Symptomatic Uterine Rupture: A Fifteen Year Review

Analysis of the uterine rupture during pregnancy and delivery in a provincial maternal and children care hospital in China: 2013-2022

BACKGROUND

Uterine rupture is rare and life-threatening for both mothers and newborns. This study aimed to explore the clinical manifestation, site of rupture, obstetric risk factors, maternal and neonatal complications, and birth outcomes with mid-trimester and late-pregnancy uterine rupture.

METHODS

Data from patients with uterine rupture occurring at Hunan Maternal and Child Health Hospital between January 2013 and December 2022 were reviewed retrospectively.

RESULTS

153,722 deliveries occurred during the 10 years of the study period. A total number of 129 uterine ruptures were identified: 12 ruptures occurred in the second trimester and 117 cases of uterine rupture diagnosed at or after 28 weeks gestation. The total incidence was 8.4/10,000. Most of the patients had a history of cesarean section (73.6%). 59.7% cases had a history of dilation and curettage. The rupture was more likely to occur on the lower uterine segment (86.82%). Seventy-one patients (55%) presented with abdominal pain or vaginal bleeding. Twenty-seven (20.9%) cases underwent a labor trial. There were 17 perinatal deaths associated with uterine rupture and neonatal asphyxia was observed in five infants. There was one maternal death. Postpartum hemorrhage occurred in 25 cases. Five patients underwent hysterectomy. Patients with uterine rupture during mid-trimester were more likely to receive a blood transfusion and exhibited higher rates of bladder injury.

CONCLUSION

Uterine rupture especially mid-gestational uterine rupture is rare and remains a diagnostic challenge. Remarkably worse maternal outcomes were seen in patients with second-trimester rupture when compared with patients who experienced late-pregnancy rupture. Pregnant women with a history of uterine surgery, even at an early gestational age, should be closely monitored by obstetricians for the risk of uterine rupture if they experience persistent abdominal pain. Early recognition and prompt intervention are key to improve maternal and child outcomes.

Risk factors and outcomes of uterine rupture before onset of labor vs. during labor: a multicenter study

OBJECTIVES

This study aims to reveal the distinctions between uterine rupture (UR) that occurs before onset of labor and during labor.

METHODS

This multicenter study was conducted across three tertiary hospitals in South China involving obstetrical UR from January 2009 to April 2022. Cases were categorized into two groups based on the timing of UR: prelabor and labor.

RESULTS

Among the cases of UR, 42 were classified in the prelabor group, and 27 in the labor group. The prelabor group had a higher prevalence of histories of myomectomies, ectopic pregnancy surgeries, congenital uterine anomalies, and prior URs. Among these ruptures, 45.2 % were located at cesarean section (CS) scars, compared to 81.5 % of cases during labor. Ruptures before onset of labor occurred across all gestational intervals, whereas those during labor, except one, occurred after 32 weeks. The median gestational age was 33 and 39 weeks in each group. Notably, prelabor cases demonstrated longer symptom-to-delivery intervals. Placenta percreta was more common in the prelabor group (16.7 vs. 3.7 % in the labor group). Among labor-related cases, 16 of the 27 occurred during trial of labor after cesarean (TOLAC), and four were identified following vaginal birth after cesarean (VBAC).

CONCLUSIONS

URs differ by timing relative to labor. Ruptures before onset of labor more often resulted from scars other than CS and placenta percreta, occurring at earlier gestational weeks. This finding highlighted challenges in diagnosis and management. In contrast, ruptures during labor mostly occurred after 32 weeks and were strongly associated with TOLAC/VBAC.

Exosomes derived from hUC-MSCs exhibit ameliorative efficacy upon previous cesarean scar defect via orchestrating β-TrCP/CHK1 axis

Previous cesarean scar defect (PCSD), also acknowledged as the myometrium of uterus defects, which commonly results in myometrial discontinuity between the uterine and cervical cavity. Current literatures have indicated the efficacy of MSCs and MSC-derived exosomes (MSC-Exos) for diverse refractory disease administration, yet the feasibility of MSC-Exos for PCSD treatment is largely obscure. In this study, we took advantage of the in vivo myofibrotic model for mimicking the typical manifestation of PCSD and the assessment of fertility. Meanwhile, the ex vivo scratch wound healing model is used for exploring the underlying molecular mechanism. On the one hand, we took advantage of the TGF-β-induced in vitro myofibrotic model and the full-thickness uterine injury rat model to verify the efficacy of human umbilical cord MSC-derived exosomes (hUC-MSC-Exos). On the other hand, with the aid of CHK1 overexpression and β-TrCP knockdown, together with multifaceted biological analyses (e.g., histopathological sections, qRT-PCR assay, western-blotting analysis, Co-IP assay, protein degradation and ubiquitination), we further dissected the underlying regulatory mechanism. We identified hUC-MSC-Exos and verified the suppressive effect of hUC-MSC-Exos upon TGF-β-induced in vitro myofibrotic model and full-thickness uterine injury in rats via delivering β-TrCP. Furthermore, we found that β-TrCP in hUC-MSC-Exos facilitated the ubiquitination degradation of CHK1 and inhibited the myofibrosis. Collectively, our data indicated the preferable ameliorative effect of hUC-MSC-Exos upon both the in vitro and in vivo myofibrotic models, together with the β-TrCP and CHK1-mediated regulatory mechanism. Our findings provided new references of hUC-MSC-Exos-based regimens for PCSD management in future.

Accuracy of sonographic lower segment thickness and prediction of vaginal birth after caesarean in a resourced-limited setting; Prospective study

OBJECTIVES

To assess the accuracy of ultrasound measurement of the lower uterine segment (LUS) thickness against findings at laparotomy, and to investigate its correlation with the success rate of vaginal birth after one previous caesarean delivery (CD) in a resource-limited setting.

DESIGN

Prospective study.

SETTING

Obstetrics and Gynaecology department in a tertiary hospital in Ghana.

POPULATION

Women with one previous CD undergoing either a trial of labour (TOLAC) or elective CD.

METHODS

Myometrial lower uterine segment thickness (mLUS) and full lower uterine segment thickness (fLUS) were measured with transvaginal ultrasound (TVUS). The women were managed according to local protocols with the clinicians blinded to the ultrasound measurements. The LUS was measured intraoperatively for comparison with ultrasound measurements.

MAIN OUTCOME MEASURES

Lower uterine segment findings at laparotomy, successful vaginal birth.

RESULTS

A total of 311 pregnant women with one previous CD were enrolled; 147 women underwent elective CD and 164 women underwent a TOLAC. Of the women that underwent TOLAC, 96 (58.5%) women had a successful vaginal birth. The mLUS was comparable to the intraoperative measurement in the elective CD group with LUS thickness <5 mm (bias of 0.01, 95% CI -0.10 to 0.12 mm) whereas fLUS overestimated LUS <5 mm (bias of 0.93, 95% CI 0.80-1.06 mm). Successful vaginal birth rate correlated with increasing mLUS values (odds ratio 1.30, 95% CI 1.03-1.64). Twelve cases of uterine defect were recorded. LUS measurement ≤2.0 mm was associated with an increased risk of uterine defects with a sensitivity of 91.7% (95% CI 61.5-99.8%) and specificity of 81.8% (95% CI 75.8-86.8%).

CONCLUSION

Accurate TVUS measurement of the LUS is technically feasible in a resource-limited setting. This approach could help in making safer decisions on mode of birth in limited-resource settings.

Complete rupture of the pregnant uterus: A 12-year retrospective study

OBJECTIVE

To assess the frequency of uterine ruptures, clinical characteristics, and maternal and neonatal outcomes in a tertiary referral center.

METHODS

Information on complete uterine rupture between July 2010 and June 2022 was investigated retrospectively at a tertiary center.

RESULTS

There were 42 cases of complete uterine rupture in 144 474 deliveries, with an incidence rate of 0.029%. Twenty-seven cases had a scarred uterus and 15 had an unscarred uterus; Rupture of the lower uterine segment was predominant in the scarred uterus, whereas rupture of the body of the uterus was predominant in the non-scarred uterus (P ≤ 0.001). Newborns with Apgar score of 7 or less at 1 min in the non-scarred uterus group was more than that in the scarred uterus group (P = 0.001). There were no significant differences in the history of gynecologic surgery, induction of labor, mode of delivery, clinical features, maternal outcomes, neonatal weight, preterm birth rate, 5-min Apgar score, or neonatal mortality between the two groups (P > 0.05).

CONCLUSION

The clinical manifestations of uterine rupture are mainly abdominal pain, abnormal fetal heartbeat, or vaginal bleeding. Attention should also be paid to the history of previous uterine surgery. Strict prenatal management, early identification, and aggressive management can help improve maternal and child outcomes. Hysterectomy is not imperative.

The incidence, indications, risk factors and pregnancy outcomes of peripartum hysterectomy at a tertiary hospital between 2013 and 2022

OBJECTIVE

To analyze the incidence, indications, risk factors and pregnancy outcomes of postpartum hemorrhage resulting in peripartum hysterectomy (PH).

METHODS

We retrospectively reviewed patients with postpartum hemorrhage requiring surgical procedures at ≥ 28 weeks of gestation from January 1, 2013 to December 31, 2022 at a tertiary hospital in Shanghai, China. The patients were divided into a PH group and a non-PH group. Maternal clinical characteristics, the management of postpartum hemorrhage, pregnancy outcomes were compared between groups. Logistic regression was used to analyze the correlations between risk factors and PH.

RESULTS

The incidence of hysterectomy was 0.2/1000 deliveries (31/150194). The variables significantly associated with PH were placenta previa with placenta increta/percreta (OR36.26), uterine rupture (OR266.16) and an estimated blood loss ≥ 3513 mL (OR431.11). The proportion of cases involving hemorrhagic shock, disseminated intravascular coagulation, bladder injury, neonatal severe asphyxia, neonatal death and hypoxic-ischemic encephalopathy were significantly higher in the PH group (P < 0.05).

CONCLUSION

The most common indications of PH were placental pathology. Efforts should be made to reduce the rate of cesarean deliveries and uterine curettage to lower the probability of abnormal placental invasion and appropriate medical indications for trial of labor after cesarean should be strictly followed to avoid the risk of uterine rupture.

Early Challenges: A Case Report of a Premature Baby with Down Syndrome and Uterine Rupture

Introduction  Uterine rupture represents one of the most severe obstetric affections. It is defined as a complete or a partial tearing of the uterine wall. Women with a prior cesarean section are reported to have a higher risk of having this situation. Moreover, maternal death and most of all middle- and long-term adverse consequences remain a great preoccupation. On another scale, neonatal death and ulterior deterioration remain very high, especially in low-income countries. Case Description  A 24-year-old woman with a history of previous cesarean section presented at 35 weeks of gestation with pelvic pain without bleeding. Emergency cesarean section revealed a complete uterine rupture at the scar site from the previous cesarean section. Remarkably, the fetus managed to seal the rupture using the right temporal region, forearm, and right leg, avoiding significant complications. The mother had an uncomplicated postoperative course and was discharged after 48 hours of surveillance. Conclusion  We present with this case an extraordinary case of a uterine rupture where both mother and child had a good outcome. This rare evolution was reported only one time in literature. For this reason, a history of caesarean delivery might present a huge challenge for obstetricians and neonates.

Using Robson classification to analyze cesarean section and induction rates in relation to changes in the standards of perinatal care in one hospital in Poland

BACKGROUND

Poland has one of the highest cesarean birth (CB) rates in Europe. For this study, we used the Robson Ten-Group Classification System (TGCS) to analyze trends in the induction and CB rates in one hospital in Poland over a period of 11 years. We compare these trends with changes in National Legislative and Medical Guidelines introduced during this time that were aimed at lowering rates of unnecessary medical interventions.

METHODS

We conducted a retrospective study including all births after 24 weeks' gestation between 2010 and 2020 from one tertiary hospital (n = 66,716 births). After the deletion of records with missing data, 66,678 births were included in the analysis. All births were classified according to the Robson TGCS. The size, CB rate, and contribution of each group for every year were calculated. Linear regression analyses were used to analyze trends over time.

RESULTS

The total CB rate varied from 29.6% to 33.0% during the study period, with a linear increase of 0.045 percentage points annually (R2 = 0.021; F(1) = 0.189; p = 0.674). This study was considerably lower than the total CB rate for Poland, which rose from 33.9% in 2010 to 45.1% in 2020, increasing at a rate of 1.13 percentage points per year (R2 = 0.93; F(1) = 61.88; p < 0.001). Induction rates among both nulliparous (R1 + R2) and multiparous (R3 + R4) women at term also increased. Study groups R5 (previous cesarean birth), R2 (nulliparous in induced or prelabor cesarean delivery), and R1 (nulliparous women at term with single cephalic pregnancy in spontaneous labor) were the highest contributors to the overall CB rate. The greatest decrease in the CB rate was detected in group R5b (more than one previous CB). None of the groups showed statistically significant increases in CB rates over the study period.

CONCLUSIONS

The CB rate in the hospital where the study was conducted was considerably lower than the total CB rate in Poland. When compared with countries with similar CB rates, group R2b (women with nulliparous, prelabor cesarean birth) in our study was considerably larger. More comparisons across different hospital settings in Poland are needed. However, as hospitals are not encouraged to routinely collect the data needed to construct TGCS, such comparisons are very difficult to conduct.

Clinical analysis of complete uterine rupture during pregnancy

BACKGROUND

Uterine rupture in pregnant women can lead to serious adverse outcomes. This study aimed to explore the clinical characteristics, treatment, and prognosis of patients with complete uterine rupture.

METHODS

Data from 33 cases of surgically confirmed complete uterine rupture at Chenzhou No.1 People's Hospital between January 2015 and December 2022 were analyzed retrospectively.

RESULTS

In total, 31,555 pregnant women delivered in our hospital during the study period. Of these, approximately 1‰ (n = 33) had complete uterine rupture. The average gestational age at complete uterine rupture was 31+4 weeks (13+1-40+3 weeks), and the average bleeding volume was 1896.97 ml (200-6000 ml). Twenty-six patients (78.79%) had undergone more than two deliveries. Twenty-five women (75.76%) experienced uterine rupture after a cesarean section, two (6.06%) after fallopian tube surgery, one (3.03%) after laparoscopic cervical cerclage, and one (3.03%) after wedge resection of the uterine horn, and Fifteen women (45.45%) presented with uterine rupture at the original cesarean section incision scar. Thirteen patients (39.39%) were transferred to our hospital after their initial diagnosis. Seven patients (21.21%) had no obvious symptoms, and only four patients (12.12%) had typical persistent lower abdominal pain. There were 13 cases (39.39%, including eight cases ≥ 28 weeks old) of fetal death in utero and two cases (6.06%, both full term) of severe neonatal asphyxia. The rates of postpartum hemorrhage, blood transfusion, hysterectomy were 66.67%, 63.64%, and 21.21%. Maternal death occurred in one case (3.03%).

CONCLUSIONS

The site of the uterine rupture was random, and was often located at the weakest point of the uterus. There is no effective means for detecting or predicting the weakest point of the uterus. Rapid recognition is key to the treatment of uterine rupture.

Provincial Maternal and Child Information System in Inner Mongolia, China: Descriptive Implementation Study

BACKGROUND

After the implementation of 2- and 3-child policies, the rising proportion of high-age and high-risk pregnancies put enormous pressure on maternal and child health (MCH) services for China. This populous nation with an increasing population flow imperatively required the support of large-scale information systems for management. Municipal MCH information systems were commonly applied in developed cities of eastern provinces in China. However, implementation of provincial MCH information systems in relatively low-income areas is lacking. In 2020, the implementation of a regional maternal and child information system (RMCIS) in Inner Mongolia filled this gap.

OBJECTIVE

This paper aimed to demonstrate the construction process and evaluate the implementation effect of an RMCIS in improving the regional MCH in Inner Mongolia.

METHODS

We conducted a descriptive study for the implementation of an RMCIS in Inner Mongolia. Based on the role analysis and information reporting process, the system architecture design had 10 modules, supporting basic health care services, special case management, health support, and administration and supervision. Five-color management was applied for pregnancy risk stratification. We collected data on the construction cost, key characteristics of patients, and use count of the main services from January 1, 2020, to October 31, 2022, in Inner Mongolia. Descriptive analysis was used to demonstrate the implementation effects of the RMCIS.

RESULTS

The construction and implementation of the RMCIS cost CNY 8 million (US $1.1 million), with a duration of 13 months. Between 2020 and 2022, the system recorded 221,772 registered pregnant women, with a 44.75% early pregnancy registry rate and 147,264 newborns, covering 278 hospitals and 225 community health care centers in 12 cities. Five-color management of high-risk pregnancies resulted in 76,975 (45.45%) pregnancies stratified as yellow (general risk), 36,627 (21.63%) as orange (relatively high risk), 156 (0.09%) as red (high risk), and 3888 (2.30%) as purple (infectious disease). A scarred uterus (n=28,159, 36.58%), BMI≥28 (n=14,164, 38.67%), aggressive placenta praevia (n=32, 20.51%), and viral hepatitis (n=1787, 45.96%) were the top factors of high-risk pregnancies (yellow, orange, red, and purple). In addition, 132,079 pregnancies, including 65,018 (49.23%) high-risk pregnancies, were registered in 2022 compared to 32,466 pregnancies, including 21,849 (67.30%) high-risk pregnancies, registered in 2020.

CONCLUSIONS

The implementation of an RMCIS in Inner Mongolia achieved the provincial MCH data interconnection for basic services and obtained both social and economic benefits, which could provide valuable experience to medical administration departments, practitioners, and medical informatics constructors worldwide.

Spontaneous uterine rupture with amniotic sac protrusion during the third trimester of a unicornuate uterus pregnancy: A rate case report

RATIONALE

Uterine rupture is an obstetrical emergency associated with severe maternal and fetal mortality. It is rare in the unscarred uterus of a primipara.

PATIENT CONCERNS

A 25-year-old woman in her 38th week of gestation presented with slight abdominal pain of sudden onset 10 hours before. An emergency cesarean section was done. After surgery, the patient and the infant survived.

DIAGNOSES

With slight abdominal pain of clinical signs, ultrasound examination showed that the amniotic sac was found in the peritoneal cavity with a rupture of the uterine fundus.

INTERVENTIONS

Uterine repair and right salpingectomy.

OUTCOMES

After surgery, the patient and the infant survived. The newborn weighed 2600 g and had an Apgar score of 10 points per minute. Forty-two days after delivery, the uterus recovered well.

LESSONS

Spontaneous uterine rupture should be considered in patients even without acute pain, regardless of gestational age, and pregnancy with abdominal cystic mass should consider the possibility of uterine rupture.

Uterine rupture in patients with a history of hysteroscopy procedures: Case series and review of literature

RATIONALE

Uterine rupture during pregnancy poses significant risks to both the fetus and the mother, resulting in high mortality and morbidity rates. While awareness of uterine rupture prevention after a cesarean section has increased, insufficient attention has been given to cases caused by pregnancy following hysteroscopy surgery.

PATIENT CONCERNS

We report 2 cases here, both of whom had a history of hysteroscopy surgery and presented with severe abdominal pain during pregnancy.

DIAGNOSES

Both patients had small uterine ruptures, with no significant abnormalities detected on ultrasonography. The diagnosis was confirmed by a CT scan, which showed hemoperitoneum.

INTERVENTIONS

We performed emergency surgeries for the 2 cases.

OUTCOMES

We repaired the uterus in 2 patients during the operation. Both patients recovered well. The children survived. No abnormalities were detected during their follow-up visits.

LESSONS

Attention should be paid to the cases of pregnancy after hysteroscopy.

Impact of myomectomy on the obstetric complications: A large cohort study in Japan

OBJECTIVE

The authors conducted a large-scale cohort study using the Japan Society of Obstetrics and Gynecology's perinatal registry database to determine the effect of myomectomy on perinatal outcomes.

METHODS

This retrospective cohort study enrolled 203 745 women who gave birth between January and December 2020 in Japan. The participants were classified into two groups based on their history of myomectomy (open/laparoscopic) to investigate fertility treatment, delivery information, obstetric complications, maternal treatment, infant information, fetal appendages, obstetric history, underlying disease, infectious disease, drugs used, and case information regarding maternal and infant death.

RESULTS

In total, 1161 pregnant women had a history of myomectomy and 202 584 did not. Compared with the nonmyomectomy group, the myomectomy group had a higher occurrence rate of uterine rupture (0.9% vs 0.06%, P < 0.01) and placenta accreta (1.5% vs 0.5%, P < 0.01). In addition, history of myomectomy (odds ratio [OR], 2.62 [95% confidence interval (CI), 1.500-4.226]; P < 0.001) was found to be an independent factor for placenta accrete and uterine rupture (OR, 14.4 [95% CI, 6.75-27.02]; P < 0.001). Furthermore, myomectomy increased the risk of uterine rupture by 14 times.

CONCLUSION

Postmyomectomy pregnancy may increase the risk of placenta accreta and uterine rupture.

Spontaneous rupture of an unscarred uterus during pregnancy: A rare but life-threatening emergency: Case series

RATIONALE

In most cases, uterine rupture occurs during the third trimester of pregnancy or during labor. Even fewer reports have been published about the occurrence of this condition without a gynecologic history of any surgical procedure. Due to their scarcity and variable clinical presentation, early diagnosis of uterine rupture may be difficult, and if the diagnosis is not timely, the condition may be life-threatening.

PATIENT CONCERNS

Herein, 3 cases of uterine rupture from a single institution are described. Three patients are at different gestational weeks and all have no history of uterine surgery. They came to the hospital due to acute abdominal pain, which is characterized by severe and persistent pain in the abdomen, with no apparent vaginal bleeding.

DIAGNOSES

All 3 patients were diagnosed with uterine rupture during the operation.

INTERVENTIONS

One patient underwent uterine repair surgery; while the other 2 underwent subtotal hysterectomy due to persistent bleeding and pathological examination after surgery confirmed placenta implantation.

OUTCOMES

The patients recovered well after the operation, and no discomfort occurred in the follow-up.

LESSONS

Acute abdominal pain during pregnancy can pose both diagnostic and therapeutic challenges. It is important to consider the possibility of uterine rupture, even in cases where there is no history of prior uterine surgery. The key to the treatment of uterine rupture is to shorten the diagnosis time as much as possible, this potential complication should be carefully monitored for and promptly addressed to ensure the best possible outcomes for both the mother and the developing fetus.

Unexpected Uterine Rupture-A Case Report, Review of the Literature and Clinical Suggestions

BACKGROUND AND OBJECTIVES

Women with a history of cesarean section are a high-risk group because they are likely to develop uterine rupture during their next pregnancy. Current evidence suggests that a vaginal birth after cesarean section (VBAC) is associated with lower maternal mortality and morbidity than elective repeat cesarean delivery (ERCD). Additionally, research suggests that uterine rupture can occur in 0.47% of cases of trial of labor after cesarean section (TOLAC).

CASE DESCRIPTION

A healthy 32-year-old woman at 41 weeks of gestation, in her fourth pregnancy, was admitted to the hospital due to a dubious CTG record. Following this, the patient gave birth vaginally, underwent a cesarean section, and successfully underwent a VBAC. Due to her advanced gestational age and favorable cervix, the patient qualified for a trial of vaginal labor (TOL). During labor induction, she displayed a pathological CTG pattern and presented symptoms such as abdominal pain and heavy vaginal bleeding. Suspecting a violent uterine rupture, an emergency cesarean section was performed. The presumed diagnosis was confirmed during the procedure-a full-thickness rupture of the pregnant uterus was found. The fetus was delivered without signs of life and successfully resuscitated after 3 min. The newborn girl of weight 3150 g had an Apgar score of 0/6/8/8 at 1, 3, 5, and 10 min. The uterine wall rupture was closed with two layers of sutures. The patient was discharged 4 days after the cesarean section without significant complications, with a healthy newborn girl.

CONCLUSIONS

Uterine rupture is a rare but severe obstetric emergency and can be associated with maternal and neonatal fatal outcomes. The risk of uterine rupture during a TOLAC attempt should always be considered, even if it is a subsequent TOLAC.

Learning from maternal deaths due to uterine rupture: review of cases from peri-urban Uganda

BACKGROUND

Maternal deaths from uterine rupture continue to occur globally, with particularly high rates in sub-Saharan Africa. Maternal death reviews have been shown to be an effective part of cohesive strategies to prevent future deaths.

OBJECTIVE

This study aimed to conduct maternal death reviews for all deaths following uterine rupture in the study center, to assess preventability, and to synthesize key learning points that may help to prevent future maternal deaths following uterine rupture.

STUDY DESIGN

Thorough case reviews of all maternal deaths from 2016 to 2018 at the study center (a national referral hospital in urban Uganda) were conducted by trained multidisciplinary panels of obstetricians and midwives. Medical records of women who died following uterine rupture (n=37, 10.6% of all maternal deaths) were extracted for further analysis.

RESULTS

Most maternal deaths due to uterine rupture (36/37, 97%) were preventable, with most having been still potentially preventable after the women reached the study center (24/36, 67%). Obstructed labor was the leading cause of uterine rupture, accounting for 73% (27/37) of cases. Previous cesarean delivery was confirmed in 38% (14/37) of cases. The incidence of grand multiparity was 11% (4/37), and 11% (4/37) were primiparous. Most women (28/37, 76%) died within 24 hours of admission. On arrival at the study center, 19 (51%) were critically ill. Exploratory laparotomy was performed in 54% (20/37) of cases, and a further 35% (13/37) died while awaiting laparotomy. Four women died shortly after arrival at the study center (within 1 hour) and received basic resuscitative treatment; 27% (10/37) of women who died had received antenatal planning or preparation.

CONCLUSION

Most deaths due to uterine rupture were preventable. The key lessons that emerged from the reviews were: (1) careful birth preparation and complication awareness for women with known risk factors, (2) early recognition of obstructed labor, (3) close monitoring of obstetrical interventions known to be associated with uterine rupture, and (4) treating incipient or suspected uterine rupture as a time-critical obstetrical emergency. The recommendations emerging from our narrative reviews are suitable for implementation in low-resource obstetrical settings, where high numbers of deaths involving uterine rupture occur.