Uterine rupture with an unscarred uterus

A previous post (and comment), led me to investigate this topic further. I’d heard of previous C-section scars giving way; and I’d heard of uterine rupture in the case of labor induction or augmentation; but I’d never heard of an unscarred uterus rupturing.

This study talks about it. Unfortunately, it is just an abstract, so I’ve got a few questions which I’m sure could be answered if I had access to the full study. Oh, well. It identified 13 ruptures in an unscarred uterus, and says 3 were caused by car wrecks, and were excluded from the study; oxytocin was used in 4 cases; prostaglandin in 3;  vacuum or forceps in 3; 2 were in women who were grand multiparas; and 2 had fetal malpresentation. It gave a rate of 1 uterine rupture in an unscarred uterus per 16,849 births. Questions I have include whether all of these ruptures were complete, or if some were dehiscence; and whether any of the women with an “unscarred uterus” had any prior uterine surgery (including a D&C, which carries with it a slight possibility of a punctured uterus). I’m assuming that all of the ruptures were complete, considering that in the study discussed in the previous post, all three uterine ruptures in unscarred uteri were complete. Of those three, two occurred in women with prior D&C, but one said she had had no prior uterine surgery.

The numbers above add up to more than 10, though, so I can’t tell from the abstract whether or not obstetric intervention was used in all of them, or if some women had both oxytocin induction or augmentation and forceps removal of the baby. It’s seems reasonable that the babies that were in a poor position were also more likely to have induction of labor or vacuum/forceps use, since such women tend to have longer and slower labors (probably the contractions help to guide the baby into a better position if given enough time; but many hospital and/or doctor protocols don’t allow that much time).

Moving along, there is this tantalizing abstract which talks about a woman whose uterus ruptured after misoprostol was used to induce labor at 29 weeks (for an intra-uterine fetal demise). It says it includes “a review of all cases of uterine rupture with misoprostol induction,” which I’d like to be able to see. There were numerous other case studies and reports of women who suffered a ruptured uterus with second-trimester abortions, typically associated with misoprostol use, sometimes with a previous C-section.

Here’s a second-trimester rupture due to placenta percreta (the placenta grew not just into the uterine lining which is normal, but through the uterine wall).

Here’s one due to fundal pressure (when the mom was pushing, somebody pressed on the top of her uterus, to “help” her push her baby out). The World Health Organization relegates this to “Practices for which Insufficient Evidence Exists to Support a Clear Recommendation and which Should be Used with Caution while Further Research Clarifies the Issue.”

This case was extremely interesting, in that the researchers said, “To the best of our knowledge, this is the first documented rupture of a gravid [pregnant] uterus occurring before onset of labour without previous risk factors.” The woman denied having a D&C or any previous abortions, didn’t have any uterine malformations or anything which were known risk factors. She went to the hospital at 32 weeks gestation because of sharp abdominal pain. Quite interesting, especially since it gives a short summary of various risk factors that other reports and studies have not mentioned. Mother and baby were fine.

This study from Ireland noted a rupture rate in unscarred uteri at 0.02% (8 cases out of more than 48,000 women who had had a previous pregnancy, not counting 0 cases out of nearly 28,000 first-time moms). But there is this case study in which a first-time mom had an unexplained uterine rupture.

This woman from California had her uterus rupture during second-stage labor (pushing), which was blamed on the rate of oxytocin (Pitocin, “Pit”) for labor induction. The researchers noted that despite having contractions every 2-3 minutes, the rate kept being increased during first- and second-stage labor. Although an emergency C-section was performed, the baby had signs of asphyxia.

So, rupture of an unscarred uterus can happen but is blessedly rare, especially when drugs used to induce or augment labor are avoided.

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4 Responses

  1. I find it interesting that induction agents lead to an increase risk of uterine rupture for ALL moms (scarred or unscarred uterus) yet OBs seem to use them without any warning to the mom. Some of these same OBs then refuse to allow a VBAC mom have a Trial of Labor because of increased risk of uterine rupture.

    It makes no sense!

  2. [...] is an elective C-section not elective? Posted on October 12, 2008 by Kathy In doing a recent post, I came across a case study about a woman whose uterus ruptured at 32 weeks for no apparent reason. [...]

  3. It’s crazy, isn’t it? Try saying “no” to an induction and you get branded by hospital staff as an uncaring mother with no concern for your baby’s life. When they mention uterine rupture as a possible risk, it’s glossed over like they don’t want you to notice it. And they sure don’t like you asking about any of the risks. They almost tried pushing me into a cesarean to prevent my baby needing a course of anti-biotics after she was born, knowing full well she was my first child. Luckily I dilated very quickly and avoided that fight. Considering I had made it to full term without a uterine rupture and through childbirth, I would be heartbroken to have to go through a pregnancy always with it in the back of my mind that my uterus could rupture at any time and my baby could possibly die from it. It seems to me that doctors involved in childbirth should be applying all their knowledge and training to prevent such complications instead of walking around with the attitude that whatever complications do arise can be fixed (albeit at a cost) or that the “small” mortality rate makes everything OK. I had a miscarriage and refused a D&C (which confused the doctors – obs) and my GP said that was probably the best desicion I could have ever made in my life. I wish GP’s could be more involved with childbirth. Yet mine said he couldn’t deliver my child. Police and firemen are trained to, but not my GP apparently. Pushing on a woman’s stomach??? Who oh who thought of that one??? Making women lie down when apparently childbirth is already dangerous? Why do ANYTHING to make contractions more intense than they already are? At the same time all we hear is the risks of natural birth. And to add insult to injury, the doctors on the radio blame women’s demands for the high intervention rate. Yet try saying “No” to anything unnatural in childbirth. That’s when the truth comes out.

  4. I see that your post is several years old, but I’m commenting because I’ve found so little on the internet about uterine rupture with no previous C-section.

    On June 13, my wife and I lost our full-term healthy baby boy during normal labor at the hospital after the head had crowned and the nurses were preparing to have her start pushing. She did have the pitocin, but they said not much, and an epidural. The OB-GYNs saved my wife’s life, is the only upside — that and our two previous healthy children, the first born with a difficult labor, the second much less so.

    I wish my baby had not asphyxiated, and I wish I understood how it happened.

    http://www.snyderfuneralhomes.com/obituaries/obit_view.phtml?id=13539

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