Complete Rupture of the Pregnant Uterus: A 10-year Retrospective Descriptive Study.

OBJECTIVE: The goal of this work is to analyze the incidence, etiology, clinical characteristics, maternal and neonatal outcomes of complete uterine rupture during pregnancy. METHODS: The information of complete uterine rupture between June 2010 and May 2020 was investigated retrospectively at a tertiary center, and included demographic data, delivery characteristics, intraoperative findings, and maternal and neonatal outcomes. The prevalence rate of uterine rupture in the early group (hospitalized from June 2010 to May 2015) and late group (June 2015 to May 2020) was compared and analyzed. RESULTS: There were 37 (0.056%) cases of complete uterine rupture in 66 092 births, including 27 (0.041%) of scar uterus and 10 (0.015%) of non-scarred uterus. High-risk factors for scarred uterine rupture included: previous cesarean section (13, 48.1%), myomectomy (8, 29.6%), corneal pregnancy resection (6, 22.2%), history of uterine rupture (1, 3.7%), and uterus perforation during abortion (1, 3.7%). Compared to the early group, the number of uterine ruptures caused by previous cesarean section was significantly reduced in the late group. Of the 10 patients with non-scarred uterine rupture, 3 (30%) occurred during delivery and 7 (70%) were spontaneous. Among the 37 complete rupture patients, 3 (8.1%) died of uterine scar rupture, 19 (51.3%) cases were reported with fetal/newborn deaths, 5 (13.5%) cases underwent hysterectomy and the rest were treated with uterine repair. CONCLUSION: Complete uterine rupture often has catastrophic effect on pregnancy outcomes. Obstetrics doctors should be vigilant to identify the risk factors and clinical presentations of uterine rupture during pregnancy. Strict prenatal management is beneficial to improve pregnancy outcomes.

Maternal and perinatal mortality and morbidity of uterine rupture and its association with prolonged duration of operation in Ethiopia: A systematic review and meta-analysis.

BACKGROUND: Uterine rupture is the leading cause of maternal and perinatal morbidity and it accounts for 36% of the maternal mortality in Ethiopia. The maternal and perinatal outcomes of uterine rupture were inconclusive for the country. Therefore, this systematic review and meta-analysis aimed to estimate the pooled maternal and perinatal mortality and morbidity of uterine rupture and its association with prolonged duration of operation. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist was used for this systematic review and meta-analysis. We systematically used PubMed, Cochrane Library, and African Journals online databases for searching. The Newcastle- Ottawa quality assessment scale was used for critical appraisal. Egger's test and I2 statistic used to assess the check for publication bias and heterogeneity. The random-effect model was used to estimate the pooled prevalence and odds ratios with 95% confidence interval (CI). RESULTS: The pooled maternal mortality and morbidity due to uterine rupture in Ethiopia was 7.75% (95% CI: 4.14, 11.36) and 37.1% (95% CI: 8.44, 65.8), respectively. The highest maternal mortality occurred in Southern region (8.91%) and shock was the commonest maternal morbidity (24.43%) due to uterine rupture. The pooled perinatal death associated with uterine rupture was 86.1% (95% CI: 83.4, 89.9). The highest prevalence of perinatal death was observed in Amhara region (91.36%) and the lowest occurred in Tigray region (78.25%). Prolonged duration of operation was a significant predictor of maternal morbidity (OR = 1.39; 95% CI: 1.06, 1.81). CONCLUSIONS: The percentage of maternal and perinatal deaths due to uterine rupture was high in Ethiopia. Uterine rupture was associated with maternal morbidity and prolonged duration of the operation was found to be associated with maternal morbidities. Therefore, birth preparedness and complication readiness plan, early referral and improving the duration of operation are recommended to improve maternal and perinatal outcomes of uterine rupture.

Determinants of Uterine Rupture and Its Management Outcomes among Mothers Who Gave Birth at Public Hospitals of Tigrai, North Ethiopia: An Unmatched Case Control Study.

INTRODUCTION: Uterine rupture is a leading cause of maternal death in Ethiopia. Despite strengthening the health care system and providing basic and comprehensive emergency obstetric care closer to the communities, uterine rupture continues to produce devastating maternal and fetal outcomes. Although risk factors of uterine rupture are context specific, there is lack of clarity in our context towards the contributing factors and untoward outcomes of uterine rupture. This study was conducted to identify the risk factors of uterine rupture and its impacts in public hospitals of Tigrai. OBJECTIVE: This study would identify determinant factors of uterine rupture and its management outcomes among mothers who gave birth in public hospitals in Tigrai region, North Ethiopia. METHOD: A retrospective hospital-based unmatched case control study design was implemented with 135 cases of women with uterine rupture and 270 controls of women without uterine rupture. Cases were enrolled consecutively from case notes of women who gave birth from 1/9/2015 to 30/6/2019, while charts (case note) of women without uterine rupture found following the cases were selected randomly and enrolled. Bivariate and multivariate logistic regression with 95% confidence interval was used to identify the determinants of uterine rupture. RESULT: Mothers referred from remote health institutions (AOR 7.29 (95% CI: 2.7, 19.68)), mothers who visited once for antenatal care (AOR 2.85 (95% CI: 1.02, 7.94)), those experiencing obstructed labor (AOR 13.33 (95% CI: 4.23, 42.05)), and birth weight of a newborn greater than four kilograms (AOR 5.68 (95% CI: 1.39, 23.2)) were significantly associated with uterine rupture. From 135 mothers who develop uterine rupture, 13 (9.6%) mothers died and 101 (74.8%) fetuses were stillborn. Obstetrical complications like abdominal hysterectomy in 75 (55.6%) of mothers and excessive blood loss in 84 (57.8%) were additional untoward outcomes of uterine rupture. CONCLUSION: Referrals from remote health institutions, once-visited antenatal care, obstructed labor, and birth weight of newborns greater than four kilograms were significant determinants of uterine rupture. Maternal death, stillbirth, hysterectomy, and hemorrhage were adverse outcomes. The findings of this study suggest early identification of factors that expose to uterine rupture during antenatal care, labor, and delivery must be attended to and further prospective studies are needed to explore predictors of untoward outcomes. Knowing the determinants of uterine rupture helps prevent the occurrence of a problem in pregnant women, which reduces maternal morbidity and mortality, and would have a tremendous help in identifying the best optional strategies in our current practices. This assertion was added to the abstract concluding session.

Magnitude and determinants of obstetric case fatality rate among women with the direct causes of maternal deaths in Ethiopia: a national cross sectional study.

BACKGROUND: In sub-Saharan Africa, maternal death due to direct obstetric complications remains an important health threat for women. A high direct obstetric case fatality rate indicates a poor quality of obstetric care. Therefore, this study was aimed at assessing the magnitude and determinants of the direct obstetric case fatality rate among women admitted to hospitals with direct maternal complications. METHODS: In 2015, the Ethiopian Public Health Institute conducted a national survey about emergency obstetric and newborn care in which data about maternal and neonatal health indicators were collected. Maternal health data from these large national dataset were analysed to address the objective of this study. Descriptive statistics were used to present hospital specific characteristics and the magnitude of direct obstetric case fatality rate. Logistic regression analysis was performed to examine determinants of the magnitude of direct obstetric case fatality rate and the degree of association was measured using an adjusted odds ratio with 95% confidence interval at p < 0.05. RESULTS: Overall, 335,054 deliveries were conducted at hospitals and 68,002 (20.3%) of these women experienced direct obstetric complications. Prolonged labour (23.4%) and hypertensive disorders (11.6%) were the two leading causes of obstetric complications. Among women who experienced direct obstetric complications, 435 died, resulting in the crude direct obstetric case fatality rate of 0.64% (95% CI: 0.58-0.70%). Hypertensive disorders (27.8%) and maternal haemorrhage (23.9%) were the two leading causes of maternal deaths. The direct obstetric case fatality rate varied considerably with the complications that occurred; highest in postpartum haemorrhage (2.88%) followed by ruptured uterus (2.71%). Considerable regional variations observed in the direct obstetric case fatality rate; ranged from 0.27% (95% CI: 0.20-0.37%) at Addis Ababa city to 3.82% (95% CI: 1.42-8.13%) at the Gambella region. Type of hospitals, managing authority and payment required for the service were significantly associated with the magnitude of direct obstetric case fatality rate. CONCLUSIONS: The high direct obstetric case fatality rate is an indication for poor quality of obstetric care. Considerable regional differences occurred with regard to the direct obstetric case fatality rate. Interventions should focus on quality improvement initiatives and equitable resource distribution to tackle the regional disparities.

Confidential enquiries into maternal deaths in Ondo State, Nigeria - a comparative analysis.

BACKGROUND: Paucity of data on state-wide maternal mortality in Nigeria hampers planning, monitoring and evaluation of the impact of interventions. The Confidential Enquiry into Maternal Deaths in Ondo State was initiated to overcome this problem. This study aimed to compare trends of maternal mortality ratios, causes of deaths, geographical distribution and other associated factors in 12-monthly reports of the Confidential Enquiry into Maternal Deaths in Ondo State. METHODS: Notification forms were distributed throughout the State to focal persons and medical records officers at community and facility levels, respectively. Maternal deaths, as defined in the International Classification of Diseases 10th version, were recorded prospectively over 3 years from 1st June 2012 to 30th May, 2015. Forms were submitted, collated and data analysed by a multidisciplinary review committee. RESULTS: Reported numbers of maternal deaths (and maternal mortality ratios) were 114 (253 per 100,000 births), 89 (192) and 81 (170), respectively per year, indicating a 33% reduction in maternal mortality ratio over the course of the study period. Assuming that the confidential enquiry process was the only intervention at the time aimed at reducing maternal mortality, simple linear regression with a correlation coefficient of 0.9314, showed a relationship though the difference in the values were not statistically significant (95% CI = - 184.55 to 101.55, p = 0.169). Postpartum haemorrhage and eclampsia were the leading causes of deaths. CONCLUSION: There was a trend of reduction in maternal mortality ratio during the period of study with postpartum haemorrhage as the major cause of death. The positive association between the confidential enquiry reports and maternal mortality ratios make us recommend that our model be adopted in other states and at the federal level.

Maternal near-miss and death among women with rupture of the gravid uterus: a secondary analysis of the Nigeria Near-miss and Maternal Death Survey.

OBJECTIVE: To investigate the burden of maternal near-miss and death due to rupture of the gravid uterus, the indicators of quality of care, and avoidable factors associated with care deficiencies for ruptured uterus in Nigerian tertiary hospitals. DESIGN: Secondary analysis of a nationwide cross-sectional study. SETTING: Forty-two tertiary hospitals. POPULATION: Women admitted for pregnancy, childbirth or puerperal complications. METHODS: Cases of severe maternal outcome [SMO: maternal near-miss (MNM) or maternal death (MD)] following uterine rupture were prospectively identified over 1 year. MAIN OUTCOME MEASURES: Incidence of SMO, indicators of quality of care, and avoidable factors associated with deficiencies in care. RESULTS: There were 91 724 live births and 3285 women with SMO during the study period. SMO due to uterine rupture occurred in 392 women: 305 MNM and 87 MD. Uterine rupture accounted for 11.9, 13.3, and 8.7% of all SMO, MNM, and MD, respectively. SMO, MNM, and intra-hospital maternal mortality ratios due to uterine rupture were 4.3/1000 live births, 3.3/1000 live births, and 94.8/100 000 live births, respectively. Mortality index (% of MD/SMO) was 22.2%, and MNM:MD ratio was 3.5. Avoidable factors contributing to deaths were related to patient-orientated problems, especially late hospital presentation and lack of insurance to cover life-saving interventions. Medical personnel problems contributed to care deficiencies in one-third of women who died. CONCLUSION: Uterine rupture significantly contributes to SMO in Nigerian tertiary hospitals. Strategies to improve maternal survival should address avoidable institutional factors and include community-based interventions to encourage skilled attendance at birth and early referral of complications. TWEETABLE ABSTRACT: Uterine rupture remains an important cause of maternal death in Nigerian tertiary hospitals.

Maternal and perinatal outcomes of uterine rupture in a tertiary care hospital: a cross-sectional study.

Objective: The current study aims to evaluate the incidence, maternal and perinatal outcomes in cases presented with uterine rupture (UR) and to explore the differences in presentation, management and outcome of UR in patients with scarred versus unscarred uterus. Materials and methods: A cross-sectional study conducted in a tertiary care hospital over a period of 2 years. The study included all women diagnosed with UR and admitted to the emergency unit between January 2016 and December 2017. A structured questionnaire was used to collect the preoperative demographic and clinical data. An observation checklist was used for intraoperative findings and management. Postoperative data were collected about maternal and fetal outcomes. Data were analyzed using SPSS software. Qualitative variables were compared between groups using chi-square test while quantitative variables were compared using the Mann-Whitney test. Results: Sixty two women were diagnosed with uterine rupture (0.32% of all deliveries). The mean age of the included patients was 29.6 ± 5.6 years while the mean parity was 3.0 ± 1.8. Uterine repair was successful in 52 cases (83.9%). There were four (6.5%) maternal deaths and 42 (67.8%) perinatal deaths. Ten patients (16.1%) were transferred to the postoperative intensive care unit (ICU). Re-exploration was carried out in three cases. The most common complication of UR was disseminated intravascular coagulopathy (DIC) occurred in eight women (12.9%). Maternal and perinatal mortality were significantly higher in patients with unscarred uterus (p = .0001 and .026, respectively). Conclusions: The incidence of UR is 32/10,000 deliveries in our tertiary hospital. Rupture of unscarred uterus is associated with more maternal and fetal mortality. However, rupture of scarred uterus was more common due to the rising rate of cesarean sections.

[Uterine rupture of the unscarred uterus: A report of 10 cases]. / Rupture utérine sur utérus non cicatriciel : à propos de 10 cas.

INTRODUCTION: Uterine rupture in the healthy uterus is a rare obstetrical complication, not much suspected and with badly identified risk factors. Thus, there exists frequent delay for treatment and therefore fetal-maternal important morbidity and mortality. This article describes clinical signs and symptoms, management, and maternal and neonatal prognosis of uterine rupture. METHODS: Descriptive retrospective study within 13 maternity hospitals, reporting 10 series of cases of uterine rupture on gravid healthy uterus during the third trimester of pregnancy. RESULT: The incidence was 2.8/100,000 births. Surgical treatment was conservative in 9 out of 10 cases, the maternal prognosis was good with no maternal deaths and 6 out of 7 patients had at least one subsequent pregnancy. The fetal prognosis was more reserved, with 2 fetal or neonatal deaths and 1 with motor disability. 6/6 patients (100%) had at least one iterative Caesarean section during the following pregnancies with healthy fetuses. CONCLUSION: In this series of 10 cases over 25years, maternal-fetal morbidity and mortality were significant, in agreement with the literature. Maternal prognosis remained favorable. When surgical treatment is conservative a subsequent pregnancy is possible and an iterative cesarean section must be performed.

A Two-Year Analysis Of Uterine Rupture In Pregnancy.

BACKGROUND: Uterine rupture, an obstetrical emergency though rare but still has grave implications. Uterine rupture is the occurrence of breach in the wall of uterus. Complete rupture involves complete disruption of uterine wall resulting in spillage of uterine contents into the abdominal cavity whereas an incomplete rupture has intact peritoneum or serosa. The most commonly reported risk factor in developed countries is previous caesarean section whereas in developing countries neglected and obstructed labour are more frequently reported predisposing factors. METHODS: This was a cross sectional descriptive study which was carried out for a period of 2 years from January 2015 to December 2016 in Gynae "A" unit of Ayub Teaching Hospital Abbottabad. RESULTS: In our study frequency of uterine rupture was 0.63%. Previous scar dehiscence was the most common risk factor for uterine rupture. Maternal mortality was 4% out of total 52 ruptured uterus, while 94.2% was perinatal mortality. CONCLUSION: Although uterine rupture can be prevented but its frequency is still high. Therefore, proper antenatal care, health education, utilisation of health facilities is needed to reduce adverse outcome associated with this avoidable condition..

Severe maternal outcomes and quality of care at district hospitals in Rwanda- a multicentre prospective case-control study.

BACKGROUND: Despite a significant decrease in maternal mortality in the last decade, Rwanda needs further progress in order to achieve Sustainable Development Goals (SDG)3 which addresses among others maternal mortality. Analysis of severe maternal outcomes (SMO) was performed to identify their characteristics, causes and contributory factors, using standard indicators for quality of care. METHODS: A prospective case-control study was conducted for which data were collected between November 2015 and April 2016 in four rural district hospitals. The occurrence of SMO with near miss incidence ratios was established, followed by an analysis of the characteristics, clinical outcomes, causes and contributory factors. RESULTS: The SMO incidence ratio was 38.4 per 1000 live births (95% CI 33.4-43.4) and the maternal near-miss incidence ratio was 36 per 1000 live births (95% CI 31.1-40.9). The leading causes of SMO were postpartum haemorrhage (23.4%), uterine rupture (22.9%), abortion related complications (16.8%), malaria (13.6%) and hypertensive disorders (8.9%). The case fatality rate was high for women with hypertensive disorders (10.5%; CI 3.3-24.3) and severe postpartum haemorrhage (8%; CI 0.5-15.5). Stillbirth (OR = 181.7; CI 43.5-757.9) and length of stay at the hospital (OR = 7.9; CI 4.5-13.8) were strongly associated with severe outcomes. CONCLUSIONS: Despite the use of life saving interventions, SMO are frequent. Mortality index was found to be low at the level of district hospitals. SMO were associated with long stay at the hospital and stillbirth. There is a need for improvement of quality of care, referral practices and certain types of infrastructure, especially blood banks, which would ensure truly comprehensive emergency obstetric care and reduce the occurrence of SMO.

Institutional maternal and perinatal deaths: a review of 40 low and middle income countries.

BACKGROUND: Understanding the magnitude and clinical causes of maternal and perinatal mortality are basic requirements for positive change. Facility-based information offers a contextualized resource for clinical and organizational quality improvement. We describe the magnitude of institutional maternal mortality, causes of death and cause-specific case fatality rates, as well as stillbirth and pre-discharge neonatal death rates. METHODS: This paper draws on secondary data from 40 low and middle income countries that conducted emergency obstetric and newborn care assessments over the last 10 years. We reviewed 6.5 million deliveries, surveyed in 15,411 facilities. Most of the data were extracted from reports and aggregated with excel. RESULTS: Hemorrhage and hypertensive diseases contributed to about one third of institutional maternal deaths and indirect causes contributed another third (given the overrepresentation of sub-Saharan African countries with large proportions of indirect causes). The most lethal obstetric complication, across all regions, was ruptured uterus, followed by sepsis in Latin America and the Caribbean and sub-Saharan Africa. Stillbirth rates exceeded pre-discharge neonatal death rates in nearly all countries, possibly because women and their newborns were discharged soon after birth. CONCLUSIONS: To a large extent, facility-based findings mirror what population-based systematic reviews have also documented. As coverage of a skilled attendant at birth increases, proportionally more deaths will occur in facilities, making improvements in record-keeping and health management information systems, especially for stillbirths and early neonatal deaths, all the more critical.

Estimates of Uterine Rupture Bad Outcomes Using Propensity Score and Determinants of Uterine Rupture in Mizan-Tepi University Teaching Hospital: Case Control Study.

BACKGROUND: Uterine rupture is a tear in the wall of uterus which carries grave risks to the mother as well as her baby. OBJECTIVES: To estimate uterine rupture bad outcomes using propensity score and its determinants in Mizan-Tepi University teaching hospital. METHODS: A case control study on 363 participants, 121 cases and 242 controls, was conducted. Data was analyzed by STATA 14. Propensity score matching analysis was used to see causes. Level of significance of p value is ≤0.05. RESULTS: Females who reside in rural areas (AOR = 3.996; 95% CI: 2.011, 7.940) are at higher risk of acquiring uterine rupture. Females who had ANC follow-up (AOR = 0.315; 95% CI: 0.164, 0.606) and preterm gestational age (AOR = 0.135; 95% CI: 0.025, 0.725) are at lower risk of developing uterine rupture. Propensity score matching analysis shows that, from 100 participants who had uterine rupture, 88.4 females lost their fetus (ß = 0.884; 95% CI: 0.827, 0.942). From 100 females who develop uterine rupture, 9.1 died (ß = 0.091; 95% CI: 0.040, 0.142). From 100 females who develop uterine rupture, 97.5 developed additional obstetric complication (ß = 0.975; 95% CI: 0.947, 1.000). CONCLUSION: Residence, ANC follow-up, and gestational age are significant determinants of uterine rupture. Fetal loss, maternal death, and obstetric complications are significant bad outcomes of 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.

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.

Silent uterine rupture in scarred uterus.

Uterine rupture in pregnancy is a rare and catastrophic complication with a high incidence of fetal and maternal morbidity. Very few cases have been reported in the literature. CASE PRESENTATION: A 28-year-old fifth gravid woman with a history of one caesarean section presented to our department at 39 weeks and 6 days gestation with complaints of headache, epigastric pain and nausea. Her blood pressure was elevated and there was proteinuria. Emergency caesarean section was performed in view of symptoms. Uterine rupture was found during the surgery. A live male infant was delivered in good condition. Postnatal recovery was unremarkable and the woman discharged on postoperative day 5. CONCLUSION: Rupture of the uterus can present in third trimester even before labour with minimal or no symptoms.

Nationwide population-based cohort study of uterine rupture in Belgium: results from the Belgian Obstetric Surveillance System.

OBJECTIVES: We aimed to assess the prevalence of uterine rupture in Belgium and to evaluate risk factors, management and outcomes for mother and child. DESIGN: Nationwide population-based prospective cohort study. SETTING: Emergency obstetric care. Participation of 97% of maternity units covering 98.6% of the deliveries in Belgium. PARTICIPANTS: All women with uterine rupture in Belgium between January 2012 and December 2013. 8 women were excluded because data collection forms were not returned. RESULTS: Data on 90 cases of confirmed uterine rupture were obtained, of which 73 had a previous Caesarean section (CS), representing an estimated prevalence of 3.6 (95% CI 2.9 to 4.4) per 10 000 deliveries overall and of 27 (95% CI 21 to 33) and 0.7 (95% CI 0.4 to 1.2) per 10 000 deliveries in women with and without previous CS, respectively. Rupture occurred during trial of labour after caesarean section (TOLAC) in 57 women (81.4%, 95% CI 68% to 88%), with a high rate of augmented (38.5%) and induced (29.8%) labour. All patients who underwent induction of labour had an unfavourable cervix at start of induction (Bishop Score ≤7 in 100%). Other uterine surgery was reported in the history of 22 cases (24%, 95% CI 17% to 34%), including 1 case of myomectomy, 3 cases of salpingectomy and 2 cases of hysteroscopic resection of a uterine septum. 14 cases ruptured in the absence of labour (15.6%, 95% CI 9.5% to 24.7%). No mothers died; 8 required hysterectomy (8.9%, 95% CI 4.6% to 16.6%). There were 10 perinatal deaths (perinatal mortality rate 117/1000 births, 95% CI 60 to 203) and perinatal asphyxia was observed in 29 infants (34.5%, 95% CI 25.2% to 45.1%). CONCLUSIONS: The prevalence of uterine rupture in Belgium is similar to that in other Western countries. There is scope for improvement through the implementation of nationally adopted guidelines on TOLAC, to prevent use of unsafe procedures, and thereby reduce avoidable morbidity and mortality.

Emergency Peripartum Hysterectomy: A Multicenter Study of Incidence, Indications and Outcomes in Southwestern Nigeria.

Objective To determine the incidence, indications and outcomes of emergency peripartum hysterectomy (EPH) in three tertiary institutions in south-west Nigeria between January, 2010 and December , 2013. Methods A retrospective review of all cases of EPH over a 4 year period was done. EPH was defined as hysterectomy performed at the time of delivery or within 24 h of delivery for uncontrollable postpartum bleeding not responsive to conservative measures. Relevant information was extracted from the hospital records and operation notes. Statistical analysis was done using SPSS software version 17.0. Statistical significance was set at p < 0.05. Results There were 102 EPHs performed among 39,738 deliveries within the study period, giving a rate of 2.6 per thousand deliveries. Indications were uterine rupture (44.1 %), uterine atony (37.3 %), morbidly adherent placenta (17.6 %) and extension of caesarean section incision involving the uterine arteries (1 %). Subtotal hysterectomy was performed in most cases (67.6 %).Maternal case fatality rate was 11.8 % and perinatal mortality rate was 55.9 %. Blood transfusion, severe postoperative anaemia, wound sepsis, febrile morbidity and acute kidney injury were common morbidities associated with the procedure. Following multivariate logistic regression, the unbooked status [odds-ratio 95 % CI = 12.80 (1.22-133.97) p = 0.03] was the only variable that significantly predicted maternal death. Conclusion The incidence of EPH from our study is high. Much more needs to be done in maternal health services, particularly provision of quality obstetric care to reduce the rates of EPH and the associated high maternal and perinatal morbidity and mortality.

Maternal near misses from two referral hospitals in Uganda: a prospective cohort study on incidence, determinants and prognostic factors.

BACKGROUND: Maternal near misses occur more often than maternal deaths and could enable more comprehensive analysis of risk factors, short-term outcomes and prognostic factors of complications during pregnancy and childbirth. The study determined the incidence, determinants and prognostic factors of severe maternal outcomes (near miss or maternal death) in two referral hospitals in Uganda. METHODS: A prospective cohort study was conducted between March 1, 2013 and February 28, 2014, where cases of severe pregnancy and childbirth complications were included. The clinical conditions included abortion-related complications, obstetric haemorrhage, hypertensive disorders, obstructed labour, infection and pregnancy-specific complications such as febrile illness, anemia and premature rupture of membranes. Near miss cases were defined according to the WHO criteria. Multivariate logistic regression analysis was conducted to identify prognostic factors for severe maternal outcomes. RESULTS: Of 3100 women with severe obstetric complications, 130 (4.2%) were maternal deaths and 695 (22.7%) were near miss cases. Severe pre-eclampsia was the commonest morbidity (incidence ratio (IR) 7.0%, case-fatality rate (CFR) 2.3%), followed by postpartum haemorrhage (IR 6.7%, CFR 7.2%). Uterine rupture (IR 5.5%) caused the highest CFR (17.9%), followed by eclampsia (IR 0.4%, CFR 17.8%). The three groups (maternal deaths, near misses and non-life-threatening obstetric complications) differed significantly regarding gravidity and education level. The commonest diagnostic criteria for maternal near miss were admission to the high dependency unit (HDU) or to the intensive care unit (ICU). Thrombocytopenia, circulatory collapse, referral to a more specialized unit, intubation unrelated to anaesthesia, and cardiopulmonary resuscitation were predictive of maternal death (p < 0.05). Gravidity (ARR 1.4, 95% C1 1.0-1.2); elevated serum lactate levels (ARR 4.5, 95% CI 2.3-8.7); intubation for conditions unrelated to general anaesthesia (ARR 2.6 (95% CI 1.2-5.7), cardiovascular collapse (ARR 4.9, 95% CI 2.5-9.5); transfusion of 4 or more units of blood (ARR 1.9, 95% CI 1.1-3.1); being an emergency referral (ARR 2.6, 95% CI 1.2-5.6); and need for cardiopulmonary resuscitation (ARR 6.1, 95% CI 3.2-11.7), were prognostic factors. CONCLUSIONS: The analysis of near misses is a useful tool in the investigation of severe maternal morbidity. The prognostic factors for maternal death, if instituted, might save many women with obstetric complications.

Maternal and perinatal outcomes associated with a trial of labour after previous caesarean section in sub-Saharan countries.

OBJECTIVE: To assess the risks of uterine rupture, maternal and perinatal outcomes associated with a trial of labour (TOL) after one previous caesarean were compared with having an elective repeated caesarean section (ERCS) without labour in low-resource settings. DESIGN: A prospective 4-year observational study. SETTING: Senegal and Mali. SAMPLE: A cohort of 9712 women with one previous caesarean delivery. METHODS: Maternal and perinatal outcomes were compared between 8083 women who underwent a TOL and 1629 women who had an ERCS. Perinatal and maternal outcomes were then stratified according to the presence or absence of risk factors associated with vaginal birth after caesarean section. These outcomes were adjusted on maternal, perinatal and institutional characteristics. MAIN OUTCOME MEASURES: The risks of uterine rupture, maternal complication and perinatal mortality associated with TOL after one previous caesarean as compared with ERCS, RESULTS: The risks of hospital-based maternal complication [adjusted odds ratio (OR) 1.52; 95% CI 1.09-2.13; P = 0.013] and perinatal mortality (adjusted OR 4.53; 95% CI 2.30-9.92; P < 0.001) were significantly higher in women with a TOL compared with women who had an ERCS. However, when restricted to low-risk women, these differences were not significant (adjusted OR 0.90, 95% CI 0.55-1.46, P = 0.68, and adjusted OR 1.13; 95% CI 0.75-1.86; P = 0.53, for each outcome, respectively). Uterine rupture occurred in 25 (0.64%) of 3885 low-risk women compared with 70 (1.66%) of 4198 women with unfavourable risk factors. CONCLUSION: Low-risk women have no increased risk of maternal complications or perinatal mortality compared with women with one or more unfavourable factors. TWEETABLE ABSTRACT: Low-risk women have a lower risk of maternal complications or perinatal mortality compared with high-risk women.

[Vaginal birth after caesarean section in out-of-hospital settings: a literature review]. / Literaturstudie zur vaginalen Geburt bei Status nach Sectio caesarea in der außerklinischen Geburtshilfe.

BACKGROUND: Even though vaginal birth after Caesarean section (VBAC) is recommended, an out-of-hospital setting is discussed controversially. First of all, uterine rupture and placental complications are named. Nevertheless, an increasing number of women with a prior Caesarean section decide to give birth in an out-of-hospital setting. What is the maternal and neonatal outcome in international studies in these cases? METHOD: The databases of Medline, Cinahl, Embase and Cochrane Library on vaginal birth after Caesarean section in out-of-hospital settings were searched. Included are studies in German and English language without a limit on year of publication, which describe maternal and neonatal outcomes. RESULTS: 5 studies were found. All of them describe a high VBAC rate (73.5-98%). Only one study found uterine ruptures. Haemorrhage/placental complications were described in 2 studies (0.5 and 1.7%). None of the studies found maternal deaths. Neonatal death was described in 3 studies in a range from 0 -1.7%. DISCUSSION: There is a wide difference in the population of the studies. An important difference is the parity of the women and the prior mode of birth. 4 of the 5 studies do not see a reason not to try VBAC in an out-of-hospital setting. Further studies are necessary to inform the increasing number of women who decide to try VBAC in an out-of-hospital setting.