Obstetric complication uterine rupture

Uterine rupture is a high-risk obstetric complication, which is dangerous to both pregnant women and fetuses. The main reason of danger is that uterine rupture will lead to blood vessel rupture, which will lead to massive bleeding. In the process of uterine bleeding, the placenta may peel off, the blood flow to the umbilical cord decreases, and the oxygen delivery decreases, which will cause fetal hypoxia and even death, which requires special attention and nursing.

High risk! Case 1 Ms. Chen, the second child, the last child was caesarean section. Because the last fetus was delivered by caesarean section, the postpartum wound was painful for a long time, so this fetus hoped to adopt natural delivery. The parturient came to give birth at night because of labor pains, and there were no special circumstances in the preliminary assessment. After being hospitalized for 3 hours, the nurse was anxious to call the doctor and said that she could not hear the fetal heartbeat.

The doctor used ultrasound scanning to confirm that the fetus had no heartbeat, half of the body had slipped out of the uterus and there was bleeding around the uterus. After the emergency operation, confirm that the uterus ruptured at the place where the last caesarean section was performed. After the delivery of the fetus, the bleeding is still difficult to control. Hysterectomy was not allowed to stop bleeding, and 4000 ml of blood was transfused, and finally his life was saved.

Case 2: Miss Lin's second child, the last one was born naturally, and this one is bigger. The parturient worked hard on the production platform for a long time, but the fetal head still couldn't come out. When the mother was working hard, the nurse next to her pushed her belly, which really made the fetus born smoothly.

But not long after, when the doctor was about to deliver the placenta, she found that the mother had fainted, and the nurse told her not to respond. After measuring blood pressure, the pressure is 80/50 mm Hg, which is close to shock. Fortunately, she is still breathing. After the examination, the uterus was found to be ruptured, and she was rushed to the operating room for surgery to stop bleeding, and 3000 ml of blood was transfused, which finally saved her life.

The fetus in front is delivered by caesarean section, so be careful when this fetus is delivered naturally! Both cases were caused by uterine rupture. The first case occurred after caesarean section of the previous fetus, and the next fetus tried to give birth naturally, resulting in uterine incision bleeding of the previous fetus. The second case occurred in a pregnant woman who gave birth naturally. Because the nurse pushed her stomach, the uterus ruptured and bled. Fortunately, both cases were successfully operated and their lives were saved. Therefore, today, I want to introduce the causes and prevention methods of the disease "uterine rupture".

Simply put, uterine rupture is a high-risk obstetric complication, which is very dangerous for pregnant women and fetuses. The main reason of danger is that uterine rupture will lead to blood vessel rupture, which will lead to massive bleeding. In the process of uterine bleeding, the placenta may peel off, the blood flow to the umbilical cord will decrease, and the oxygen delivery will also decrease, leading to fetal hypoxia and even death.

On the other hand, pregnant women are in danger of death from shock due to massive intra-abdominal bleeding, so they must undergo emergency surgery to stop bleeding. However, in order to stop bleeding, hysterectomy is sometimes needed. Most cases occur when the previous fetus is delivered by caesarean section, and this fetus tries to give birth naturally (* * *). It is precisely because of the fear of uterine rupture that most pregnant women who had a previous caesarean section will choose direct caesarean section in the next delivery, instead of trying natural delivery.

The incidence of uterine rupture in pregnant women is actually very small. The average maternal morbidity is estimated to be around 5000 ~ 1/20000. However, if it is a caesarean section of the first child, the probability of a pregnant woman trying to give birth naturally (* * *) will increase to 100 to 200. So it is estimated that there may be dozens of pregnant women in Taiwan Province province a year.

Which pregnant mothers should pay attention! ? 1. Pregnant women who are most likely to have caesarean section account for more than 90% of the cases. If it was a caesarean section before and the next fetus tried to give birth, the probability of uterine rupture was between 100 ~ 1/200. A normal uterus may rupture during childbirth, but the probability is very, very low.

The operation mode of caesarean section in front of the fetus also has an influence; If caesarean section is performed in the transverse direction of the lower uterus, the probability is 100 to 1/200. If caesarean section is performed in the vertical direction of the uterus, the probability of uterine rupture can be as high as 3% ~ 10%. Therefore, it is not recommended that these women try to have children next time because the risk is too high.

2. If the uterus has been operated before, and the uterus has been completely removed (such as myomectomy or plastic surgery), if you try to give birth to a fetus, the probability of uterine rupture will reach 1%.

3. If the previous fetus is delivered by caesarean section, this fetus will try to give birth naturally. If you use drugs that promote uterine contraction, such as oxytocin (intravenous drip) or PGE2( ***), you will increase the risk of uterine rupture.

If the previous fetus is delivered by caesarean section, this fetus will try to give birth naturally. When waiting for labor, pregnant women whose cervix has loosened and thinned will have a higher success rate in the end. On the contrary, pregnant women whose cervix is still hard and tight, or whose labor process is not smooth (dystocia), not only have difficulty in delivery, but also have a higher chance of uterine rupture.

4. If the labor is normal, the delay of labor (dystocia) is too long, and the duration of intrauterine pressure is too long, which will also increase the risk of uterine rupture. At present, when dystocia occurs in China, caesarean section will be taken. Therefore, there are few cases of uterine rupture caused by prolonged dystocia.

5. Some medical interventions will increase the risk of uterine rupture. Including the use of powerful drugs, you can also use forceps to produce (uterine injury), or try to produce by hand if the fetal position is not correct.

6. external force bumps. For example, if you are injured in a car accident and hit your stomach, it may also lead to uterine rupture; Usually in the third trimester of pregnancy, the bigger the uterus, the easier it is to directly hit the uterus, leading to rupture. In addition, when pregnant women are about to give birth, some women are not physically strong enough for the fetus to be born. Some medical staff will press the abdomen to help them give birth quickly, but in rare cases, the force of pressing the abdomen may also lead to uterine rupture, so be careful.

9 diagnostic methods 1 The earliest and most common symptom is abnormal fetal heart sound. Because of uterine blood loss, or because of placental abruption, fetal blood flow is insufficient, and fetal heartbeat changes. Some normal heartbeat speeds up and variability disappears, but the heartbeat slows down and slows down. If it continues, it may be stillborn. Therefore, if you are a pregnant woman who delivered a caesarean section before the fetus, you should be very careful to consider whether there is a uterine rupture once you find abnormal fetal heart sounds. If there is no other reason to explain the slow heartbeat, she should strongly suspect that it is a uterine rupture and should be treated quickly (emergency surgery). Even if the uterus is not ruptured, as long as the fetal heart sounds continue to be abnormal, caesarean section is needed.

A large amount of bleeding at the laceration will flow out of the uterus and then into the abdominal cavity, which will cause excessive blood loss of pregnant women and rapid drop of blood pressure, causing shock and coma. Therefore, if the mother suddenly goes into shock and coma before and after delivery, it is necessary to consider whether there is uterine rupture.

3 Hemorrhage flowing into abdominal cavity will reach the diaphragm at the junction of chest cavity and abdominal cavity. If the diaphragm nerve * * *, it will make the patient feel chest pain or shoulder pain, which may make the medical staff mistakenly think that it is a chest and lung problem.

4 A large amount of bleeding at the laceration will flow into the uterus (because the pressure in the uterus is relatively high) and then flow out of the cervix, so a small number of pregnant women will have bleeding before the birth of the fetus. Because there is not much blood flowing out of * *, it will make people ignore the severity, because most of the bleeding is in the abdominal cavity. If bleeding occurs during the delivery of the fetus, the intrauterine pressure will decrease after the birth of the fetus, and the amount of bleeding will increase greatly. Therefore, postpartum hemorrhage should also be included in one of the possible reasons.

A few pregnant women will feel that the uterine contraction intensity is weakened, the contraction frequency is reduced, or even stopped. It can also be seen from the uterine pressure monitor tied to the pregnant woman's stomach that the uterine contraction intensity is gradually weakening.

A few pregnant women will suddenly feel pain and tenderness in the lower abdomen, or suddenly feel more pain. However, if pregnant women give birth painlessly or inject painkillers, they may not feel special pain.

A few pregnant women, whose fetal head has entered the pelvic cavity, were found during the internal diagnosis and returned (have left the uterus and entered the abdominal cavity).

If the fetus has partially or completely slipped out of the uterus from the uterine rupture, entered the abdominal cavity, and palpated the pregnant woman's stomach, a part of the fetus can be touched, indicating that the fetus is already outside the uterus. At this time, observing the pregnant woman's stomach, we can also find that the shape of the pregnant woman's stomach has changed slightly after the fetus partially slipped out of the uterus.

If the rupture is close to the bladder, or even the bladder breaks and bleeds, hematuria will occur.

Once 6 kinds of clinical treatments 1 are found, emergency laparotomy will be arranged immediately to see if there is any chance of saving. By the time the symptoms are obvious, it is already very serious. Even in the best medical center, placental function will deteriorate within a few minutes due to massive bleeding, and the chance of being rescued is not very high. Even if the fetus is alive, the fetus may be in a state of hypoxia during the period of blood loss of pregnant women, and the function of the brain may be damaged after birth.

The mortality rate of pregnant women depends on the blood volume, hemostasis speed and blood transfusion ability of the hospital. If it is in a medical center, the mortality rate can be controlled within 5%, and if it is in an area lacking medical care and medicine, the mortality rate can reach 20% to 30%.

Hemostasis after laparotomy can be divided into two methods: direct suture of uterine laceration and hysterectomy. Direct hysterectomy is preferred by most doctors because it is more reliable and easier to stop bleeding. However, if you can't give birth after hysterectomy, you must first obtain the consent of the patient or family members.

4. A large number of blood transfusions and intravenous drip should be given as soon as possible to avoid maternal death due to hemorrhagic shock.

Maybe the obstetricians and gynecologists themselves are very capable and confident, but in order to minimize the maternal risk, it is better to find backup as soon as possible, including other obstetricians and gynecologists to assist in the operation, anesthesiologists to assist in anesthesia, blood banks to provide blood transfusion, pediatricians to assist in the first aid of newborns (if the fetus is still alive), and the intensive care unit should be prepared first. If the hospital is short of equipment or manpower, it should be referred to a larger hospital as soon as possible.

Of course, the sooner we find out and operate, the higher the chances of fetal survival. In the medical center, the fetus can be born within half an hour; If the fetus can be delivered within 20 minutes, not only the survival rate is high, but also the complications caused by hypoxia will be minimized in the future. However, it also depends on the different conditions and severity, and whether the placenta still maintains its function when the uterus ruptures. If the placenta also falls off, the situation is not optimistic.

Expected consequences 1. If the rupture is so large that the fetus has slipped out of the uterus, the expected consequences are not optimistic. Fetal mortality is between 50% and 80%, because the key to fetal survival is whether the placenta is still working normally. However, due to the bleeding caused by uterine rupture, the placental blood flow will be reduced, or placental abruption will lose its function, so the expected consequences are not optimistic. If the fetus survives, some babies will have cerebral palsy due to lack of oxygen.

2. Although the uterus ruptures, it will lead to internal bleeding and even shock in pregnant women. Only by timely laparotomy, surgical hemostasis and rapid blood transfusion can most of them save their lives. However, the more delayed detection and diagnosis, the more bleeding, which will increase the mortality rate of pregnant women.

Can the next child be pregnant again?

If you choose hysterectomy after uterine rupture, you will not be pregnant again. If you choose to repair the uterine dehiscence wound, it is still possible to get pregnant again. The probability of recurrence of uterine rupture in the next fetus is at least above 20%, even as high as 80%. Because the probability of recurrence of uterine rupture is too high, most doctors recommend direct caesarean section and early surgery before the uterus begins to labor pains.

Lv Education: Doctor of Medicine, Taiwan Province Provincial University, Obstetrics Researcher, Yale University Experience: Attending physician, Guotai Hospital, S? o Paulo Hospital Current position: Director of Obstetrics and Gynecology, Taoyuan Hospital, Ministry of Health and Welfare.

Text/Director of Obstetrics and Gynecology, Taoyuan Hospital, Ministry of Health and Welfare Lv Lizheng Series/Wu Huimin Photography/Xiao Jiang