Rupture of the uterus

Rupture of the uterus is a severe complication of pregnancy and childbirth. It can be spontaneous, arising without external influence, and violent - under the influence of extraneous interference; By the degree of damage - complete, capturing all the walls of the uterine wall, and incomplete, when the rupture captures the endometrium and myometrium, while the perimetry remains intact. Uterine ruptures occur with a spatial discrepancy between the present fetus and the pelvis (narrow pelvis, transverse fetal position), extensor and asynclital insertions of the head (large fetus, scarring of the soft tissues of the birth canal, pelvic tumors that prevent natural delivery). Uterine ruptures are also observed in pathological changes of its wall due to inflammatory and dystrophic processes, as well as for scar after cesarean section or operation of removal of fibroma nodes.

Symptoms, course. Distinguish threatening, started and completed rupture of the uterus. The threatening rupture proceeds clinically differently depending on the mechanism of rupture.

With a spatial discrepancy between the size of the fetus and the pelvis against the background of rough labor after the outflow of amniotic fluid, signs of overstretch of the lower uterine segment appear; The uterus stretches out in length, the contraction ring is high (at the level of the navel) and oblique, the contours of the uterus resemble an hourglass, the round uterine ligaments are strained and painful. When palpation of the lower uterine segment, tension and soreness are determined. The fruit is almost entirely located in the overgrown lower segment of the uterus. The lying-in woman is restless, rushes, screams, tries to push with the highly positioned part of the fetus. Intrauterine fetal asphyxia quickly occurs.

The clinical picture of a threatening rupture of the uterus, due to pathological changes in the uterine wall, is less characteristic, so it is more difficult to diagnose. Labor activity is weak, contractions are painful, despite the absence of regular labor. There is an involuntary and ineffective exertion activity with a high-standing head above the entrance to the small pelvis. There is a protrusion over the womb as a result of edema of paravezic fiber and overgrowth of the bladder. The lower uterine segment is less overextended and more painful than with a threatening rupture, due to a spatial discrepancy between the size of the fetus and the pelvis. For a threatening rupture of the uterus, the scar is characterized by thinning and local soreness of the scar in the area of ​​the emerging rupture. Of great importance for diagnostics are the indications in the anamnesis for the complicated course of the postoperative period with the secondary healing of the wound of the anterior abdominal wall.

The beginning of the rupture of the uterus is characterized by symptoms of a threatening rupture with the addition of signs indicating an increase in the uterine wall: the appearance of bloody discharge from the vagina, an admixture of blood in the urine, fetal asphyxia.

The ruptured uterus is accompanied by a typical clinical picture and usually does not cause difficulties in diagnosis. At the moment of rupture, the woman in labor feels a strong pain in her abdomen, labor activity stops, signs of shock appear. The fetus quickly dies in utero, there is flatulence, a symptom of Shchetkin - Blumberg, blood is released from the vagina. When the fetus passes into the abdominal cavity, the abdomen becomes irregular in shape, the small parts of the fetus are clearly palpable through the anterior abdominal wall. Sometimes the diagnosis of rupture of the uterus is put late - after the end of labor or during the first days of the postpartum period, which threatens the development of diffuse peritonitis and sepsis. In connection with this, the uterine rupture should be considered in those cases when the puerpera suddenly develop external bleeding after delivery and discharge after a well-contracted uterus. Suspicion of uterine rupture should occur with delayed afterbirth in the uterus and unsuccessful removal by the method of Krede-Lazarevich, after difficult obstetric operations (external-internal turn, fruit-destroying operations). In these cases, manual examination of the uterus can reveal a rupture.

Treatment. In case of a threatening and started rupture of the uterus, it is necessary to urgently stop the labor activity with the help of deep ether anesthesia (anesthesia should be started immediately). A woman in childbirth with a threatening and beginning rupture of the uterus is not transportable. The delivery is performed on site. The choice of an operative method of delivery depends on the obstetrical situation (caesarean section, fruit-destroying operation). A ruptured uterus requires immediate intubation without first removing the fetus. At the same time, measures are being taken to combat shock and collapse. The extent of surgical intervention depends on the duration of the rupture, signs of infection, the condition of the torn uterine tissue, the localization of the rupture (suturing of the uterus, supravaginal amputation of the uterus, extirpation of the uterus).

Prevention. All women with a history of obstetrical anamnesis (caesarean section, removal of myomatous nodes, perforation of the uterus during the abortion), having a narrow pelvis, incorrect fetal position, large fetus and other complications dangerous for rupture of the uterus are taken into special account and hospitalized For 2 weeks before childbirth. Obstetrical operations (turning and extraction of the fetus, application of obstetric forceps, vacuum extraction) should be carried out with strict account of conditions and indications.