Original Research ajog.

org

OBSTETRICS
Infant outcome after complete uterine rupture
Iqbal Al-Zirqi, MD, FRCOG, PhD; Anne Kjersti Daltveit, PhD; Siri Vangen, MD, PhD

BACKGROUND: Complete uterine rupture is a rare peripartum
complication often associated with a catastrophic outcome for both mother
and child. However, little has been written based on large data sets about
maternal and infant outcome after complete ruptures. This is partly due to
the rarity of the event and the serious maternal and infant outcome; it is also
partly due to the use of international diagnostic codes that do not differ-
entiate between the less catastrophic partial rupture and more catastrophic
complete uterine rupture. As uterine rupture is expected to increase due to
increased cesarean delivery rates worldwide, it is important to know more
completely about the outcome following complete uterine rupture.
OBJECTIVE: We sought to explore risk factors associated with poor
infant outcome in cases of complete uterine rupture.
STUDY DESIGN: This population-based study used data from the
Medical Birth Registry of Norway, the Patient Administration System, and
medical records. We included births with complete uterine rupture after
start of labor in all maternity units in Norway during the period 1967
through 2008 (n ¼ 244 births), identified among 2,455,797 births.
Uterine ruptures were identified and further studied through a review of
medical records. We estimated the associations between infant outcomes
and demographic and labor risk factors using logistic regression analyses.
Odds ratios with 95% confidence intervals for each risk factor were
determined after adjustment for demographic factors and period of birth.
The main outcome measure was infant outcome: healthy infant, intra-
partum/infant deaths, hypoxic ischemic encephalopathy, and admission to
the neonatal intensive care unit.
RESULTS: We identified 109 (44.7%) healthy infants, 56 (23.0%)
infants needing neonatal intensive care unit admission, 64 (26.2%)
intrapartum/infant deaths, and 15 (6.1%) infants with hypoxic ischemic
encephalopathy. The highest number of intrapartum/infant deaths
occurred in 1967 through 1977 (51.6%) and the fewest in 2000 through
2008 (15.0%). Unscarred uterine ruptures did not significantly increase
intrapartum/infant deaths compared to scarred uterine ruptures. Placental
separation and/or fetal extrusion had the highest odds ratio for intra-
partum/infant deaths (odds ratio, 17.9; 95% confidence interval,
7.5e42.4). Time-to-delivery interval <20 minutes resulted in fewest
intrapartum/infant deaths (9.9%), although there were 2 deaths at
10-minute interval. Time to delivery >30 minutes vs <20 minutes
increased risk of death (odds ratio, 16.7; 95% confidence interval,
6.4e43.5).
CONCLUSION: Intrapartum/infant death after complete uterine
rupture decreased significantly over the decades. Time to delivery >30
minutes and placental separation and/or fetal extrusion had the highest
association with intrapartum/infant deaths after complete uterine rupture.
Time to delivery <20 minutes limited the incidence of intrapartum/infant
deaths.
Key words: complete uterine rupture, hypoxic ischemic encephalopa-
thy, infant extrusion, infant outcome, intrapartum/infant death, placental
separation, risk factors, scarred uteri, time-to-delivery interval, unscarred
uteri

Introduction
Complete uterine rupture is a rare peri-
partum complication often associated
with a catastrophic outcome for both
mother and child.1 A scarred uterus,
predominantly due to a previous cesar-
ean delivery (CS), substantially increases
the risk of uterine rupture.1,2 Previous
studies describing maternal and peri-
natal outcomes after complete uterine
rupture are limited, most likely due to
the rarity of the event. Most previous
studies were based on registries using
international diagnostic codes that did
not differentiate between complete and
Cite this article as: Al-Zirqi I, Daltveit AK, Vangen S.
Infant outcome after complete uterine rupture. Am J
Obstet Gynecol 2018;219:109.e1-8.
0002-9378/$36.00
ª 2018 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.ajog.2018.04.010
partial rupture. Basing studies on clinical
records often results in a small sample
underpowered for detecting any associ-
ations between risk factors and out-
comes following the rare event of uterine
rupture. Previous studies have generally
concentrated on the outcome of uterine
rupture only in scarred uteri, and few
have described the outcome in unscarred
uteri.3-5 To achieve a large sample, we
studied complete rupture of scarred and
unscarred uteri after the start of labor
over 41 years based on population-based
registry data. All medical records were
reviewed for accuracy of diagnosis. In
Norway, all mothers with 1 previous CS
are offered a trial of labor unless there is
an absolute contraindication against
vaginal delivery. The trial of labor rate
after previous CS is high with 64%.6
Among those with a trial of labor, 80%
undergo vaginal birth. We published
earlier an article about risk factors for
complete uterine rupture using a
validated population of 22 out of a total
of 48 maternity units in Norway in 1967
through 2008.7 In this current study, we
used the total pregnant population of all
48 units, to get a larger sample of com-
plete uterine ruptures. Our aim was to
explore risk factors of poor infant out-
comes after complete uterine rupture.
Materials and Methods
Overview
All cases of uterine rupture after the start
of labor were identified through diag-
nostic codes in the Medical Birth Regis-
try of Norway (MBRN) (1967 through
2008, from all 48 maternity units
in Norway) and the Patient Adminis-
tration System (PAS) (1970 through
2008, from 21 units only). Established
in 1967, the MBRN contains informa-
tion on all births in Norway >16 weeks
of gestation. The midwives attending
a birth complete and send a stan-
dardized MBRN form within 7 days after

JULY 2018 American Journal of Obstetrics & Gynecology 109.e1

Original Research OBSTETRICS ajog.org

(reference) and nonscarred; maternal

AJOG at a Glance age, categorized into <35 and 35 years;
Why was this study conducted? parity, categorized into para 1-2 (refer-
This study was conducted to determine the risk factors associated with poor ence), para 0, and para 3; sudden loss
infant outcome in cases with complete uterine rupture. of contractions; prolonged second stage
of labor (from complete dilatation of
Key findings cervix to delivery of infant), defined as
Suspected diagnosis to delivery time <20 minutes limited the incidence of duration, in nulliparous as >2 hours
perinatal deaths, although there were 2 deaths at 10-minute interval, and no (without epidural) and >3 hours (with
deaths <10 minutes. epidural), and in multiparous as >1
hour (without epidural) and >2 hours
What does this add to what is known? (with epidural); mode of delivery, cate-
Suspected diagnosis to delivery time >30 minutes, placental separation, loss of gorized into delivery by emergency
uterine contractions, and delivery after midnight significantly increased perinatal CS (reference), instrumental vaginal
deaths, which nonetheless were decreasing in recent years. delivery, and noninstrumental vaginal
delivery; placental separation and/or
fetal extrusion (yes or no); and time of
delivery. The PAS is a local registry at Measures delivery, grouped into 08:00-15:00
each maternity unit that maintains re- The 4 infant outcome measures, each (reference), 15.00-24:00, and 24:00-
cords of all diagnoses for inpatients categorized as Yes or No, included healthy 08:00 hours.
since 1970. infant (not requiring admission to the In addition, we calculated the time
In the MBRN, the internal code used neonatal intensive care unit [NICU]); from clinical suspicion of uterine
for uterine rupture before 1999 was 71; NICU admission due to severe asphyxia rupture to delivery of the infant in
from 1999 and onwards, diagnostic codes without encephalopathy or other causes; minutes, as identified in the medical
from the International Statistical Classifi- intrapartum/infant death, excluding records. The symptoms or signs of sus-
cation of Diseases, 10th Revision8 were those due to congenital malformations; pected rupture were: maternal and fetal,
used (O710, O711). In the PAS, uterine and hypoxic ischemic encephalopathy fetal signs only on cardiotocography
rupture was identified by International (HIE), defined by the pediatrician as signs (CTG) (abnormalities), maternal symp-
Classification of Diseases, Adapted, 8th of cerebral irritation or depression or toms/signs only (defined as acute
Revision9 codes 956 (1967 through 1978); seizures in the presence of asphyxia with abdominal pains, vaginal bleeding, or
International Classification of Diseases, no resulting death. Infants admitted to preshock or shock), or none (defined as
Ninth Revision10 codes 6650 and 6651 the NICU for other causes were those undocumented maternal or fetal symp-
(1979 through 1998); and International admitted for any cause, excluding those toms or signs). Time to delivery was
Statistical Classification of Diseases, 10th with HIE or neonatal deaths. Intrapartum categorized later into <20 minutes
Revision8 codes O710 and O711 (1999 death is intrauterine fetal death during (reference), 20-30 minutes, and >30
through 2008). These codes did not labor; infant death was defined as death minutes. Furthermore, we studied the
specify rupture type. The type of rupture after birth until 1 year old (excluding association between time to delivery
(complete or partial) was identified in the deaths due to congenital malformations). stratified into the presence or absence of
medical records using our definition of Cerebral irritation was defined by placental separation and/or fetal extru-
complete rupture as rupture of all uterine national consensus as a stage-1 encepha- sion, grouped into the following: no
wall layers, including serosa and amniotic lopathy, and cerebral depression as placental separation and/or fetal extru-
membranes. stage-2 encephalopathy.12 Cerebral sion and time <20 minutes (reference),
All births with uterine rupture iden- sequelae after HIE was defined as a per- placental separation and/or fetal extru-
tified after the start of labor were studied manent brain injury or impairment due sion and time <20 minutes, no placental
further by the first author by reading the to HIE as diagnosed by a pediatrician later separation and/or fetal extrusion and
medical records of mothers, after visiting in childhood. Such impairment can time 20-30 minutes, placental separation
maternity units in Norway. Only those include epilepsy, developmental delay, and/or fetal extrusion and time 20-30
with complete ruptures were included in motor impairment, neurodevelopmental minutes, no placental separation and/or
the study.11 In addition, the first author delay, and cognitive impairment. fetal extrusion and time >30 minutes,
studied the pediatric notes written about Potential risk factors included periods and placental separation and/or fetal
all births with ruptures and the medical of birth, grouped into first period extrusion and time >30 minutes.
records of infants who required follow- (1967 through 1977), second period
up up to the age of 5 years. (1978 through 1988), third period (1989 Data analysis
The Regional Ethics Committee through 1999), and fourth period (2000 The incidences of outcomes were
(2010/1609-4) and the Data Inspectorate through 2008) (reference); uterine wall obtained from frequency tables. Cross-
of Norway approved the study. integrity, categorized into scarred tabulation and logistic regression

109.e2 American Journal of Obstetrics & Gynecology JULY 2018

ajog.org
FIGURE
Infant outcome after complete uterine rupture
Infant outcomes after complete uterine rupture (N ¼ 244 births).
NICU, neonatal intensive care unit.
Al-Zirqi et al. Infant outcome in complete uterine rupture. Am J Obstet Gynecol 2018.
models were used to measure the asso-
ciation between different demographic
and labor risk factors and different
infant outcomes. Factors that were sig-
nificant in bivariate analysis were
included in separate multiple regression
models adjusted for demographic factors
(maternal age, parity, unscarred uterus,
and periods of birth). Separate logistic
regression models were used to estimate
the association between time to delivery
in minutes (continuous and categorical)
and each infant outcome.
Cross-tabulation was used to measure
the association between the variable time
to delivery and each of the infant out-
comes in separate models stratified for
placental separation/fetal extrusion. The
level of significance was set to P < .05.
All analyses were performed using soft-
ware (SPSS, Version 21; IBM Corp,
Armonk, NY).
Results
We identified 253 births with complete
ruptures among 2,455,797 births recor-
ded in 1967 through 2008 (0.1/1000).
Nine of these births were antepartum
fetal deaths and were excluded.
The final sample included 244 births
(184 from the 48 units registered in
MBRN and 60 from the 21 units in the
OBSTETRICS
PAS), comprising 106 live births and 38
intrapartum deaths.
Among 244 infants, 138 (56.5%) were
gestational age 37-40 weeks, 94 (38.5%)
41 weeks, 11 (4.5%) 28-36 weeks, and
1 (0.4%) 23-28 weeks. The number of
complete ruptures was highest (120) in
2000 through 2008 and lowest (20) in
1978 through 1988. Among 164 with
scarred uteri, there were 157 who had 1
previous CS, 3 who had 2 previous CS,
and 4 had non-CS scars from myomec-
tomy or tubal corneal resection. Eighty
mothers had unscarred uteri.
Compared to scarred uteri, unscarred
uteri ruptures were detected significantly
more often postpartum at laparotomy
(51.3% vs 20.7%, P < .001).
In all, 109 (44.7%) healthy infants did
not require admission to the NICU, 56
(23.0%) infants required NICU admis-
sion for severe asphyxia only or other
causes, 64 (26.2%) infants were classified
as intrapartum/infant deaths presum-
ably due to the hypoxic effects of uterine
rupture, and 15 (6.1%) surviving infants
had HIE (Figure). Only 2 of the infants
with HIE had cerebral sequelae diag-
nosed by 5 years of age. Among the 64
deaths, 38 died intrapartum, 25 during
the neonatal period (within 28 days),
and 1 at 2 months old.
JULY 2018 American Journal of Obstetrics & Gynecology
Original Research
A total of 169 ruptures were detected
intrapartum during emergency CS, and
75 were detected postpartum at lapa-
rotomy after vaginal delivery. The
symptoms and signs of rupture in each
group are provided in Table 1. The
most CTG abnormality noticed was
fetal bradycardia; maternal symptoms
were mainly abdominal pain, feeling
unwell, and having tachycardia or signs
of shock. Few presented with vaginal
bleeding (10%), as most of bleeding
was intraabdominal (concealed). The
majority presented with combined se-
vere pains and CTG changes. Those
who had epidural during labor did not
present with less pain than those
without epidural. Those 9 who had no
symptoms or signs documented had CS
done due to prolonged labor. Fetal signs
only were detected in a significantly
larger percentage (60%) in 2000
through 2008 compared with 1967
through 1977 (11.4%). Mothers with
detected ruptures postpartum had
significantly higher percentage of
maternal symptoms or signs vs mothers
with detected ruptures intrapartum.
The median time from suspected
rupture to delivery was 20 minutes (Q1:
15, Q3: 30). From the time of clinically
suspected uterine rupture, 91 infants
were delivered <20 minutes, 104
delivered 20-30 minutes, and 49 deliv-
ered >30 minutes. We found that time-
to-delivery interval >30 minutes was
significantly higher in 1967 through
1977 at 35.5% (vs 2000 through 2008 at
11.7%; P < .005).
Tables 2 and 3 shows the association
between demographic and labor risk
factors and infant outcome after com-
plete rupture. Compared to ruptures in
2000 through 2008, the occurrence of
ruptures in 1967 through 1977 signifi-
cantly increased the risk of intra-
partum/infant death by 6.0 times, and
decreased the percentage of healthy in-
fants and admission to the NICU by
60% each. Ruptures in unscarred uteri
resulted in slightly higher intrapartum/
infant deaths than ruptures in scarred
uteri, but this association was not sta-
tistically significant. Intrapartum/infant
death was significantly increased by
sudden loss of contractions and parity
109.e3
Original Research OBSTETRICS ajog.org

times vs delivery between 08:00-15:00

TABLE 1
hours (Table 3).
Symptoms or signs of uterine rupture in 244 births with complete uterine
There were 9 intrapartum/infant
rupture
deaths at time interval <20 minutes
Rupture detected Rupture detected (Table 4); 2 of them were at 10-minute
intrapartum postpartuma interval, and were associated with
n ¼ 169 n ¼ 75 P placental separation. Time to delivery
Symptoms/signs N % N % >30 minutes significantly increased the
None 9 5.3 0 0.0 NA risk of intrapartum/infant death by 16.7
b times vs delivery <20 minutes even after
Fetal only 35 20.7 0 0.0 NA
correcting for periods of birth. Regres-
Maternal onlyb 23 13.6 26 34.7 <.001 sion analysis with time to delivery as a
Maternal and fetal 102 60.4 49 65.3 .9 linear term estimated that every addi-
NA, nonapplicable. tional minute of time until delivery is
a
Detected through laparotomy after vaginal delivery (noninstrumental or instrumental vaginal); b Fetal: cardiotocography associated with an approximate 10%
changes, in majority bradycardia followed by late and complicated variable decelerationsematernal: acute abdomen or increase in intrapartum/infancy death,
preshock/shock or vaginal bleeding.
Al-Zirqi et al. Infant outcome in complete uterine rupture. Am J Obstet Gynecol 2018. 5% decrease in delivering a healthy in-
fant, and 5% increase in admission to the
NICU.
We found 84 cases with placental
3 (47% with unscarred uterus) vs odds ratio [OR], 0.1; 95% confidence separation and/or fetal extrusion. This
parity 1-2. Prolonged second stage of interval, 0.03e0.5). Placental separation resulted in 25 (96.2%) deaths and only
labor significantly increased the risk of and/or fetal extrusion occurred in 1 healthy infant when time to delivery
HIE by 4.5 times. Ruptures detected 34.4% of complete ruptures and was >30 minutes (Table 5). When
after noninstrumental vaginal delivery increased risk of intrapartum/infant time to delivery was <20 minutes,
resulted in significantly lower percent- deaths by 17.1 times. Delivery time af- placental separation and/or fetal
age of intrapartum/infant deaths vs ter midnight significantly increased the extrusion resulted in 5 intrapartum/
ruptures detected during CS (adjusted risk for intrapartum/infant death by 4.3 infant deaths and 4 cases of HIE.

TABLE 2
Association between demographic risk factors and infant outcomes following complete uterine rupture (N [ 244)
Hypoxic ischemic NICU, severe
Healthy infant Intrapartum/infant death encephalopathy asphyxia only/others
N ¼ 109 N ¼ 64 N ¼ 15 N ¼ 56
N (%) AORa (95% CI) N (%) AORa (95% CI) N (%) AORa (95% CI) N (%) AORa (95% CI)
Periods of birth
2000 through 2008, n ¼ 120 60 (50.0) 1 18 (15.0) 1 10 (8.3) 1 32 (26.7) 1
1967 through 1977, n ¼ 62 21 (33.9) 0.4 (0.2e0.9) 32 (51.6) 6.0 (3.0e12.2) 3 (4.8) 0.4 (0.1e1.9) 6 (9.7) 0.4 (0.1e0.9)
1978 through 1988, n ¼ 20 11 (55.0) 1.1 (0.4e2.8) 6 (30.0) 2.4 (0.8e7.1) 0 (0) NA 3 (15.0) 0.6 (0.1e2.1)
1989 through 1999, n ¼ 42 17 (40.5) 0.6 (0.3e1.3) 8 (19.0) 1.3 (0.5e3.3) 2 (4.8) 0.5 (0.1e2.4) 15 (35.7) 1.7 (0.8e3.6)
Unscarred uterus
No, n ¼ 164 72 (43.9) 1 38 (23.2) 1 10 (6.1) 1 44 (26.8) 1
Yes, n ¼ 80 37 (46.3) 1.5 (0.8e2.7) 26 (32.5) 0.7 (0.4e1.6) 5 (6.3) 1.5 (0.4e5.3) 12 (15.0) 0.6 (0.3e1.4)
Parity
1e2, n ¼ 185 86 (46.5) 1 39 (21.1) 1 12 (6.5) 1 48 (25.9) 1
0, n ¼ 16 11 (68.8) 2.8 (0.8e9.2) 3 (18.8) 0.5 (0.1e2.2) 1 (6.3) 0.9 (0.1e9.7) 1 (6.3) 0.3 (0.03e2.3)
3, n ¼ 43 12 (27.9) 0.5 (0.2e1.1) 22 (51.2) 3.3 (1.5e7.3) 2 (4.7) 1.5 (0.1e2.9) 7 (16.3) 0.7 (0.3e1.7)
AOR, adjusted odds ratio; CI, confidence interval; NICU, neonatal intensive care unit.
a
Adjusted to each other.
Al-Zirqi et al. Infant outcome in complete uterine rupture. Am J Obstet Gynecol 2018.

109.e4 American Journal of Obstetrics & Gynecology JULY 2018

ajog.org OBSTETRICS Original Research

When time to delivery was >30 mi-

nutes without placental separation

AORa (95% CI)

1.1 (0.4e2.6)

1.1 (0.5e2.1)

1.2 (0.6e2.0)

0.6 (0.3e1.4)
0.7 (0.3e1.6)
and/or fetal extrusion, there were 9
(39.1%) deaths. The OR for having a
NICU, severe asphyxia

healthy infant after placental separa-

tion and/or fetal extrusion >30 mi-
1

1
nutes was 0.02 (95% confidence
only/others

47 (23.0)
9 (22.5)

36 (23.4)
20 (22.2)

35 (21.9)
20 (23.8)

15 (26.8)
24 (21.1)
17 (23.0)
interval, 0.01e0.1) vs no placental
N ¼ 56
N (%)

separation and/or fetal extrusion and

delivery <20 minutes.

4.5 (1.4e14.6) Comment

2.5 (0.5e13.0)
AOR (95% CI)

2.4 (0.7e8.8)

1.6 (0.5e4.8)

1.3 (0.2e6.8)
Principal findings
Complete uterine rupture in Norway
was associated with a large percentage of
Hypoxic ischemic

1
intrapartum/infant deaths (26.2%),
encephalopathy

especially in 1967 through 1977 (51.6%).

The most recent study period (2000
4 (10.0)

10 (11.1)
11 (5.4)

5 (3.2)

9 (5.6)
6 (7.1)

2 (3.6)
6 (5.3)
7 (9.5)
N ¼ 15
Association between labor risk factors and infant outcomes following complete uterine rupture (N [ 244)

N (%)

through 2008) was associated with less

mortality (15.0%). Unscarred uterine
ruptures did not significantly increase
intrapartum/infant deaths compared to
17.1 (7.2e40.5)

4.3 (1.6e11.1)
AORa (95% CI)

scarred uterine ruptures. Parity 3,

2.9 (1.3e6.4)

1.4 (0.7e2.7)

2.8 (0.8e9.2)

sudden loss of contraction, delivery after

Intrapartum/infant death

midnight, placental separation, and/or

infant extrusion significantly increased
1

the risk of intrapartum/infant deaths,

particularly when the time from rupture
44 (21.6)
20 (50.0)

36 (23.4)
28 (31.1)

17 (10.6)
47 (56.0)

9 (16.1)
28 (24.6)
27 (36.5)
N ¼ 64

to delivery exceeded 30 minutes. Time

N (%)

interval <20 minutes had least intra-

partum/infant deaths. For every addi-
tional minute, there was a 10% increase
0.08 (0.04e0.1)

in intrapartum/infant deaths and 5%

AORa (95% CI)

0.2 (0.1e0.6)

0.5 (0.3e0.9)

0.8 (0.4e1.6)
0.4 (0.1e0.8)

decrease in the delivery of a healthy

infant.
Al-Zirqi et al. Infant outcome in complete uterine rupture. Am J Obstet Gynecol 2018.

Meaning of the findings/clinical

1

1
Healthy infant

implications
AOR, adjusted odds ratio; CI, confidence interval; NICU, neonatal intensive care unit.

Our present results confirmed the result

102 (50.0)
7 (17.9)

77 (50.0)
32 (35.6)

99 (61.9)
10 (11.9)

30 (53.6)
56 (49.1)
23 (31.1)
N ¼ 109

of our previous study performed only on

N (%)

21 units in Norway, showing increased

rupture rates in recent years, yet
decreased incidence of intrapartum/
Placental separation and/or infant extrusion

infant death following such ruptures

Adjusted for demographic factors in separate models.

with time.13 In comparison to 3 previous

studies in developed countries, we found
in total a greater percentage of intra-
partum/infant deaths (26.2%), even
when limiting the results to 2000
Prolonged second stage

15:00e24:00, n ¼ 114
08:00e15:00, n ¼ 56

24:00e08:00, n ¼ 74

through 2008 (15%),4,5,14 Zwart et al4

Loss of contractions

included all births in the Netherlands

Time of delivery

in 2004 through 2006 and found a

No, n ¼ 204

No, n ¼ 154

No, n ¼ 160
Yes, n ¼ 40

Yes, n ¼ 90

Yes, n ¼ 84
TABLE 3

perinatal mortality of 8.7% following

210 uterine ruptures. Barger et al5
included all births in Massachusetts in
a

1990 through 1998 and found a 6.8%

JULY 2018 American Journal of Obstetrics & Gynecology 109.e5

Original Research OBSTETRICS ajog.org

perinatal mortality or poor prognosis at

discharge following 176 ruptures. Bujold

0.95 (0.92e0.98)
and Gauthier14 reported (4.7%)

AORb (95% CI)

0.8 (0.4e1.6)
0.3 (0.1e0.8)
neonatal death following 23 ruptures in
1988 through 2000. Ofir et al1 included

NICU, severe asphyxia

.003
1 area in Israel in 1988 through 1999

1
and found almost a similar percentage
only/others as ours (19.0%) for 42 ruptures. Meth-
odological aspects such as sample size

27 (29.7)
24 (23.1)
5 (10.2)
N ¼ 56
N (%) and ascertainment of cases and out-
comes could affect the precision of re-
sults. We cannot exclude, however, that
we in reality may have higher perinatal

0.99 (0.95e1.1)
0.3 (0.04e3.1) deaths following complete ruptures than
AORb (95% CI)

1.6 (0.5e5.0)
encephalopathy, no death

these countries of previous studies. Most

of our perinatal deaths were in the first
period of birth (1967 through 1977),
.63
Hypoxic ischemic

when also the time to delivery >30 mi-

1

nutes was more prevalent, indicating

suboptimal management of labor. In our
N ¼ 15

5 (5.5)
9 (8.7)
1 (2.0)
N (%)

study, the percentage of healthy infants

increased as intrapartum/infant death
decreased with time, indicating
improved obstetric management as well
Intrapartum/infant deatha N ¼ 64

1.10 (1.07e1.1)
16.7 (6.4e43.5)

advances in neonatal resuscitation. The

1.8 (0.7e4.4)
AORb (95%CI)

prevalence of HIE is expected to increase

as a result of fewer deaths. However, the
<.001

absolute number of HIE cases was very

1

small, and most of them recovered

without sequelae.
Ruptures in unscarred, compared to
21 (20.2)
34 (69.4)
9 (9.9)

scarred, uteri were not significantly

N (%)

associated with more serious infant

outcomes, which is in agreement with
some previous studies3,5,15 but contra-
dicts 2 other studies.4,16 Our study has
0.95 (0.93e0.98)

Al-Zirqi et al. Infant outcome in complete uterine rupture. Am J Obstet Gynecol 2018.

the largest sample of unscarred uteri

0.7 (0.4e1.3)
0.2 (0.1e0.4)
AORb (95%CI)

ruptures (80 cases compared to 25, 27,

AOR, adjusted odds ratio; CI, confidence interval; NICU, neonatal intensive care unit.
Excluding deaths due to congenital malformations; b Adjusted for periods of birth.

and 36 cases in Zwart et al,4 Ofir et al,3

<.001
Time-to-delivery interval and infant outcomes

and Barger et al,5 respectively). We

1

were expecting deaths to be higher

Healthy infant

among ruptures of unscarred uteri due

to a commonly lower index of suspicion
50 (54.9)
50 (48.1)
9 (18.4)
N ¼ 109

and consequent delay in delivery. How-

N (%)

ever, this was not the case here, which

may be explained by many unscarred
uterine ruptures in our study being
Time to delivery, categories

detected postpartum, indicating that

rupture occurred shortly before deliv-
20e30 min, n ¼ 104

Time to delivery, min

ering the infant, with a short duration of

hypoxia. Parity 3 and sudden loss of
<20 min, n ¼ 91

>30 min, n ¼ 49

contractions were associated with

TABLE 4

P for trend

increased intrapartum/infant deaths in

our study; we speculate that less vigi-
lance from health personnel in such
a

groups may play a role. The highest risk

109.e6 American Journal of Obstetrics & Gynecology JULY 2018

ajog.org OBSTETRICS Original Research

TABLE 5
Association between placental separation and/or fetal extrusion combined with time to delivery and infant outcome
(N [ 244 births)
Hypoxic ischemic NICU, severe
Healthy Intrapartum/ encephalopathy, asphyxia
infant infant death no death only/others
N ¼ 109 N ¼ 64a N ¼ 15 N ¼ 56
No placental separation and/or fetal extrusion, < 20 min, n ¼ 58 42 (72.4) 4 (6.9) 1 (1.7) 11 (19.0)
Placental separation and/or fetal extrusion, <20 min, n ¼ 33 8 (24.2) 5 (15.2) 4 (12.1) 16 (48.5)
No placental separation and/or fetal extrusion, 20e30 min, n ¼ 79 49 (62.0) 4 (5.1) 7 (8.9) 19 (24.1)
Placental separation and/or fetal extrusion, 20e30 min, n ¼ 25 1 (4.0) 17 (68.0) 2 (8.0) 5 (20.0)
No placental separation and/or fetal extrusion, >30 min, n ¼ 23 8 (34.8) 9 (39.1) 1 (4.3) 5 (21.7)
Placental separation and/or fetal extrusion, >30 min, n ¼ 26 1 (3.8) 25 (96.2) 0 (0.0) 0 (0.0)
Data are presented as n (%).
NICU, neonatal intensive care unit.
a
Excluding deaths due to congenital malformations.
Al-Zirqi et al. Infant outcome in complete uterine rupture. Am J Obstet Gynecol 2018.

of intrapartum/infant death was when
rupture was associated with placental
separation and/or fetal extrusion, in
agreement with Bujold and Gauthier14
and Leung et al.17 Interestingly, delivery
after midnight was associated with an
increased risk of infant death and
morbidity, possibly due to human fac-
tors (eg, fewer staff or suboptimal con-
centration and clinical judgment during
night time).
We showed that time to delivery >30
minutes was a significant risk factor
for intrapartum/infant death, even in
present time as shown in previous
studies.17,18 Every additional minute
increased death by 10%, compared to an
8.8% increase in HE in the study of 36
ruptures by Holmgren et al.18 An earlier
study by Leung et al17 from 1993
including 99 ruptures reported 2 peri-
natal deaths when delivery was >30
minutes; neither Leung et al17 nor
Holmgren et al18 found any perinatal
mortality or morbidity when time-to-
delivery interval was <18 minutes.
Deaths and HE did occur in our study,
even when time to delivery was <20
minutes, which is in agreement with
Bujold and Gauthier;14 we had 2 deaths
at 10-minute interval. However, we
showed that time to delivery <20 mi-
nutes limited the incidence of such
deaths. Furthermore, we showed that
placental separation and/or fetal extru-
sion had an important association with
worse infant outcome regardless of
duration. The association would be more
profound as time from rupture to
delivery increases 20 minutes, and
especially >30 minutes. Currently, pre-
dicting placental separation is not
possible, but one thing seems clear: the
longer we wait with delivering the infant,
the less chance for a healthy infant.
Strengths and weaknesses
Due to the rarity of the uterine rupture,
there is a paucity of literature describing
the clinical features and outcomes,
especially in unscarred uteri.19 This
study is the largest thus far, especially
regarding the number of unscarred uteri
included, thereby increasing the preci-
sion of the results. Moreover, all infor-
mation was extracted from the medical
records reviewed by the first author,
increasing the validity of the results and
ensuring the diagnosis of complete
ruptures vs partial ruptures, and accu-
rately identifying studied outcomes and
risk factors. Our sample also represents
the whole Norwegian pregnant popula-
tion, avoiding selection bias.
A weakness of this study is that we
may have lost additional ruptures that
were not recorded in the MBRN, as
only 21 units were searched in the PAS.
We previously published an article
regarding risk factors for complete
uterine rupture in a validated popula-
tion of 1,411,268 births, where 163
complete ruptures were identified
(0.11/1000).7 In this current study, we
used the total pregnant population,
even those not fully validated, to get a
larger sample of complete uterine rup-
tures (244 ruptures). To see whether
missed cases affected the reliability of
our current results, we repeated our
analysis among only 163 ruptures from
the fully validated population. We
found similar results to our findings
among the 244 ruptures regarding risk
factors for infant outcomes following
complete uterine ruptures. Therefore,
potentially missed cases did not influ-
ence the study results.
The cases were collected from
different periods of time. Therefore, we
did a sensitivity analysis testing the
association between different risk factors
in the fourth period of time only (2000
through 2008) (results are not shown in
article). The results showed that when
limiting the cases to the most recent
period, the effect of different risk factors
on infant outcome was similar to the
effect in the whole study period.
Placental separation and/or fetal extru-
sion effect in 2000 through 2008 was still
significant though the OR dropped from

JULY 2018 American Journal of Obstetrics & Gynecology 109.e7

Original Research OBSTETRICS
17.1 in the whole study period to 11.4 in
2000 through 2008 only.
Conclusion
Intrapartum/infant deaths after com-
plete uterine ruptures decreased
significantly over the decades. Time-to-
delivery interval <20 minutes resulted
in fewest intrapartum/infant deaths,
although there were 2 deaths at
10-minute interval. Time to delivery
>30 minutes and placental separation
and/or fetal extrusion at complete
uterine rupture significantly increased
intrapartum/infant deaths. n Feb. 24, 2014.
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Author and article information
From the Norwegian National Advisory Unit on Women’s
Health (Drs Al-Zirqi and Vangen) and Women and
Children’s Division (Dr Al-Zirqi), Rikshospitalet, Oslo
University Hospital, Oslo; Department of Global Public
Health and Primary Care, University of Bergen, Bergen
(Dr Daltveit); Medical Birth Registry of Norway, Norwegian
Institute of Public Health, Bergen, Bergen (Dr Daltveit);
and Institute of Clinical Medicine, University of Oslo, Oslo
(Dr Vangen), Norway.
Received Feb. 9, 2018; revised April 3, 2018;
accepted April 6, 2018.
Supported by South-East Health Region.
The authors report no conflict of interest.
Corresponding author: Iqbal Al-Zirqi, MD, FRCOG,
PhD. ialzirqi@ous-hf.no