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Uterine rupture: a review of 15 cases at bandier maternity hospital in Somalia

Siddig Omer Handady

Department of Obstetrical and Gynecology Imperial Hospital, Khartoum, Sudan

Hajar Hassan Sakin

Department of Obstetrical and Gynecology Royal Hayat Hospital, Elkwait, Sudan

Awad Ali M. Alawad

Faculty of Medicine, University of Medical Sciences and Technology, Khartoum, Sudan

E-mail : awadali82@hotmail.com

DOI: 10.15761/COGRM.1000115

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Abstract

Background

 Uterine rupture is a deadly obstetrical emergency endangering the life of both mother and fetus.

Objective

To determine the frequency of ruptured uterus at Bandier Hospital and to elicit possible causes and type of management. 

Methods

It was cross sectional and hospital based descriptive study implemented during a time period of six months (July – December 2013) in Bandier maternity hospital and a total of 15 women presented with rupture uterus during the period of the study were included.

Results

There were 15 cases of ruptured uterus out of a total of 2142 deliveries. Incidence of uterine rupture was found to be 0.7%. The mean age of women was 30.03 ± 4.55 years. Concerning risk factors for rupture uterus, 10 (66.7%) had previous uterine surgery, obstructed labor was found in 33.3%, and oxytocin was used in 46.7% of respondents. Repair was done for 8 (53.3%), 3 (20.6%) of respondents underwent total abdominal hysterectomy and 4 (26.7%) were ended by subtotal hysterectomy. 

Conclusions

 Previous uterine surgery, obstructed labour and improper use of oxytocin increase the risk of uterine rupture in this study. Half of the patients underwent hysterectomy.

Key words

 uterine rupture, previous uterine surgery, obstructed labour

Introduction

Rupture uterus is a grave condition, which is almost always fatal for the fetus. Uterine rupture may develop as a result of preexisting injury like scar or perforation or anomaly [1]. It may be associated with trauma or it may complicate labour in a previously unscarred uterus. The most common cause of uterine rupture is dehiscence of a previous Caesarian section scar [2]. There are two types of uterine rupture, complete and incomplete, distinguished by whether or not the serous coat of the uterus is involved. In the former the uterine contents including fetus and occasionally placenta, may be discharged into the peritoneal cavity, whereas in the latter the serous coat is intact and fetus and placenta are inside the uterine cavity. The complete variety appears to be more dangerous of the two varieties. Rupture of uterus during labour is more dangerous than that occurring in pregnancy because shock is greater and infection is almost inevi.

Studies conducted in the developing world give strong evidence that uterine rupture is a major health problem in these countries with the rate being high in rural areas [1,3,4]. According to the World Health Organization “exploring factors which are beyond the biomedical causes will have essential implication for preventive programs in the developing countries'' [2]. The aim of the present study is to determine the incidence of ruptured uterus at Bandier Hospital and to elicit possible causes and type of management. 

Material and methods

 This study was conducted in Bandier maternity hospital in Maqdishue which is the largest referral hospital in Somalia for obstetrics and gynecological. It was cross sectional study conducted in six month (July – December 2013).  A probabilistic sample of 15 women of uterine rupture that arrived to or occurred in the hospital were collected, interviewed, examined and followed up. All patients were followed up until their discharge from the hospital. The questionnaire covered the following information: Reproductive characteristics, socio-demographic characteristics, the presenting complain, type of operation, maternal outcome and follow up characteristics. 

Data was entered into SPSS version 16 and analyzed accordingly. The quantitative variables were presented in mean and standard deviation and qualitative variables were presented in frequency and percentages. Important summary statistics were obtained and associations were examined using chi-square test. Significance level of 0.05 (i.e. P < 0.05) was used to determine the significance of associations being examined.

Ethical clearance and approval for conducting this research was obtained from the general manager of the hospital and informed written consent was obtained from every respondent who agreed to participate in the study. Of course, the respondents informed that the study is not associated with experimental or therapeutic intervention and information were collected from her. 

Results

The mean ages was 30.03 ± 3.15 years, the mean (SD) of parity was 6.2 ± 1. Regarding Gestational Age (GA), 3(20.0%) were at GA (37-39) weeks, 6 (40.0%) were at GA (40-20) weeks and 6(40.0%) were at GA more than 42 weeks. No any patients had regular antenatal care, 4 (26.7%) had irregular and 11 (73.3%) were without any antenatal car. The majority of respondents 10 (66.7%) were housewives, 1 (6.7%) were employer and 4 (26.7%) were worker. The majority of respondents 10 (66.7%) were illiterates, 2 (13.3 %) were primary and 3(20.0%) were secondary education ( 1).

Concerning risk factors for rupture uterus, ( 2) shows that 10 (66.7%) had previous Cesarean Section (CS), two of which was “classical”. Other previous surgeries were mainly curettage in 6 (40.0%) and myomectomy in 2 (13.3%), obstructed labor was found in 33.3 %, contracted pelvis in 26.7% of cases and oxytocin was used in 7 (46.7%) of respondents. With regard to methods of management done for respondents included in the study, repair was done for 8 (53.3%), 3(20.6%) of respondents underwent total abdominal hysterectomy and 4 (26.7%) were ended by subtotal hysterectomy and regarding intra operative complications 6 (40.0%) of patients were developed intra operative bleeding, one patient developed injury to the bladder and one maternal deaths due to massive bleeding. Concerning post-partum complications, about 86.6% patients in the study had transfusions of 500 - 1000 ml of blood before, after and during the operation, 2 (13.3%) of patients developed bleeding, one patient was developed pulmonary embolism and died 2nd day post-operative ( 3).

4 shows the overall managements in relation to parity .This trend was statistically significant, as P-value was < 0.05.

X2 = 25.123, P-value = 0.000

Discussion

Africa is the continent in the world mostly plagued with poverty and diseases. With only one years remaining to 2015, there are signs of progress in achieving the health-related Millennium Development Goals (MDGs) in some countries; while in other countries, like Somalia progress has been limited because of 22 years of civil war ,conflicts, poor governance, economic or humanitarian crises, lack of resources , lack of stability  and some entrenched cultural and traditional practices.

The most critical aspects of treatment in the case of uterine rupture are establishing a timely diagnosis and minimizing the time from the onset of signs and symptoms until the start of definitive surgical therapy. Once a diagnosis of uterine rupture is established, the immediate stabilization of the mother and the delivery of the fetus are imperative.  As a rule, the time available for successful intervention after frank uterine rupture and before the onset of major fetal morbidity is only 10-37 minutes. Therefore, once the diagnosis of uterine rupture is considered, all available resources must quickly and effectively be mobilized to successfully institute a timely surgical treatment that results in favorable outcomes for both the newborn and the mother. After the fetus is successfully delivered, the type of surgical treatment for the mother should depend on the following factors: type and extent of uterine rupture, degree of hemorrhage, general condition of the mother and mother's desire for future childbearing. Uterine bleeding is typically most profuse when the uterine tear is longitudinal rather than transverse. Conservative surgical management involving uterine repair should be reserved for women who have the following findings: desire for future childbearing, low transverse uterine rupture, no extension of the tear to the broad ligament, cervix, or paracolpos, easily controllable uterine hemorrhage ,good general condition and no clinical or laboratory evidence of an evolving coagulopathy [5]. Hysterectomy should be considered the treatment of choice when intrac uterine bleeding occurs or when the uterine rupture sites are multiple, longitudinal, or low lying [6]. Because of the short time available for successful intervention, the following 2 premises should always be kept firmly in mind. Maintain a suitably high level of suspicion regarding a potential diagnosis of uterine rupture, especially in high-risk patients, and when in doubt, act quickly and definitively.

The results of current study revealed that, the incidence of uterine rupture was 0.71% (15 in 2300 deliveries).  A finding that is inferior to other developing countries – 0.57% in Ethiopia and 0.45% in Morocco but very high to those reported by 0.086 % in Australia and 0.023 % in Ireland [7-10]. Regarding risk factors for rupture uterus, the present study showed obstructed labor due to cephalopelvic disproportion and mal presentation was the major direct factors for uterine rupture. Obstructed labor was found in 33.3% and contracted pelvis in 26.7% of cases. The malpresentation was very difficult to diagnose in some cases due to the uterus being already ruptured on admission. Obstructed labor can cause up to 93% uterine rupture as was reported in Ethiopia [7].  It is surprising to notice that, findings of the current study showed; poor practice of antenatal care services and more than two thirds of the respondents (73.0%) had never had any type of antenatal care during this pregnancy. The rest attended antenatal care to a different extent indicating poor health services (informational, financial or physical) that played a major role as a risk factor for uterine rupture.

The present study agrees with all previous studies and showed strong relation between previous surgery of uterus and rupture uterus [2,4,7,11,12]. A uterine scar from a previous cesarean sectionis the most common risk factor. Other forms of uterine surgery that result in full-thickness incisions (such as a myomectomy), dysfunctional labor, labor augmentation by oxytocin or prostaglandins, and high parity may also set the stage for uterine rupture. In 2008, an extremely rare case of uterine rupture in a first pregnancy with no risk factors was reported [13]. Overall, ten cases (66.7%) of uterine rupture in this study had a history of caesarean section, two of which was “classical”. Other previous surgeries were mainly curettage (40.0%) and myomectomy (13.3%). It could be concluded that more than two third of our patients had a surgical interference, which is considered a risk for rupture of the uterus. Moreover, trial of labor in previously scarred uteri following CS can be safe when observing a number of rules but unfortunately this study showed that these rules were often lost. Absence of continuous electronic fetal monitoring in labor, none accurate facilities ,environmental and cultural prejudices,  lack of remote settlements and anesthetic and blood-transfusion and absence of availability of comprehensive essential obstetric care as barriers hindering  from utilization these rules. The previous uterine surgery especially previous caesarean section and the augmentation of labor by oxytocin are interacting risks. Oxytocin infusion and prostaglandin vaginal application are other direct obstetrical risk factors for uterine rupture. This study showed about; 46.7% of the respondents were given this drug and very interested to notice that five cases with previous scar were used it by midwifes at home through intravenous infusion.  Also the current study find that bad practice of using oxytocin in labour ward in the hospital by midwifes without control or supervision increase rate of rupture uterus among women in this study .

About 86.6% patients in the study had received at least two units of   blood before, after and during the operation, though a majority of them had already low hemoglobin level before the operation. Blood availability is a real big problem in Somalia; although blood donors are available, no available kits or even bags and all patients included in this study received blood without screening.

Maternal outcome in this study showed two deaths due to massive post-partum hemorrhage and pulmonary embolism. Almost half of patients (50.0 %) had a repair of the rupture, 26.7 % had total hysterectomy, and 23.3% had subtotal hysterectomy. The causes of uterine rupture in Somalia can’t be defined on medical bases alone. There are causes behind causes. Lack of health centers, forces many of the women to turn to traditional birth attendants, some of whom are not skillful enough, and result in uterine rupture and maternal mortality. Conflict, civil war and lack of stability again, prevent most of the women from proper care of themselves during pregnancy. Women in Somalia have increased risk of uterine rupture because no access to the family planning services and Contraceptive Prevalence Rate 1.2%. The present paper focus on how rupture uterus was managed among women attending Bandier Hospital in Maqdeshue City.

Conclusion

The study concluded that conservative surgical management involving uterine repair was done for half of women and the rest were underwent hysterectomy. Parity ,obstructed labour, previous uterine surgery and previous Caesarean section scar specially if associated with the use of oxytocin  without proper care are common causes of  rupture uterus among Somali pregnant women.

References

  1. Fofie CO, Baffoe P (2010) A Two-Year Review of Uterine Rupture in a Regional Hospital. Ghana Med J 44: 98-102. [Crossref]
  2. Hofmeyr GJ, Say L, Gülmezoglu AM (2005) WHO systematic review of maternal mortality and morbidity: the prevalence of uterine rupture. BJOG 112: 1221-1228. [Crossref]
  3. Guise JM, McDonagh MS, Osterweil P, Nygren P, Chan BK, et al. (2004) Systematic review of the incidence and consequences of uterine rupture in women with previous caesarean section. BMJ 329: 19-25 [Crossref]
  4. Diaz SD, Jones JE, Seryakov M, Mann WJ (2002) Uterine rupture and dehiscence: ten-year review and case-control study. South Med J 95: 431-435.
  5. Al Qahtani NH, Al Hajeri F (2011) Pregnancy outcome and fertility after complete uterine rupture: a report of 20 pregnancies and a review of literature. Arch Gynecol Obstet 284: 1123-1126. [Crossref]
  6. Tae Sugawara, Masaki Ogawa, Toshinobu Tanaka (2014) Repair of Uterine Rupture during Second Trimester Leading to Successful Pregnancy Outcome: Case Study and Literature's Review. AJP Rep 4: 9-12. [Crossref]
  7. Khan S, Parveen Z, Begum S, Alam I (2003) Uterine rupture: a review of 34 cases at Ayub Teaching Hospital Abbottabad. J Ayub Med Coll Abbottabad 15: 50-52. [Crossref]
  8. Ekpo EE (2000) Uterine rupture as seen in the University of Calabar Teaching Hospital, Nigeria: a five-year review. J Obstet Gynaecol 20: 154-156. [Crossref]
  9. Valiton-CrusiA (1996) Uterine rupture: literature review and Genevan experience (1980-1994). Rev Med Suisse Romande 116: 273-276. [Crossref]
  10. Chen LH, Tan KH, Yeo GS (1995) A ten-year review of uterine rupture in modern obstetric practice. Ann Acad Med Singapore 24: 830-835. [Crossref]
  11. Koo FH, Chao ST, Wang PH, Wang HI, Shen SH, et al. (2014) Delayed postpartum hemorrhage secondary to idiopathic rupture of right uterine artery: a case report and literature review. Taiwan J Obstet Gynecol 53: 276-278. [Crossref]
  12. Hicks P (2005) Systematic review of the risk of uterine rupture with the use of amnioinfusion after previous cesarean delivery. South Med J 98: 458-461. [Crossref]
  13. Fatfouta I, Villeroy de Galhau S, Dietsch J, Eicher E, Perrin D (2008) Spontaneous uterine rupture of an unscarred uterus during labor: case report and review of the literature. J Gynecol Obstet Biol Reprod (Paris) 37: 200-203. [Crossref]

Editorial Information

Editor-in-Chief

Lee P. Shulman
Northwestern University

and

Amos Ber
Tel Aviv University

Article Type

Case Study

Publication history

Received date: July 13, 2015
Accepted date: August 28, 2015
Published date: August 31, 2015

Copyright

©2015 Handady SO. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Citation

Handady SO, Sakin HH, Alawad AAM (2015) Uterine rupture: a review of 15 cases at bandier maternity hospital in Somalia. Clin Obstet Gynecol Reprod Med 1: doi: 10.15761/COGRM.1000115

Corresponding author

Awad Ali M. Alawad

Faculty of Medicine, University of Medical Sciences and Technology, Khartoum, Sudan.

E-mail : awadali82@hotmail.com

Table 1. Shows demographic characteristics among patients (n = 15).

Variable

Frequency

Percentage

Age                

<20 years

20-30 years

31-40 years

>40 years

 

1

5

6

3

 

(06.7%)

(33.3%)

(40.0%)

(20.0%)

Occupation

House wife

Employer

Worker

 

10

1

4

 

(66.7)

(06.7%)

(26.7%)

Antenatal care

Regular

Irregular

None

 

0

4

11

 

(00.0%)

(26.7%)

(73.3%)

Education 

 Illiterate

Primary

secondary

 

10

2

3

 

 

(66.7%)

(13.3%)

(20.0%)

 

Gestational age                

<37weeks

37-39weeks

40-42weeks

>42weeks

 

0

3

6

6

 

(00.0%)

(20.0%) 

(40.0%)

(40.0%)

Parity                    

Primigravida

Multiparty

Grand   multiparty

 

1

5

9

 

(06.7%)

(33.3%)

(60.0%)

 

 

 

 

Table 2. Shows the distribution of the patientsaccording to the risk factors (n = 15).

Variable

Frequency

Percentage

Previous caesarean  section

Yes

No

 

10

5

 

(66.7%)

(33.3%)

No of previouscaesarean  section

1

2

3

>3

Total

 

4

3

2

1

10

 

(40.0%)

(30.0%)

(20. 0%)

(10 0%)

(100.0%)

Previous classical caesarean  section

Yes

No

Total

 

2

8

10

 

(20.0%)

(80.0%)

(100.0%)

Myomectomy

Yes

No

 

2

13

 

(13.3%)

(86.7%)

Uterine malformation

Yes

No

 

1

14

 

(06.7%)

(93.3%)

Duration of labour

<12 hours

12-24 hours

<24 hours

 

 

3

5

7

 

(20.0%)

(33.3%)

(46.7%)

Obstructed labour

Yes

No

 

5

10

 

(33.3%)

(66.7%)

Oxytocin use

Yes

No

 

7

8

 

(46.7%)

(53.3%)

Contracted pelvic

Yes

No

 

3

12

 

(20.0%)

(80.0%)

Curettage

Yes

No

 

6

9

 

(40.0%)

(60.0%)

 

Table 3. Shows distribution of the patients according to the management and outcome (n = 15).

Variable

Frequency

Percent

Management

Repair

Total Abd hysterectomy

Subtotal Abd hysterectomy

 

8

3

4

 

(53.3%)

(20.0%)

(26.7%)

Intra operative complications

Bleeding

Injury to other organ

No complication    

Death

 

6

1

7  

1

 

(40.0%)

(06.7%)

(46.6%)

(6.7%)

Post-operative complications

Bleeding

Infection

Pulmonary embolism

Death

None

 

2

5

1

1

6

 

(13.3%)

(33.3%)

(06.7%)

(06.7%)

(40.0%)

Post-operative care

Routine

HDU

ICU

 

10

5

0

 

(66.7%)

(33.3%)

(00.0%)

Site of uterine rupture

Anterior

Posterior

Other

 

6

7

2

 

(40.0%)

(46.6%)

(13. 4%)

Previous uterine rupture

Yes

No

 

                  1

14

 

(6.7%)

(93.3%)

Massive blood transfusion

Yes

No

 

13

2

 

(86.7%)

(13.3%)

 

 

 

Table 4. Shows a cross-tabulation between parity and overall management.

 

Overall management * Parity Cross-tabulation

 

Parity

Total

PG

Paras

Grandmultipra

Overall management 

Repair

1

3

4

8

Subtotal hysterectomy

0

2

2

4

Total Hysterectomy

0

0

3

3

Total

1

5

9

15

X2 = 25.123, P-value = 0.000