shape of the abdomen changes and parts of the fetus can be felt under the skin. The woman’s condition is serious, bleeding symptoms predominate:

• low blood pressure;
• pale skin;
• dry mouth;
• weakness, loss of consciousness;
• tachycardia;
• The pulse is practically not felt.

Bleeding from the genital tract increases. The uterus becomes irregular as it moves upward. The fracture along the length of the scar produces a convexity; there is a convexity along the anterior wall. In case of incomplete rupture and hematoma formation, it is felt as a bulky mass adhering to the lateral surface.

If the rupture occurred during the expulsion period, the child may remain alive and not show signs of hypoxia. But immediately after childbirth, the mother’s condition deteriorates sharply, massive bleeding begins, and symptoms of hemorrhagic shock appear.

Chernyaeva V.I., Goncharova N.N., Novikova O.N., Marochko T.Yu., Zotova O.A., Shakirova E.A., Surina M.N., Moses V.G., Karelina O .B.

Kemerovo State Medical University", Kemerovo Regional Clinical Hospital named after S.V. Belyaev, Kemerovo, Russia Leninsk-Kuznetsk City Hospital No. 1", Leninsk-Kuznetsky, Russia

COMPLETE RUPTURE OF THE UTERUS ACCORDING TO AN OLD SCAR DURING PREGNANCY

We describe a clinical observation of a complete uterine rupture along an old scar outside the hospital at 39-40 weeks of pregnancy in a patient with a burdened obstetric and gynecological history. The patient was operated on for emergency reasons, 10 minutes after admission. Timely assistance provided determined a favorable outcome for the mother and fetus.

Keywords:

obstetric traumatism; scar on the uterus after cesarean section; causes of uterine rupture; emergency help

Chernyaeva VI, Goncharova NN, Novikova ON, Marochko T.Yu., Zotova OA, Shakirova EA, Surina MN, Moses VG, Karelina OB

Kemerovo State Medical University, Kemerovo Regional Clinical Hospital named after SV Beljaev, Kemerovo, Russia, Leninsk-Kuznetsky City Hospital N 1, Leninsk-Kuznetsky, Russia

COMPLETE RUPTURE OF THE UTERUS ALONG THE PREVIOUS SCAR DURING PREGNANCY

Describes the clinical observation of a complete rupture of the uterus along the previous scar during pregnancy of 39-40 gestation weeks in a patient with a burdened obstetric and gynecological history outside the hospital. The patient was undergoing surgical operation for emergency indications after 10 minutes from the moment of admission to the hospital. Timely assistance provided predetermined a favorable outcome for the mother and fetus.

Key words:

obstetric injury; scar on the uterus after cesarean section; causes of uterine rupture; emergency care

Address correspondence to:

CHERNYAEVA Valentina Ivanovna 650056, Kemerovo, st. Voroshilova, 22a, Kemerovo State Medical University, Ministry of Health of Russia E-mail

Information about authors:

CHERNYAEVA Valentina Ivanovna Ph.D. honey. Sciences, Associate Professor, Department of Obstetrics and Gynecology named after. G.A. Ushakova, Federal State Budgetary Educational Institution of Higher Education Kemerovo State Medical University of the Ministry of Health of Russia, Kemerovo, Russia E-mail

GONCHAROVA Natalya Nikolaevna obstetrician-gynecologist, head. obstetric department, State Autonomous Institution KO LKGB No. 1, Leninsk-Kuznetsky, Russia E-mail

NOVIKOVA Oksana Nikolaevna Doctor of Medicine. Sciences, Associate Professor, Professor of the Department of Obstetrics and Gynecology named after. G.A. Ushakova, Federal State Budgetary Educational Institution of Higher Education Kemerovo State Medical University of the Ministry of Health of Russia, Kemerovo, Russia E-mail

MAROCHKO Tatyana Yurievna Ph.D. honey. Sciences, Associate Professor, Department of Obstetrics and Gynecology named after. G.A. Ushakova, Federal State Budgetary Educational Institution of Higher Education Kemerovo State Medical University of the Ministry of Health of Russia, Kemerovo, Russia E-mail

ZOTOVA Olga Aleksandrovna Ph.D. honey. Sciences, obstetrician-gynecologist, reproductologist, head. IVF center, GAUZ KO KOKB named after. S.V. Belyaeva, Kemerovo, RussiaE-mail

SHAKIROVA Elena Aleksandrovna Ph.D. honey. Sciences, Associate Professor, Associate Professor of the Department of Obstetrics and Gynecology named after G.A. Ushakova, Kemerovo State Medical University, Ministry of Health of Russia, Kemerovo, RussiaE-mail

SURINA Maria Nikolaevna Ph.D. honey. Sciences, Associate Professor, Associate Professor of the Department of Obstetrics and Gynecology named after G.A. Ushakova, Kemerovo State Medical University, Ministry of Health of Russia, Kemerovo, RussiaE-mail

MOSES Vadim Gelievich Doctor of Medicine. Sciences, Associate Professor, Professor of the Department of Obstetrics and Gynecology named after G.A. Ushakova, Federal State Budgetary Educational Institution of Higher Education Kemerovo State Medical University of the Ministry of Health of Russia, Kemerovo, Russia E-mail

KARELINA Olga Borisovna Ph.D. honey. Sciences, Associate Professor, Associate Professor of the Department of Obstetrics and Gynecology named after G.A. Ushakova, Federal State Budgetary Educational Institution of Higher Education Kemerovo State Medical University of the Ministry of Health of Russia, Kemerovo, Russia E-mail

Information about authors:

CHERNYAEVA Valentina Ivanovna candidate of medical sciences, docent, department of obstetrics and gynecology named after GA Ushakova, Kemerovo State Medical University, Kemerovo, Russia E-mail

GONCHAROVA Natalia Nikolaevna obstetrician-gynecologist, head of the obstetric department, Leninsk-Kuznetsky City Hospital N 1, Leninsk-Kuznetsky, Russia E-mail

NOVIKOVA Oxana Nikolaevna doctor of medical sciences, docent, professor of the department of obstetrics and gynecology named after GA Ushakova, Kemerovo State Medical University, Kemerovo, Russia E-mail

MAROCHKO Tatyana Yuryevna candidate of medical sciences, docent, department of obstetrics and gynecology named after GA Ushakova, Kemerovo State Medical University, Kemerovo, Russia E-mail

ZOTOVA Olga Alexandrovna candidate of medical sciences, obstetrician-gynecologist, reproductologist, head of the IVF center, Kemerovo Regional Clinical Hospital named after SV Beljaev, Kemerovo, Russia E-mail

SHAKIROVA Elena Aleksandrovna candidate of medical sciences, docent, department of obstetrics and gynecology named after GA Ushakova, Kemerovo State Medical University, Kemerovo, RussiaE-mail

SURINA Maria Nikolaevna candidate of medical sciences, docent, department of obstetrics and gynecology named after GA Ushakova, Kemerovo State Medical University, Kemerovo, RussiaE-mail

MOZES Vadim Gelievich doctor of medical sciences, docent, professor of the department of obstetrics and gynecology. GA Ushakova, Kemerovo State Medical University, Kemerovo, Russia E-mail

KARELINA Olga Borisovna candidate of medical sciences, docent, department of obstetrics and gynecology named after GA Ushakova, Kemerovo State Medical University, Kemerovo, Russia E-mail

Uterine rupture is a serious obstetric complication, potentially life-threatening for both mother and fetus. In this regard, the presence of a scar after cesarean section (CS) has traditionally been considered the main risk factor for uterine rupture, being the main cause in the majority (50-90%) of cases over the past decade [1]. The frequency of cesarean sections is increasing, reaching 23.4% in Russia, 15-17% in European countries, 24% in the UK, and 32% in the USA [2-4]. Uterine rupture occurs on average in 0.005-0.1% of all births. According to WHO (2010), the global average incidence of uterine rupture is 0.05-0.31%; 9 out of 10 ruptures occur during childbirth, 1 - during pregnancy. From 17 to 60% of uterine ruptures occur more often against the background of a burdened obstetric history or after undergoing surgery on the uterus. The only reliable sign of a disaster, accompanying 78-87% of all uterine ruptures, both beginning and completed, is acute fetal hypoxia [5]. Maternal mortality due to uterine rupture reaches 60-70% of women hospitalized late, fetal death is 70-92% [6]. Uterine ruptures during pregnancy and childbirth are one of the most severe complications in obstetrics, as they are always accompanied by bleeding, severe combined shock (traumatic and hemorrhagic), and often the death of the fetus, and sometimes the woman. Uterine rupture requires immediate surgery to save the fetus and repair the uterus or hysterectomy. Among obstetric complications leading to massive blood loss and often hysterectomy, uterine rupture is the third most common, second only to hypotonic uterine bleeding and premature placental abruption. Uterine rupture, associated with high maternal and perinatal morbidity and mortality, is becoming a frequent cause of litigation in developed countries [7]. Most studies are devoted to the analysis of uterine rupture after a cesarean section, since in developed countries more than 90% of ruptures occur in this category of patients [2, 8]. Extensive trauma, massive blood loss, shock, and often associated infection require not only qualified surgical intervention, but also targeted resuscitation measures and long-term infusion therapy. In this regard, saving a pregnant or parturient woman is not always possible; about 80 thousand women die every year around the world from uterine rupture and amniotic fluid embolism [6]. Uterine ruptures are observed mainly in patients who have given birth many times, with a burdened obstetric history, and very rarely in primigravida women. According to the literature, five main reasons can be identified that are aggravating factors for the risk of uterine rupture during childbirth:

- morphological structural inferiority of the myometrium is caused by processes of damage to the myometrium with the development of inflammatory and cicatricial changes (fibrosis, scarring); - mechanical and functional obstacles to the opening of the cervix (uterine pharynx) or the advancement of the fetus along the birth canal; — hyperdynamic uncoordinated nature of labor; — violent factors of uterine rupture as a result of violent acts during childbirth; - rupture of the rudimentary uterine horn.

The main factor in the risk of uterine rupture during childbirth is the morphological structural inferiority of the myometrium, in which the vessels are damaged, their permeability increases, perivascular edema, microthrombosis and hemorrhage are formed. The main morphological damaging factors are hypoxia, decreased blood supply to the myometrium (ischemia), inflammation, and mechanical stress. After an incision in the uterine wall (caesarean section, often repeated), a limited number of muscle and connective tissue cells die, and the myometrial structure is not fully restored. Excessive load on defective areas of the myometrium, which occurs during violent labor, can cause them to “spread” or rupture [5].

CLINICAL OBSERVATION

Patient L., 27 years old, multiparous. This is the seventh pregnancy, the seventh birth is coming. The first pregnancy in 2007 was a cesarean section, the second pregnancy in 2009 was a repeat cesarean section due to premature placental abruption. Third, fourth, fifth, sixth births through the natural birth canal at the Regional Clinical Perinatal Center. This pregnancy occurred against the background of mild gestational anemia and bacterial vaginosis. In the first half of pregnancy there is marginal chorionic presentation, followed by low placentation. The weight gain during pregnancy was 5 kg. The somatic history is burdened by the presence of mitral valve prolapse of the first degree, carriage of the herpes simplex virus, hepatitis B. Denies gynecological diseases, heredity is not burdened. The patient was admitted to the obstetric department on May 19, 2017 at 06:00 am with complaints of cramping pain in the lower abdomen, bloody discharge from the genital tract with clots. According to the woman, on the morning of May 18, 2017, she had an appointment with an obstetrician-gynecologist with a diagnosis of “Pregnancy 39-40 weeks. Harbingers of childbirth." She refused hospitalization. At 05:00 on May 19, 2017, cramping pain in the lower abdomen began, bleeding appeared, and she was taken by personal transport to the obstetric hospital at the place of residence (level I). Upon admission, the general condition was assessed as moderate due to pain. The physique is correct, the diet is moderate, the skin is of normal color, there is no swelling. Peripheral lymph nodes are not palpable. Blood pressure – 110/70 mm Hg. Art. on both hands. Pulse – 86 beats per minute, satisfactory quality. Heart: clear, rhythmic tones, no murmurs. In the lungs there is vesicular breathing, no wheezing. The effleurage symptom is negative on both sides. Urination is not impaired. External obstetric examination: The abdomen is enlarged due to the pregnant uterus, corresponding to the full-term stage of pregnancy. On palpation there is sharp pain in the lower abdomen. The position of the fetus is longitudinal, cephalic presentation, the head is pressed to the entrance to the pelvis. The fetal heartbeat is dull. According to the woman, she feels the movement of the fetus. An anesthesiologist was invited. In a fully operational operating room, a vaginal examination was performed: the external genitalia were formed correctly, with female-type hair growth. The vagina of a woman giving birth. The cervix along the pelvic axis is softened, shortened to 1 cm. The discharge is dark with clots in a volume of 80 ml. The lining is heavily moistened with blood. Diagnosis made:

Main – Pregnancy 39-40 weeks.
Low placentation. Complications – Premature abruption of the low-lying placenta. Concomitant – OAGA (two scars on the uterus). Carrier of HSV, hepatitis B. First degree mitral valve prolapse. A decision was made to immediately deliver by cesarean section. 05/19/2017 at 06:10 (10 minutes from the moment of admission) the operation began; when the abdominal cavity was opened, the fetal head was presented into the wound. A male child weighing 3400 g, body length 53 cm, with an Apgar score of 2/3 points was removed and transferred to a neonatologist for resuscitation (sanitation of the upper respiratory tract, mechanical ventilation with an Ambu bag, tracheal intubation). Diagnosis of the newborn: Severe asphyxia. Cerebral ischemia grade 3, central nervous system depression syndrome. Due to the severity of the condition, the newborn was evacuated to the NICU of the Regional Children's Clinical Hospital, transportation was carried out by the neonatal resuscitation team. When examining the abdominal cavity: along the anterior surface of the uterus in the area of ​​the scar there is a complete rupture with transition to the right rib of the uterus to the uterosacral ligament on the right, separation of the round ligament on the right, separation of the pelvic peritoneum from the bladder and the lateral wall of the pelvis on the right. Retroperitoneal hematoma in the area of ​​the cecum and ascending colon. Imbibition of prevesical tissue. A decision was made to amputate the uterus without appendages for health reasons. Operation protocol:
The uterus was brought out into the wound.
On the right, the torn round ligament is bandaged. Clamps were applied to the round ligament of the uterus on the left, the fallopian tubes, and the proper ligaments of the ovaries on both sides: they were cut off and ligated. Between the stumps of the round ligaments, the vesicouterine fold is dissected in the transverse direction, the peritoneum from the bladder is moved with a tupper to the cervix, below the internal os. Clamps are applied to the vascular bundles: the vessels are crossed and ligated. The body of the uterus is cut off. The stump is sutured with two rows of separate sutures (Vicryl) connecting the anterior and posterior parts of the neck. Drainage is installed through the cervical stump and vagina. Peritonization of the cervical stump due to the vesicouterine fold. The surgeon performed an inspection of the retroperitoneal space on the right. The walls of the cecum and ascending and colon are healthy, not swollen, peristalsis is preserved. The great vessels are not damaged. The pelvic peritoneum was sutured on the right with drainage of the retroperitoneal space through the anterior abdominal wall. The urologist examined the bladder: the bladder was filled through a catheter with 150.0 ml of 0.9% sodium chloride solution, the bladder wall was sound, no damage was found. The abdominal cavity was drained and an inspection was performed. The count of napkins and tools coincided. The abdominal wall is sutured tightly in layers. Separate silk threads are applied to the skin. Aseptic dressing. The urine from the catheter is light, 350.0 ml. Total blood loss 2000.0 ml. Infusion therapy: sodium chloride solution 0.9% - 1250.0 ml, tranexamic acid 1000 mg, voluven - 500.0 ml, FFP - 1160.0 ml, washed red blood cells were ordered in a volume of 800.0 ml. The duration of the operation was 3 hours. On extended mechanical ventilation, the postpartum mother was transferred to the intensive care unit. Postoperative diagnosis:
Main: Pregnancy 39-40 weeks.
Complete rupture of the uterus along an old scar in the lower segment with transition to the right rib of the uterus. Right round ligament tear. Separation of the pelvic peritoneum from the bladder and the lateral wall of the pelvis on the right. Retroperitoneal hematoma in the area of ​​the cecum and ascending colon. Imbibition of prevesical tissue. Bleeding due to premature abruption of the low-lying placenta. Concomitant diagnosis: OAGA. Carrier of HSV, hepatitis B. Mitral valve prolapse, degree I. Operation:
Pfannenstiel laparotomy.
Supravaginal amputation of the uterus without appendages. Restoring the integrity of the peritoneum of the right lateral wall of the abdominal cavity and the lateral wall of the pelvis. Drainage of the pelvis. Drainage of the right retroperitoneal space. ETH. Posthemorrhagic anemia. Macroscopic specimen:
The uterus is enlarged up to 16 weeks of conditional pregnancy.
The uterus is pale pink. Along the front wall at the location of the scar there is a complete rupture with transition to the right side wall, the edges of the wound are uneven. Afterbirth - multiple petrification, areas of detachment, old and new clots on the surface. Protocol of pathological and anatomical examination of the surgical material dated June 02, 2017:
uterus - body of the uterus, size 18 × 16 × 7 cm, the surface is smooth, bluish-gray, along one of the edges there is a gap measuring 6 × 3 cm, the edges are uneven with multi-lumpy areas.
In the uterine cavity there are dense brown clots, in the area of ​​the placental area the myometrium is soft, the bed is made of dense brown clots. Placenta of the third trimester of pregnancy, weighing 709 g, with a central attachment of the umbilical cord, diameter 1.3 cm. The vessels of the umbilical cord are full of blood, there are small hemorrhages in the membranes. Many small terminal villi, with sharply dilated capillaries, multiple chronic infarctions of varying sizes. Conclusion:
Postpartum uterus with a wall rupture in the lower segment. Placenta: Chronic placental insufficiency in the compensation stage. The postoperative period proceeded without complications, infusion, antibacterial and antianemic therapy was carried out. The patient was discharged on the 11th day in satisfactory condition, the sutures of the anterior abdominal wall healed by primary intention, lactation was preserved. The newborn was discharged in satisfactory condition on the 10th day. Currently growing and developing normally. It should be noted that the patient received timely and complete assistance in a level I medical institution.

CONCLUSION

Thus, all patients with a uterine scar after cesarean section are at high risk for uterine rupture, both during pregnancy and during childbirth. Unfavorable factors provoking uterine rupture, regardless of the condition of the scar area during echography, are a history of repeated surgical delivery. All patients with a uterine scar should be aware of the clinical signs of postoperative scar failure and be carefully monitored on an outpatient basis with a view to timely hospitalization in level 3 institutions.

Funding and conflict of interest information

The study had no sponsorship. The authors declare that there are no obvious or potential conflicts of interest related to the publication of this article.

LITERATURE/REFERENCES:

1. Kaczmarczyk V, Sparen P, Terry P, Cnattingius S. Risk factors for uterine rupture and neonatal consequences of uterine rupture: a population – based on severe maternal and perinatal outcomes from rupture amonq women at term with a trial of labor. BJOG.

2007;
114(10): 1208-1214 2. Barger MK, Nannini A, Weiss J, Declercq ER, Stubblefield P, Werier M, Ringer S. Severe maternal and perinatal outcomes from uterine rupture amonq women at term with a trial of labor. J Perinatol.
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32(11): 837-843. DOI: 10.1038/jp.2012.2 3. American College of Obstetricians and Gynecolojists. ACOG Practice bulletin no. 115: Vaginal birth after previous cesarean delivery. Obstet Gynecol.
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116(2 Pt1): 450-463. DOI: 10.1097/AOG.0b013e3181eeb251 4. De Lau H, Gremmels H, Schuitemaker NW, Kwee A. Risk of uterine rupture in women undergoing trial of labor with a history of both a caesarean section and a vaginal delivery. Arch Gynecol Obstet.
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284(5): 1053-1058. DOI: 10.1007/s00404-011-2048-x 5. Radzinsky V.E. Obstetric aggression v.2.0. M.: Status Praesens, 2017. P. 603-604. Russian (Radzinsky V.E. Obstetric aggression v.2.0. M.: Status Praesens, 2021. P. 603-604) 6. Aylamazyan EK. Emergencyobstetrics. A Guide for Doctors. 5th ed. M.: GEOTAR-Media, 2015. P. 83-109. Russian (Aylamazyan E.K. Emergency care in obstetrics. A guide for doctors. 5th ed. M.: GEOTAR-Media, 2015. P. 83-109) 7. Mavroforou A, Koumantakis E, Michalodimitrakis E. Physiciansfiability in obstetrics and gynecology. Med Law.
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24(1): 1-9 8. Fitzpatrick KE, Kurnczuk JJ, Aifirevic Z, Spark P, Brocklehurst P, Knight M. Uterine rupture by intended mode of delivery in the UK; a national case – control study. PloS Med.
2012; 9(3): e10011184. DOI: 10.1371/journal. Pmed,1001184

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Diagnostic techniques

Already during pregnancy, pregnant women undergo examination and are classified as at risk of developing congenital anomalies. A history of miscarriage, chronic inflammation of the uterus, previous cesarean section or surgery increases the likelihood of injury.

Assessing the integrity of the scar is mandatory. Vaginal birth after the first cesarean section is not contraindicated, but a second cesarean section is often preferred in the post-Soviet space.

Diagnosing a rupture during labor can be difficult. The doctor must urgently assess the deterioration of the condition of the mother and fetus, determine the diagnosis and tactics of the procedure.

When examining the birth canal, the following symptoms are noted:

• increased obstetric swelling on the fetal head;
• no head advancement;
• The anterior part of the mucous membrane of the cervical spine is pinched and swollen;
• The swelling spreads to the vagina and external genitalia.

Upon external examination, the contractile ring is high and may be inclined.

Diagnosis includes measuring blood pressure and pulse. To determine the condition of the fetus, CTG is performed.

When a first-degree uterine rupture occurs during childbirth, diagnosis is not difficult. There are all signs of massive bleeding; the woman’s condition requires emergency assistance.

Sometimes the diagnosis can be made after birth. The woman has abdominal bloating. Manual examination of the uterine cavity allows you to identify the defect and take the necessary measures to eliminate bleeding and its consequences. If the disease is not diagnosed in the delivery room, symptoms of peritonitis appear the next day.

Recovery process and suture care

How long a woman in labor will take to recover depends on the severity of the injuries. The shortest period of recovery and healing of perineal ruptures after childbirth occurs from 4 months.

In the first days, the seams are treated with brilliant green or hydrogen peroxide. Next, the patient must follow simple rules so as not to harm or disturb the seam.

1. After each visit to the toilet, wash with warm water, moving from the vagina to the anus (from front to back.)
2. Keep the seam areas dry by blotting them with a towel or paper napkin.
3. Wear sanitary pads and change them every 2 hours if possible.
4. The perineal area should have access to air.
5. Walk more often, provided there is no discomfort or pain.
6. Monitor digestion, avoiding constipation or eliminating it with rectal glycerin suppositories.
7. If you notice a strange smell, an increase in body temperature, discharge of a strange color, and the pain begins to intensify, consult a doctor immediately.
8. Try not to sit down for a week. If you really want to sit down, it’s best to do it on an inflatable rubber ring to prevent the seams from coming apart.

Caring for a woman during pregnancy and childbirth

Women with an imminent breakup should not be transported. This means that she should not be transferred to another hospital if she develops worrying symptoms, even if adequate care cannot be provided under the circumstances. Fetal and maternal death may occur during transmission when treatment is not possible.

Clinical guidelines for this complication prohibit active labor and require delivery by cesarean section. The woman is given deep anesthesia. If the fetus is still alive, the operation is performed regardless of the obstetric situation.

Even if the fetal head is in the pelvic cavity, you should not try to remove it without surgery. Then the state of emergency would become a fait accompli.

If the fetus is dead, a caesarean section is not performed but is replaced by surgery to remove the fetus.

The treatment protocol for a uterine rupture that has already occurred includes performing an emergency laparotomy. In this case, childbirth is not carried out, since fetal death occurs almost immediately. It is necessary to stop the bleeding and prevent the development of severe hemorrhagic shock and disseminated intravascular coagulation. Therefore, already in preparation for surgery, blood, plasma or other anti-shock solutions should be transfused.

We are trying to complete the operation as soon as possible. This requires ligation of the feeding vessels and elimination of bleeding. Indications for hysterectomy in case of rupture have been determined:

• hemorrhagic shock;
• damage to the main vascular bundle;
• extensive gap.

In the case of a linear crack, the wall defect is sutured. The abdominal cavity is inspected and blood clots are removed. In case of incomplete rupture, it is necessary to remove the resulting hematoma, determine the source of bleeding and stop it.

After surgery, infusions of solutions are prescribed to compensate for blood loss and antibiotics to prevent infectious complications. Accurate anesthesia is required.

Women who have lost a child during childbirth may need the help of an experienced psychologist.

Treatment

Uterine rupture requires emergency surgery. If there is a threat to life, the patient should stop labor. For this purpose, anesthesia is administered and artificial ventilation is started. A woman is being prepared for a caesarean section. In most cases, the patient is in serious condition and there is a high risk of death. During surgery after the baby is born, the uterus is removed from the pelvis.

In case of linear ruptures, a small anhydrous gap and the absence of infection, they are sutured with mandatory drainage of the abdominal cavity.

In case of complete rupture, damaged uterine arteries, or the presence of a retroperitoneal hematoma, extirpation, supravaginal amputation, and ligation of the internal iliac arteries are performed. The abdominal cavity is drained, and antibiotic solutions are injected through the hole. Antishock therapy is carried out, blood loss is compensated.

Consequences and possibilities of prevention

The consequences of myometrial rupture can be dire. This condition, even with the current level of maternal health care, is accompanied by a high percentage of fetal death. A woman suffering from heavy bleeding requires a long recovery period.

Blood transfusion is always accompanied by a risk of contracting HIV and hepatitis C. However, the danger is massive bleeding, which leads to hypoxia of the pituitary gland and the development of Sheehan syndrome. This hormonal imbalance makes it difficult to become pregnant again.

Prevention takes place even at the stage of pregnancy planning. Women after surgery require a comprehensive assessment of the density of the uterine scar, which should include not only ultrasound data, but also hysteroscopy.

Your doctor's instructions should be followed throughout your pregnancy. If several risk factors are present, birth may only take place in first- or second-degree institutions, including regional maternity hospitals and large perinatal centers. Hospitalization should be carried out in advance.

Hemorrhagic shock

A severe maternal complication of massive bleeding is hemorrhagic (hypovolemic) shock. With blood loss of more than 25% of the circulating blood volume (CBV), or more than 1500 ml, the clinical picture of hemorrhagic shock develops. In 10% of cases of PVP that resulted in fetal death, that is, with abruption of > 2/3 of the placenta, the development of disseminated intravascular coagulation, or disseminated intravascular coagulation syndrome (DIC) is possible.

This syndrome develops as a result of the entry of massive doses of tissue thromboplastin (from places of damage to the placenta) into the maternal vascular system, which promotes the activation of the coagulation cascade, primarily in the microvascular bed. This leads to the development of ischemic necrosis of parenchymal organs - kidneys, liver, adrenal glands, pituitary gland.

Ischemic renal necrosis can develop as a result of acute tubular necrosis or bilateral cortical necrosis and manifests with oliguria and anuria. Bilateral cortical necrosis is a fatal complication that requires hemodialysis and can lead to death of the woman due to uremia in 1-2 weeks.

Management of patients with hypovolemic shock requires rapid restoration of lost blood volume. Central venous catheterization is performed, central venous pressure is measured to monitor the restoration of blood loss, a catheter is inserted into the bladder to monitor diuresis, oxygen inhalation is introduced, and infusion of blood and blood substitutes is started until the NET level is more than 30% and urine output is > 0.5 ml/kg / hour Studies of platelet counts, fibrinogen levels and serum potassium are performed after infusion of every 4-6 vials of blood.

Blood coagulation tests (tests for DIC) are carried out every 4 hours before delivery. The most sensitive clinical test for the development of DIC syndrome is the level of fibrinogen degradation products (FDP), although only a single study of the FDP level has prognostic significance, i.e. Based on the level of PDF, one cannot draw a conclusion about the effectiveness of treatment. Although normal PDP results do not exclude the possibility of DIC, fibrinogen levels and platelet counts are the most important markers of DIC.

Urgent delivery is the main component of the treatment of DIC syndrome, and leads to regression of its manifestations. The method of choice is caesarean section. If the fetus dies and the patient's condition is stable, vaginal delivery is possible. If the platelet count is <50,000 or the fibrinogen level is <1 g/L, these blood components must be restored. Restoration of fibrinogen levels is achieved by transfusion of fresh frozen plasma or cryoprecipitate. Heparin is not usually used.