Rupture of the gravid uterus: a review

Abstract

A total of 105 patients were treated for ruptured gravid uteri at the Kenyatta National Hospital, Nairobi, Kenya, over a five year period, January, 1984 to December, 1988. During the same period, there were 44,156 deliveries, giving an incidence of uterine rupture of 1:425 deliveries. Of these, records for 95 patients were traced and analysed, and the results are presented here. Majority (61.0%) of these patients were aged less than 30 years, and 62.1% were gravida 5 or less. 54 (56.8%) of them had rupture of scarred uteri, 33 (34.7%) had spontaneous rupture, while 8 (8.4%) had traumatic rupture. 56 (59.0%) ruptured while at the Kenyatta National Hospital. Repair of the uterus without tubal ligation was the treatment offered to most of them, while total abdominal hysterectomy was rarely done. The perinatal case fatality rate was 60% and there were two maternal deaths giving a maternal case fatality rate of 2.1%. Factors associated with uterine rupture at the Kenyatta National Hospital are discussed, and possible ways of reducing the incidence suggested.

PIP: Physicians treated 105 patients with uterine rupture at Kenyatta National Hospital (KNH) in Nairobi, Kenya between January 1984-December 1988. The ruptured gravid uterus incidence during the study period was 1:425. 56.8% of the mothers were between 20-29 years old. 62.1% were gravida 5. 21.1% had received no prenatal care. 59% ruptured at this hospital. Adequate labor monitoring would have prevented rupturing. 56.8% experienced at least 1 previous cesarean section (C-section). Only 2 women had had a classical C-section. Moreover 21.1% of mothers who had prenatal care at KNH underwent a previous C-section. Perhaps health workers did not evaluate these women properly. 74% of the mothers were at least 38 weeks gestation. 34.7% had a spontaneous rupture due to prolonged labor (12 hours). 8.4% experienced a traumatic rupture. 94.7% happened during labor. Most of the tears (51.6%) occurred along the lower anterior uterine segment primarily on the transverse or on a C-section scar. Surgeons were able to repair the uterus without tubal ligation in 47.4% of the cases. They could repair the uterus of 11.6%, but also had to perform a tubal ligation. They conducted a partial hysterectomy on 38% and total hysterectomy on 3.2%. 38.9% gave birth to their infants vaginally. 55.8% of the mothers gave birth to a stillborn infant. 35.8% of the infants were delivered in good condition and survived. 4.2% were in poor condition and survived and 4.2% were in poor condition and died. All the infants in the peritoneal cavity were already dead, but not all of those in the uterus died. The case fatality rate stood at 60%. 2.1% of the mothers died, all after surgery. 1 mother actually died of injuries from an earlier assault. In conclusion, C-section was the major predisposing factor. Ruptured gravida uteri continued to be a major obstetric problem in Kenya.