Introduction

Rupture of the gravid uterus with its sequelae remains one of the most disastrous complications of pregnancy, occurring invariably at or near term¹. It has adverse effects on the mother and foetus. In India it is accounted for 5-10% of maternal deaths². It reflects the overall socioeconomic development and availability of health care facilities in a country³. Though the frequency of uterine rupture has not changed but the etiology of rupture has changed appreciably and its outcome has improved⁴. Uterine rupture of unscarred variety is still common in the developing nations reflecting a grim scenario of poor health care services. In developed countries, rupture of scarred uterus is the primary risk factor mostly during the course of trial of labour for vaginal birth after caesarean section^4-6. Common etiological factors⁷ for uterine rupture are grand multiparity, neglected obstructed labour, previous scar, use of oxytocic agents, superadded with lack of supervision before, during and after delivery^7,8.

Matrial and Methods

100 women with uterine rupture were studied over a period of two years from March 2007 to March 2009 in Lalla Ded Hospital (a tertiary care centre of Kashmir valley), an associated hospital of Government Medical College Srinagar. Cases included pregnant women reporting with clinical features suggestive of uterine rupture, presenting with suspected rupture after vaginal delivery and developing rupture after admission to the hospital. Relevant history was taken from patients and/or attendants and detailed examination, baseline investigations were done. The operative findings were noted regarding haemoperitoneum, baby and or placenta in peritoneal cavity; site and extent of rupture and associated injuries to other structures were noted. Blood transfusions received during operation and the condition of baby were also recorded. Some patients underwent hysterectomy while as repair was done in some patients. Postoperative patients were monitored carefully and complications noted.

Results

Out of 46,740 deliveries during the period, 100 women had uterine rupture, the ratio being 1:467 deliveries (0.2%). We had more caesarean deliveries because large number of women were referred to our tertiary care hospital for difficulties during labour. 97% of cases were illiterate, 72% had no antenatal care, 84% of women were from rural areas, 91% of cases were in labour and 60% of uterine rupture occurred in unscarred uterus (table 1). Clinical presentation was as shock in 48% of cases, abnormal vaginal bleeding in 38% and abdominal pain and or tenderness in 45%, spontaneous rupture occurred in 73% of cases, 85% were admitted with rupture. 80% of cases had rupture in lower uterine segment, 6% had it it upper segment, while as 14% had both segments involved. 21% of cases had broad ligament injury, 12% had injury to urinary bladder and 1% of cases sustained ureteric injuries (table 4). Almost all women with uterine rupture needed blood transfusions. 42% developed postoperative infections, 59% of cases with rupture underwent hysterectomy 53% subtotal and 6% total hysterectomy) rest 41% had repair of uterus (table 5).

Figure 1

Table – 1 - Comparison of rupture among previously scarred and intact (unscarred) uteri according to parity.

Figure 2

Table – 2 - Distribution of cases according to their ages in years

Figure 3

Table – 3 - Distribution of cases in terms of apparent etiological factors

Figure 4

Table – 4 - Injuries to other abdominal structures during rupture process

Figure 5

Table – 5 - Profile of definitive surgical procedures

Discussion

Rupture of gravid uterus in a way is an index of overall socioeconomic development³, literacy rate and availability of health care facilities in a country has undergone tremendous change in terms of its incidence, etiology and fetomaternal outcome^4,5.

Our incidence of one rupture in 467 deliveries (women) was similar to other studies in third world countries as 1:425 of Lema VM et al ⁹ and 1:367 of Elkandy AA et al from Egypt¹⁰. The incidence of rupture has almost remained same as compared to previous study of Dhar et al (1490)²³, but the incidence was higher as compared to 1:2558 of Planche et al in USA¹² and 1:4366 of Gurdal F et al in Ireland¹³, 1:1457 of Saglamtus M et al in Turkey¹⁴. Incidence was low as compared to 1:44 deliveries of Lankoande J et al in West Africa¹⁵. Incidence of uterine rupture in booked cases is only 12.5% and incidence of rural cases is as high as 80%. Uterine rupture is rare in primigravidae as they usually respond to obstruction with uterine inertia, an incidence of only 2.2% was reported among primigravidae¹⁷. Oxytocin and prostaglandins are now being used in previous caesarean section cases for augmentation of labour, such practice should be accompanied by great diligence¹⁸.

The higher incidence may be because of a large peripheral rural area cattered only by our tertiary care hospital²³. 97% of women with uterine rupture were illiterate with a low socioeconomic status. 72% had an antenatal care. 84% were from rural areas similar to 84.7% being unbooked reported by Ogunewa et al¹⁹ and 75% by Vangeenderhuysen C et al²⁰. 60% rupture occurred in unscarred uterus while as 40% occurred in scarred uterus (table 1) similar to the report of Khanam et al²¹ and 83 and 83.5% reported by Khan S et al²².

Availability of blood transfusion and timely referred to a tertiary care hospital will go a long way in reducing morbidity and mortality among the pregnant women with difficulties during labour. Availing antenatal care and identification of high-risk cases are most important for avoiding catastrophic outcomes. Injudicious use of oxytocics needed to be deplored. The main effort for reduction and prevention of this dramatic situation (in Kashmir) requires overall socioeconomic development with special emphasis on literacy of mother and efficient health care delivery system in rural area¹¹.