Incidence and factors associated with outcomes of uterine rupture among women delivered at Felegehiwot referral hospital, Bahir Dar, Ethiopia: cross sectional study.

BACKGROUND: Maternal mortality is a major public health challenge in Ethiopia. Uterine rupture is an obstetrical emergency with serious undesired complications for laboring mothers resulting in fatal maternal and neonatal outcomes. Uterine rupture has been contributing to high maternal morbidity and mortality. However, there is limited research on the factors and management outcomes of women with uterine rupture. Understanding the factors and management outcomes might delineate strategies to support survivors. Therefore the aim of this study is to assess the incidence and factors associated with outcomes of uterine rupture among laboring mothers at Felegehiwot Referral Hospital in Bahir Dar City, Northwest Ethiopia. METHODS: This is a cross sectional study with retrospective facility based data collection technique. All pregnant women who were managed for ruptured uterus at Felegehiwot referral hospital from September 11 2012 to August 30 2017 were included. The chart numbers of the women collected from operation theatre registers. Their case folders retrieved from the medical records room for analysis. Using structured check list, information on their sociodemography, booking status, clinical features at presentation and the place of attempted vaginal delivery was extracted. Data on the intraoperative findings, treatment, and associated complications and outcomes also collected. The collected data cleaned, coded and entered into EPI- Info version (7.1.2.0) and then exported in to SPSS Version 20.0 for analysis. Statistical comparison was done using chi square (X2). Strength of association between the explanatory variables and outcome variables described using odds ratio at 95% CI and P value less than 0.05. The results presented in tables. RESULTS: We studied 239 cases of uterine rupture in the 5 years period. Mothers without previous cesarean delivery including eight primigravidas took 87% of the cases. From all study participants, 54 of mothers (22.6%) developed undesired outcomes whereas 185(77.4%) discharged without major sequel. More than half (56.9%) arrived in hypovolemic shock. Total abdominal hysterectomy was the commonest procedure accounting for 61.5%. Duration of surgery was less than 2 h in 67.8% of the procedures. Anemia is the commonest complication (80.3%) followed by wound infection and VVF (11.7% each). There were 5 maternal deaths (2.1%). Mothers who had prolonged operation time (> 2 h) (AOR: 2.2, 95% CI: 1.10, 4.63) were significantly associated with undesired maternal outcomes after management of uterine rupture. CONCLUSION: Incidence of ruptured uterus and its complications were high in the study area. It reflects the need for improvement in obstetric care and strong collaboration with referring health facilities to ensure prompt referral and management.

Maternal and fetal outcomes of uterine rupture and factors associated with maternal death secondary to uterine rupture.

BACKGROUND: Maternal mortality and morbidity are the priority agenda for sub-Saharan Africa including Ethiopia. Uterine rupture is the leading cause of maternal and fetal death in developing countries. Limited evidence is available on the magnitude of uterine rupture; maternal and fetal outcomes of uterine rupture and factors associated with maternal death secondary to uterine rupture in Ethiopia. This study aimed to assess the magnitude of uterine rupture; maternal and fetal outcome of uterine rupture and factors associated with maternal death secondary to uterine rupture in Debremarkos Referral Hospital, Northwest Ethiopia. METHODS: An institutional-based cross-sectional study was conducted in December 2015 in Debremarkos referral hospital, Northwest Ethiopia. A total of 242 records of mothers with uterine rupture at Debremarkos referral Hospital during the year 2011-2014 were included in the study. Secondary data was collected from the records of mothers admitted for the management of uterine rupture. Descriptive statistics were performed to characterize the study population. Bivariate and multivariable logistic regression model was fitted to identify factors associated with maternal death secondary to uterine rupture. Odds ratio with 95% confidence interval was computed to determine the level of significance. RESULTS: A total of 10,379 deliveries were attended A total of 242 uterine rupture cases were included in this study. The magnitude of uterine rupture was 2.44% (1 in 41 deliveries). Sixteen (6.6%) mothers died from uterine rupture. Fourteen (5.8%) had experienced Vesico Vaginal Fistula. The majority of the mothers, 72% (176), admitted for uterine rupture stayed in hospital for 6-10 days. Fetal outcome was grave, 98.3% (238) were stillborn. Place of labor [Adjusted odds ratio (AOR): 6.92, 95% confidence interval (CI): (1.16, 33.74)], occurrence of hypo volume shock [AOR: 3.48, 95% CI: (1.01, 11.96)] and postoperative severe anemia [AOR: 0.092, 95% CI: (0.01, 0.956)] were significantly associated with maternal death secondary to uterine rupture. CONCLUSION: The magnitude of uterine rupture was high in the study area. Initiation of labor at health institutions, early treatment of hypo-volumia and prevention of postoperative anemia is recommended to decrease maternal death secondary to uterine rupture.

High rate of uterine rupture in a conflict setting of Hajjah, Yemen.

A descriptive study was conducted to investigate the epidemiology and the outcome of uterine rupture at Hajjah Hospital, Yemen, during September 2014-August 2016. There were 110 cases of ruptured uterus and 3457 deliveries (31.8 per 1000 delivery). The majority (82, 74.5%) of these patients were illiterate. One hundred and four (96.3%) of them had no antenatal care. Seventy-eight of these women (70.9%) delivered at home and 32 (29.1%) delivered at hospital. Out of these 110 cases, 74 (67.3%) and 36 (32.7%) had unscarred uterus and scarred uterus, respectively. The causes of ruptured uterus were as follows: obstructed labour 59 (53.6%), previous caesarean delivery 36 (32.7%), use of oxytocin 10 (9.1%) and misoprostol 5 (4.6%). Hysterectomy was carried out in 50 (45.4%) %), repair in 39 (35.4%), repair with tubal ligation in 18 (16.4%) patients and 3 (2.7%) patients died before operation. There was 8 (7.2%) and 101 (91.8%) maternal and perinatal mortality, respectively. Nineteen (17.3%), 6 (5.4%) and 2 (1.8%) women developed sepsis, had urinary bladder injury and developed vesicovaginal fistulae, respectively.

Obstetric morbidity and socio-cultural predictors of ruptured uterus among women in Southeast Nigeria.

This study determined the incidence, obstetric morbidity and the socio-cultural factors associated with ruptured uterus. A 6-year prospective review of ruptured uterus and an enquiry into socio-cultural barriers to specialised care was conducted. The incidence of ruptured uterus was 12 per 1000 deliveries. Occurrence was common in uneducated (78/116; 67.2%), unbooked (110/116; 94.8%) and rural women (112/116; 96.6%). The major causes were prolonged obstructed labour (104/116; 89.7%) and injudicious use of oxytocics (90/116; 77.6%). The maternal and perinatal case fatality rates were 18.1% and 96.6%, respectively. Complications resulted from haemorrhage and sepsis. Lack of birth plan (97/116; 79.3%) and unskilled birth attendance (110/116; 94.8%) were major socio-cultural risk factors. There was an association between education (p = 0.001), parity (p = 0.002), residence (<0.001), type of birth attendance (<0.001) and ruptured uterus. Women in low-income settings face threats of complications and death from uterine rupture, owing to preventable socio-cultural barriers of accessing specialised obstetric care.

Gestational diabetes mellitus and late preterm birth: outcomes with and without antenatal corticosteroid exposure.

BACKGROUND: Unlike pregestational diabetes mellitus, the American College of Obstetricians and Gynecologists recommends antenatal corticosteroids in those with gestational diabetes mellitus at risk for preterm birth. However, this recommendation is based on limited data, only 10.6% of the Antenatal Late Preterm Steroids study sample had gestational diabetes mellitus. There is a paucity of data on the risk of neonatal respiratory and other morbidity in this population. OBJECTIVE: This study aimed to examine respiratory outcomes in parturients with gestational diabetes mellitus who received antenatal corticosteroids and delivered during the late preterm period vs those who did not. STUDY DESIGN: This population-based cohort study used the US Vital Statistics dataset between 2016 to 2020. The inclusion criteria were singleton, nonanomalous individuals who delivered between 34.0 to 36.6 weeks with gestational diabetes mellitus and known status of antepartum corticosteroid exposure. The primary outcome, a composite neonatal adverse outcome, included Apgar score <5 at 5 minutes, immediate assisted ventilation, assisted ventilation >6 hours, surfactant use, seizure, or neonatal mortality. The secondary outcome was a composite maternal adverse outcome, including maternal blood transfusion, ruptured uterus, unplanned hysterectomy, and admission to the intensive care unit. Multivariable Poisson regression models were used to estimate adjusted relative risks and 95% confidence intervals. Average annual percent change was calculated to assess changes in rates of corticosteroid exposure over the study period. RESULTS: Of 19 million births during the study period, 110,197 (0.6%) met the inclusion criteria, and among them, 23,028 (20.9%) individuals with gestational diabetes mellitus received antenatal corticosteroids. The rate of antenatal steroid exposure remained stable over the 5 years (APC=10.7; 95% confidence interval, -5.4 to 29.4). The composite neonatal adverse outcome was significantly higher among those who received corticosteroids than among those who did not (137.1 vs 216.5 per 1000 live births; adjusted relative risk 1.24; 95% confidence interval, 1.20-1.28). Three components of the composite neonatal adverse outcome-immediate assisted ventilation, intubation >6 hours, and surfactant use-were significantly higher with exposure than without. In addition, the composite maternal adverse outcome was significantly higher among those who received corticosteroids (adjusted relative risk, 1.34; 95% confidence interval, 1.18-1.52). Three components of the composite maternal adverse outcome-admission to intensive care unit, blood transfusion, and unplanned hysterectomy-were significantly higher among the exposed group. Subgroup analysis, among large for gestational age, by gestational age, and race and ethnicity, confirm the trend of increased likelihood of adverse outcomes with exposure to corticosteroid. CONCLUSION: Individuals with gestational diabetes mellitus and antenatal corticosteroid exposure, who delivered in the late preterm, were at higher risk of neonatal and maternal adverse outcomes than those unexposed to corticosteroid.

Uterine rupture in a term pregnancy after a previous uterine artery embolization to manage a large fibroid. A case report.

Uterine artery embolization (UAE) is an effective minimally invasive alternative to surgery for the treatment of symptomatic uterine fibroids. Uterine rupture is an obstetrical emergency that requires early diagnosis and prompt management to improve perinatal and maternal outcomes. A 33-year-old woman at 37 weeks of gestation who had had previous two uncomplicated vaginal deliveries at term presented with abdominal pain and rupture of membranes. The patient had undergone UAE for the management of a large anterior wall uterine fibroid three years prior to conception. Vaginal examination revealed cord prolapse and ultrasound showed negative fetal heart. Intrauterine fetal demise with cord prolapse was diagnosed. After admission the patient developed vaginal bleeding and features of hypovolemic shock. Urgent laparotomy revealed a ruptured uterus with a large hemoperitoneum and dead fetus in the abdominal cavity. Obstetricians should be attentive to the possibility of a spontaneous uterine rupture in pregnant women who have previously undergone UAE for the management of a uterine fibroid.

Case series of unscarred uterine rupture in primigravida.

Objective: To present a highly rare case series of uterine rupture in primigravida individuals with an unscarred uterus. Case: The unscarred uterus in primigravida patients is supposed to be impervious to rupture, yet we have four cases of ruptured uterus in primigravida patients in our institute over a three-year period (2018-2021). In this case series, the ruptured uterus was discovered in primigravida women with premature labour, obstructed labour, instrumental delivery, and abruptio placentae. In the absence of previous surgery or multiparity, uterine rupture may go unnoticed, resulting in late diagnosis and considerable mortality and morbidity. All four cases required immediate resuscitation and laparotomy; uterine repair was performed in three cases, although a peripartum hysterectomy was needed in one. Conclusion: Rupture uterus can occur even in the unscarred uterus of primigravida patients and early diagnosis and timely management can prevent high maternal mortality and morbidity.

Ruptured Rudimentary Horn Pregnancy Revealed on Emergency Laparotomy: A Case of Primigravida Presenting in a Developing Country.

Developmental defects in the Mullerian ducts can result in several uterine anomalies including a unicornuate uterus with a rudimentary horn. Pregnancy in a rudimentary horn is extremely rare occurring in 1:76,000-1:160,000 pregnancies. We present a case of an 18-year-old primigravida with a ruptured rudimentary horn pregnancy (RHP) presenting as acute abdomen at 17 weeks of gestation. Hemodynamic instability led us to perform a life-saving emergency laparotomy. A 1.5 liters hemoperitoneum was encountered with a ruptured non-communicating rudimentary horn. Excision of the horn and unilateral salpingectomy was performed. In addition to ectopic pregnancy and appendicitis, rare uterine anomalies must also be considered in patients presenting with an acute abdomen especially after 10 weeks of gestation. Basic diagnostic facilities may not be available in developing countries. Therefore, clinicians must be aware of this rare entity in order to manage such patients efficiently.

Unsafe abortion: Addressing the anaesthetic confronts.

Unsafe abortion has a global incidence of about 20 million cases annually, out of which 97% cases are reported from developing nations. There are many reports showing the occurrence of bowel or uterine perforation in such instances, but most of them have concentrated upon surgical or obstetric complications. We report a case of unsafe abortion with ruptured uterus, intra-abdominal foetus, and bowel infarction that developed intraoperative cardiac arrest during the emergency laparotomy. This case highlights anaesthetic challenges in managing such critically ill-patients.

Peripartum hysterectomy: two years experience at Nelson Mandela Academic hospital, Mthatha, Eastern Cape South Africa.

BACKGROUND: Obstetric haemorrhage is the leading direct cause of maternal mortality in South Africa. OBJECTIVE: To determine the incidence, indications, associations and maternal outcomes of emergency peripartum hysterectomies. METHODS: A descriptive and retrospective analysis of patients who had peripartum hysterectomy between 1(st) February 2007 and 31(st) January 2009 in Nelson Mandela Academic Hospital at Mthatha city. RESULTS: The incidence of 0.95% of peripartum hysterectomies (n=63 or 9.5/1000 births) increased with the increasing maternal age from 0.121% at age of less than 20 years to 0.5% at age more or equal to 30 years. Similarly the incidence increased with parity from 0.332% for Primiparity to 0.468% at parity of four or more. The indications for the operation were uterine atony 19/63 (30.2%), secondary haemorrhage/puerperal sepsis 17/63 (27%) and ruptured uterus 16/63 (23.4%). The main intra operative complication was haemorrhage 13/63 (20.6%). Repeat laparotomy was done in 10/63 (15%) of patients due to haemorrhage. Admission to intensive care unit was 25/63 (39.7%). The case specific mortality rate was of 19 % (n=12). The main causes of death were hypovolaemic shock and septicemia. CONCLUSION: The incidence of peripartum hysterectomies was high and was associated with ruptured uterus and puerperal sepsis which are preventable.

The spontaneous prelabour rupture of anunscarred uterus at 34 weeks of pregnancy.

Uterine rupture is an obstetric emergency needs immediate surgery and is associated with poor fetal & maternal outcome. Usually uterine rupture occurs at the lower segment (weakest part) if there is no history of uterine surgery. We hereby are reporting a case of spontaneous uterine rupture at fundus, at 34 weeks of gestation in a patient who has never had uterine surgery. Only uterine curettage was done once for missed abortion. In this case, diagnosis was delayed until the patient went into massive hemorrhagic shock; because, there was no history of previous uterine surgery. However, clinical picture of the ruptured uterus at the fundus suggests there was some weakness at the fundus. Thereafter, D & C operation was taken into account. Subtotal hysterectomy was done as the rupture was irreparable damage to the fundus. Her one month follow up was uneventful.

Emergency obstetric hysterectomy in a tertiary hospital in sokoto, Nigeria.

BACKGROUND: Emergency obstetric hysterectomy (EOH) is a life-saving procedure which is often performed to treat some obstetric complications, as a last resort, to prevent maternal mortality. OBJECTIVES: This study was designed to determine the rate, indications, and complications of the EOH procedure at Usmanu Danfodito University Teaching Hospital (UDUTH), Sokoto. MATERIALS AND METHODS: This retrospective study involved all the patients who had EOH at UDUTH, Sokoto, Nigeria, between January 2005 and December 2010. The case records of these patients were retrieved from the medical record library and information relating to age, parity, booking status, indications, type of hysterectomy, cadre of the surgeon, type of anesthesia, and complications of the procedure were extracted. The data were processed via SPSS version 11.5 and the χ(2) test was used to analyze some of the results with the confidence limit set at 95%. RESULTS: During the 6-year period, 83 EOH were performed out of 16,249 deliveries giving the rate of the former as 0.51%, i.e. 1 in 196 deliveries. However, the case records of only 74 patients (82.9%) were available for the study. The rate of EOH increased with advancing maternal age and increasing parity. The majority of the patients (89.2%) were unbooked for antenatal care, and the rate of the procedure among these patients (1.82%) was significantly higher than 0.07% observed amongst booked subjects (P<0.001). The main indication for the procedure was ruptured uterus (93.2%) and the majority of the patients (95.9%) had subtotal hysterectomy. Anemia (66.2%), excessive hemorrhage (35.5%), septicemia (18.9%), and wound infection (16.2%) were the leading complications. Excessive hemorrhage was significantly higher in the procedure performed by the senior registrars (51.2%) compared to those undertaken by consultants (16.2%); P=0.03. The case fatality rate of the EOH procedure was 12.1%. However, the case fatality rates in the procedure performed by consultants and senior registrars were 6.5% and 16.3%, respectively. CONCLUSION: The rate of EOH in the centre is relatively high and ruptured uterus is responsible for the majority of the procedure. Prevention of prolonged obstructed labor, and therefore uterine rupture, through antenatal care and supervision of labor will reduce the rate of EOH whereas performance of the procedure by the most experienced surgeon will minimize the maternal morbidity and mortality.

A ruptured uterus in a pregnant woman not in labor.

Reducing maternal mortality constitutes one of the eight Millennium Development Goals. While significant progress has been made, system issues and professional training continue to affect maternal survival, especially when unusual, but deadly, complications arise. This rare case of survival after the rupture of an unscarred uterus in a grand multiparous woman from a remote village in Ghana illustrates how systemic transportation issues and limited access to advanced medical care put women with obstetric complications at risk. The usual clinical presentation of ruptured uteri and methods to prevent this catastrophic event are discussed. This case illustrates the systemic transportation issue that often limits access to prenatal and emergency care throughout much of the developing world and demonstrates how advanced training for emergency nurses and the use of ultrasound diagnosis can expedite difficult diagnoses and lead to maternal survival, even in the most adverse circumstances.