ANDRES BONIFACIO COLLEGE

College Park, Dipolog City

SCHOOL OF NURSING
Telephone No. (65) 212 – 9776
abcollege.nursing@gmail.com

CARE OF THE PATIENT WITH UTERINE RUPTURE

Submitted by:

Michelle B. Dingding

Thrizsa Cathlyn Ashley M. Legados

BSN – II

Submitted by:
 Mrs. Julyn Marie Abad – Gallardo, RN, MN

Clinical Instructor

Submitted to:

ANDRES BONIFACIO COLLEGE

INSTITUTIONAL VISION AND MISSION

VISION:

A center of excellence in instruction, research, technology, extension, athletics and arts.

MISSION:

We commit to provide affordable quality education with values in industry, intelligence, integrity and undertake relevant research and
socially-responsive community service using innovative technologies.

School of Nursing Vision

Excellent Nursing Education

School of Nursing Mission

The School of Nursing shall generate, competent, safe and compassionate professional nurses committed to:
a. Practice high standards of nursing care utilizing research and evidence-based practices that are culturally appropriate and
sensitive.
b. Active involvement in local, national and global issues affecting nursing, people’s health and the environment.
c. Ongoing holistic growth and development of the self and others.
 T a b l e o f C o n t e n t s

I. Learning Objectives --------------------------------------------------------

II. Introduction --------------------------------------------------------

III. Anatomy and Physiology --------------------------------------------------------

IV. Pathophysiology --------------------------------------------------------

V. Nursing Care Plans --------------------------------------------------------

VI. Related Literature --------------------------------------------------------

VII. References --------------------------------------------------------

I. LEARNING OBJECTIVES

 General Objectives:

At the end of the Case Presentation, the Learners shall improve their understanding, enhance their knowledge and manifest

desirable attitude in providing immediate and holistic care to patients with uterine rupture.

 Specific Objectives:

Within 1 hour of discussion, the listeners will be able to:

o Identify what is uterine rupture.

o Identify signs and symptoms of uterine rupture.

o Identify the complication of uterine rupture.

o Review the Anatomy and Physiology of Female Reproductive System

o Discuss the disease process and its pathophysiology effectively.

o Identify and discuss its appropriate management effectively.

 II. INTRODUCTION

UTERINE RUPTURE

Uterine rupture in pregnancy is a rare and often catastrophic complication with a high incidence of fetal and maternal morbidity. Numerous factors are known to
increase the risk of uterine rupture, but even in high-risk subgroups, the overall incidence of uterine rupture is low. From 1976-2012, 25 peer-reviewed publications
described the incidence of uterine rupture, and these reported 2,084 cases among 2,951,297 pregnant women, yielding an overall uterine rupture rate of 1 in 1,146
pregnancies (0.07%).The initial signs and symptoms of uterine rupture are typically nonspecific, which makes the diagnosis difficult and sometimes delays
definitive therapy. From the time of diagnosis to delivery, generally only 10-37 minutes are available before clinically significant fetal morbidity becomes
inevitable. Fetal morbidity occurs as a result of catastrophic hemorrhage, fetal anoxia, or both.

Uterine rupture during pregnancy is a rare event and frequently results in life-threatening maternal and fetal compromise. It can either occur in women with a
native, unscarred uterus or a uterus with a surgical scar from previous surgery. Uterine scar dehiscence constitutes separation of a pre-existing that does not disrupt
the overlying visceral peritoneum (uterine serosa) and that does not significantly bleed from its edges. In addition, the fetus, placenta, and umbilical cord must be
contained within the uterie cavity, without a need for caesarean delivery due to fetal distress.

During labor, pressure builds as the baby moves through the mother’s birth canal. This pressure can cause the mother’s uterus to tear. Often, it tears along
the site of a previous cesarean delivery scar. When a uterine rupture occurs, the uterus’s contents including the baby may spill into the mother’s abdomen.
 By contrast, uterine rupture is defined as a full-thickness separation of the uterine wall and the overlying serosa. Uterine rupture is associated with clinically
significant uterine bleeding, fetal distress, expulsion or protrusion of the fetus, placenta or both into the abdominal cavity and the need for prompt caesarean delivery
and uterine repair or hysterectomy.

TYPES OF UTERINE RUPTURE

A. Scarred Uterus Rupture

 Uterine scar dehiscence - herniation of intact amniotic membrane into an existing scar ( when there is separation of previous scar with intact
peritoneum).
 Uterine scar rupture - separation of scar along entire length often with involvement of the amniotic membranes.

B. Unscarred Uterus Rupture

 Complete uterine rupture- a total disruption of the wall of the pregnant uterus with or without extrusion of its content (when uterine cavity
communicates directly with peritoneal cavity). During complete uterine rupture, the peritoneum tears and the contents of the mother’s uterus
can spill into her peritoneal cavity. The peritoneal cavity is the fluid-filled gap that separates the abdomen walls and its organs. It is suggested
that delivery via cesarean section should occur within approximately 10 to 35 minutes after a complete uterine rupture occurs. The fetal
morbidity rate increases dramatically after this period.
  Incomplete uterine rupture- A partial disruption of the wall of the pregnant uterus without extrusion of its content (uterine cavity is
separated from peritoneal cavity visceral peritoneum or broad ligament). In an incomplete uterine rupture, the mother’s peritoneum remains
intact. The peritoneum is the membrane that lines the abdominal organs. It also acts as a channel for blood vessels and nerves. An incomplete
uterine rupture is significantly less dangerous with fewer complications to the delivery process.

TYPES OF SCAR THAT CAN CAUSE A RUPTURED UTERUS

A. C-section
B. Hysterectomy scar- hysterectomy is in incision in the uterus made during a C-section when the baby has shoulder dystocia ( shoulder caught on
mother’s pelvis).
C. Uterine perforation scar- this can occur as a result of any complication involving the uterus and trans-cervical procedures.
D. Myomectomy or metroplasty scar- scars from removal of fibroids in the uterus.

CAUSES OF UTERINE RUPTURE

A. Cephalopelvic disproportion - this is when the mother’s pelvis is too small for the size of the baby, resulting in the baby being unable to pass through
the birth canal.
B. Grand Multiparity – this is when the mother has given birth 5 or more times.
 C. Uncontrolled use of Pitocin (Oxytocin) – this is probably the leading causes of rupture of the unscarres uterus. Oxytocin can cause contractions to be
too strong and too frequent which puts a lot of strain on the uterus.

CLASSIFICATION OF UTERINE RUPTURE

A. Classification by etiology:

 Scarred uterus rupture- classical caesarean (hysterectomy) scar, previous perforation of uterus
 Unscarred uterus rupture:
 Traumatic rupture- caused by accident
 Uterine Distention-Delay in labor progression because of fetal malpresentation
 Fetal macrosomia and multiple gestations
 Overdose of oxytocin

B. Classification by pathogenesis:

 Spontaneous- histochemical etiology of uterine rupture- occurs without any function of uterus
 Voluntary- result of hyperfunction of uterus.

C. Classification by Layers of uterus involved in rupture:

  Complete rupture- commonly spontaneous
 Incomplete rupture- commonly traumatic

D. Classification by location of rupture

 Lower segment rupture
 Rupture of corpus/ fundus of uterus

E. Classification by time:

 During pregnancy
 During labor

F. Classification of carelessness or negligence

 Carelessness of the patient

 Negligence of the doctor
 III. ANATOMY AND PHYSIOLOGY OF THE UTERUS

UTERUS
The Uterus is the organ of pregnancy as this is where implantation and
development of the fetus occurs. The Uterus is the reproductive organ with the
most species variations. These variations occur in the anatomical types of uterus as
well as the uterine horn appearance and endometrial linings. The normal position is
an anteverted uterus, which is tipped forward, whereas a etroverted uterus is angled
slightly posterior. The uterine position is also sometimes described in relation to
the location of the fundus; that is; an anteflexed uterus, which is normal and where
the fundus tilts forward.

1) STRUCTURE
 Perimetrium
- This is the outside layer of tissue that lines the outside of the uterus.
- Serosal connective tissue layer continuous with the broad ligament.

 Myometrium
- The middle layer of the uterus is primarily made up of smooth muscle.
- Muscularis layer made up from thick inner circular smooth muscle layer and thin outer longitudinal muscle layer.
- The circular and longitudinal layers are separated by the Stratum Vasculare, a connective tissue layer containing the blood vessels and nerves of
the uterine wall.

 Endometrium
- The inside layer of the uterus that is the layer that builds up over the course of a month and is shed each month if no pregnancy occurs. This
shedding of the lining of the uterus is the menstrual period.
- Mucosa & Sub mucosa layer containing endometrial glands.
- The surface of the endometrium differs between species:
i. Ruminants - Numerous round button like elevations of the endometrium called Caruncles occur. These are the sites of attachment and
maternal tissue contribution to the placenta. Maternal Caruncle + fetal cotyledon = A placentome.
ii. Sow and Mare - uterine folds are present.
- Not shed in domestic species, only shed in primates.
2) FUNCTION

 Provides a suitable environment for embryo development and attachment. The secretions produced by the endometrial glands are important for
maintaining the preimplantion embryo.
 In response to increasing amounts of oxytocin production by the corpus luteum during the luteal phase the endometrium produces luteolytic PGF2a to
cause degeneration of the corpus luteum if the female is not pregnant.
 The uterus contributes varying amounts of maternal tissues towards the placenta.
 The myometrium is involved with sperm transport through the uterus towards the oviduct.
 Contractions of the myometrium during parturition are important for fetus and placenta expulsion.
 When pregnancy occurs, the endometrium supplies nutrients to the fertilized egg, and eventually supports the placenta.
 The muscular nature of the uterus allows it to expand to accommodate a growing fetus. During childbirth muscular contractions in the uterus help to push
the baby out of the body.
 During childbirth, the uterus contracts to help push the fetus from the body.
 These contractions squeeze the fetus out of the uterus and into the vagina with a series of muscular movements. After the baby is born, the uterus
continues to contract, which helps the organ to return to its normal size and also assists in stopping bleeding that occurs in the uterus during delivery.

3) ANATOMICAL LOCATION AND BOUNDARIES

 The Uterus body and Uterine horns are located within the abdominal cavity dorsal to the Intestinal mass
  The uterus is attached to the dorsal body wall via the myometrium broad ligament.

4) HISTOLOGY

- The appearance of the uterus varies with the stages of the estrus cycle.

 Follicular phase-Estrus
- Increasing numbers of uterine glands developing and elongating within the endometrium due to the influence of estrogens produced by the
developing follicles.
- General increase in the thickness of the endometrium.
- The epithelium lining the glands is Simple Columnar epithelium.
 Luteal phase
- The endometrium is at its maximum thickness with a large number of highly developed glands.
- This is the secretory phase for the endometrium.

 Anestrus
- The endothelium is relatively thin with little endometrial proliferation or gland development.
- This is due to the absence of ovarian steroids estradiol and progesterone.
- The glands are lined by Simple Cuboidal epithelium.
5) INNERVATION

- The uterus is innervated by both Sympathetic and Parasympathetic fibers which play a part in the regulation of uterine activity. This is
highlighted by iatrogenic manipulation of parturition using β-Adrenoreceptor agonists for delaying parturition and antagonists for inducing
parturition. However, uterine activity and normal parturition can be achieved when these nerves are severed.

6) VASCULATURE

- Uterine branch of the ovarian artery supplies the cranial parts of the uterine horns.
- Uterine artery supplies the rest of the uterine horns and the uterine body. This is a branch off the Internal Iliac artery in most domestic species,
except the Mare where instead it is a branch off the External Iliac artery. The Uterine artery and the ovarian artery anastomose within the Broad
ligament.

7) UTERUS AND SURGERY

- A hysterectomy is a surgery to remove the uterus and is typically performed when the uterus is diseased (such as cancer) or when dysfunctional
uterine bleeding (heavy periods, long periods that cause anemia) is unable to be treated using less invasive methods.
IV. PATHOPHYSIOLOGY
 V. NURSING CARE PLANS

1. Nursing dx: Deficient fluid volume r/t active fluid loss from hemorrhage.

Assessment Planning Intervention Rationale Evaluation

 Tachycardia By the end of my duty, The INDEPENDENT:
 Weak, rapid HR patient should:  Monitor and document  To have a baseline of the  The patient’s vital signs
 Alteration in mental state  Retain fluid balance. vital signs especially BP vital sign of the patient. went back to normal.
 Decreases venous filling  Have normal vital signs. and HR. Decrease in the blood  Fluid balance is retained.
pressure volume can cause  Venous filling pressure is
 Hypotension hypotension and back to normal.
 Dehydration tachycardia. Alteration in  Patient manifested normal
HR is a compensatory rhythm of breathing.
mechanism to maintain
cardiac output.
DEPENDENT:

2. Nursing dx: Acute pain r/t rupture of uterus
Assessment
 Patient reports pain in the
area ruptured
 Bleeding in the vagina
 Altered vital signs
 Tachycardia
 Administer blood products
as prescribe
Planning Intervention
At the end of my duty, the INDEPENDENT:
patient will:  Assess vital signs noting
 Report pain tachycardia, hypertension,
relieved/controlled. and increased respiration
 Appear relax, able to  Evaluate pain q2h noting
rest/sleep. COLDSPA in a 0-10 pain
scale. Emphasize patient’s
responsibility for reporting
pain/relief of pain
completely.
 Reposition client qh as
 Blood transfusion may be
required to correct fluid
loss from active uterine
tear bleeding.
Rationale Evaluation
 Changes in vital signs may  The patient will establish
indicate acute pain and the absence of pain and is
discomfort. relieved.
 To have data about the  Patient feels relaxed and is
patient whether the pain of able to rest or sleep well
the patient is relieved and and not having any
provides information about discomfort.
how important informing
the health care provider the
need to inform the pain
being experienced for data
gathering.
 May relieve pain and
 indicated: Semi-Fowler’s;
Lateral Sim’s
enhance circulation. Semi-
Fowler’s position relieves
abdominal muscle tension
while Sim’s will relieve
dorsal tension.

3. Nursing dx: Fear r/t situational crisis and threat of death

Assessment Planning Intervention Rationale Evaluation

 Restlessness At the end of my duty, the INDEPENDENT:
 Facial tension patient will:  Provide preoperative  To relieve patient from  Patient is relaxed and is
 Crying  Appear relaxed, able to education. anxiety and fear. able to sleep well.
 Fear rest and can sleep  Control external stimuli.  Extraneous noises and  Patient distinguished
 Anxious appropriately. commotion may accelerate decrease in fear and
 Distinguish decreased fear anxiety. anxiety is reduced to a
and anxiety reduced to a  Prevent unnecessary body  Patients are concerned manageable level.
tolerable level. exposure during transfer about loss of dignity and
and in OR suite. inability to exercise
control.
DEPENDENT:
 Administer local  Reduces concern that
anesthesia and sedative patient may “See” the
 that drowsiness and sleep procedure.
will occur.

VI. RELATED LITERATURE

Uterine Rupture at 26 Weeks of Pregnancy

Following Laparoscopic Salpingectomy
With Resection of the Interstitial Portion:
A Case Report

Uterine rupture in pregnancy can occur in patients with a history of uterine surgery such as myomectomy and Cesarean section. Here, we report a case of
spontaneous uterine rupture that occurred in the early third trimester in a pregnant woman who had previously undergone laparoscopic removal of the right fallopian
tube and interstitial portion for treatment of interstitial pregnancy. The patient presented with sudden onset of abdominal pain at 26 weeks of gestation. Detailed
ultrasonography and magnetic resonance imaging led to diagnosis of uterine rupture. In emergency laparotomy, the fetus was delivered by Cesarean section, the
placenta and membranes were removed, and the uterus was preserved with closure of the rupture and wound. This case highlights the importance of close follow-up
of a pregnant patient who has previously had a uterine incision. The case also raises the question of whether the prevalence of uterine rupture may increase as more
patients are treated with laparoscopic surgery of the uterus.
INTRODUCTION :

The standard surgical therapy for interstitial pregnancy has been laparotomy with resection of the cornual portion of the uterus or hysterectomy. Due to
recent advances in laparoscopic surgery, laparoscopic salpingectomy with corneal resection is now an option. Uterine rupture after salpingectomy with cornual
resection is a rare but serious complication in pregnancy that can induce massive hemorrhage and frequently requires hysterectomy. Here, we report a case of
uterine rupture that occurred at 26 weeks’ gestation in a patient with a history of interstitial pregnancy treated with laparoscopic salpingectomy with cornual
resection.

CASE REPORT:

A 45-year-old, gravida 2, para 0 woman had an ectopic (interstitial) second pregnancy that was treated by laparoscopic salpingectomy with resection of the
interstitial portion. Four years later, in her third pregnancy, an ultrasound scan showed an intrauterine singleton pregnancy. At 26 weeks, the patient complained of
constant abdominal pain and visited a community hospital where a tentative diagnosis of uterine rupture was made based on ultrasonography and magnetic
resonance imaging (MRI) findings. She was transferred and admitted to our hospital for surgical treatment. At admission, her vital signs were stable. Blood pressure
was 110/70 mmHg, the abdomen was flexible, and the fetal heart rate was 140 bpm. Laboratory data revealed severe anemia with a hemoglobin concentration of 5.6
g/dL, suggestive of intraperitoneal hemorrhage. Detailed ultrasonography showed the intrauterine amniotic sac protruding into the abdominal cavity, indicative of
uterine rupture. MRI provided similar findings and clearly identified the site of uterine rupture as the right interstitial region. The sac protruded into the peritoneal
cavity while the fetus was in the uterus with a cephalic presentation. The placenta was located in the anterior portion of the uterine wall and was not related to the
area of rupture. Emergency laparotomy confirmed the imaging findings. Massive intraperitoneal hemorrhage (estimated blood loss of 1345 ml) was found. A boy
with a birth weight of 774 g was delivered by Cesarean section with Apgar scores of 4 and 7 at 1 and 5 minutes, respectively. The rupture was closed in two layers
with absorbable sutures. The postoperative course of the mother was uneventful and she was discharged on day 7.

DISCUSSION:
 Uterine rupture is a serious complication of pregnancy that may be fatal for the mother and fetus. An increased risk of uterine rupture is associated with
uterine scars such as those caused by Cesarean section or myomectomy. Conservative surgery for interstitial pregnancy involves resection of the cornual portion of
the uterus, thus leaving the patient at risk for uterine rupture in subsequent pregnancies. In a report of 5 cases of uterine rupture during pregnancy after
salpingectomy with cornual resection, Arbab et al. suggested that this procedure could attenuate the uterine musculature in the cornual region and that this could
lead to rupture of the uterus in a subsequent pregnancy.

Laparoscopic uterine surgeries such as laparoscopyassisted myomectomy may also be associated with uterine rupture in subsequent pregnancies. Ayoubiet
al. described a case of uterine rupture at 20 weeks of gestation in a woman who had previously undergone laparoscopic salpingectomy with cornual resection. The
patient in the present case had undergone a similar operation and uterine rupture occurred at 26 weeks in the subsequent pregnancy. Several authors have questioned
the quality of the uterine scar after a laparoscopic myomectomy; thus, a scar after laparoscopic uterine suture could be inferior to that after normal manual suture
[8].During laparotomy, hemostasis is generally achieved by closing the uterine defect in a layered fashion.

On the other hand, at laparoscopy, bleeding from the edges of the uterine incision is mostly controlled with bipolar coagulation forceps and the uterine defect
is usually closed in only one or two layers. The technical difficulty of laparoscopic suturing and the smaller number of sutures used to close the uterine defect could
allow a hematoma to form within the uterine wall, leading to a weakened incision line. Further, extensive use of electrocautery could cause more damaged tissue to
be incorporated into the uterine closure site than occurs at laparotomy. Therefore, an uterine scar after laparoscopic myomectomy might not be as strong as that after
a traditional myomectomy, not only due to how the defect is closed but also due to how it is created. However, there is a lack of evidence for this conclusion and
more studies are needed to examine this hypothesis. Nevertheless, for appropriate hemostasis to be done, the laparoscopist should always aim for advanced
laparoscopic suture skills with prudent use of electrocautery.

A history of interstitial pregnancy treated with surgical conservative therapy appears to be associated with uterine rupture in a subsequent pregnancy, but the
extent of the risk is unclear. Pregnant patients with such a history should be closely monitored and informed of possible signs or symptoms of uterine rupture, so
that an earlier diagnosis of uterine rupture can be made. With accumulation of more cases, a more appropriate management approach should emerge. We have
succeeded in preserving the uterus in this case. No reliable evidence exists on how such patients should be managed in a subsequent pregnancy. However, most
obstetricians would agree that they carry an increased risk for re-rupture of the uterus in a next pregnancy. Therefore, prenatal visits at a highrisk care unit from an
early stage of pregnancy may be a practical option for the management of such patients in their subsequent pregnancies.

VII. REFERENCES
 Grobman WA and Milad MP. Conservative laparoscopic management of a large cornual ectopic pregnancy. Hum Reprod. 1998; 13: 2002-4.
 Osuga Y., et al. Usefulness of long-jaw forceps in laparoscopic cornual resection of interstitial pregnancies. J Am Assoc Gynecol Laparosc. 2001; 8: 429-
32.
 Ayoubi JM, et al. Rupture of a uterine horn after laparoscopic salpingectomy. A case report. J Reprod Med. 2003; 48: 290-2.
 Arbab F, et al. Uterine rupture in first or second trimester of pregnancy after in-vitro fertilization and embryo transfer. Hum Reprod. 1996; 11: 1120-2.
 Weissman A. and Fishman A. Uterine rupture following conservative surgery for interstitial pregnancy. Eur J Obstet Gynecol Reprod Biol. 1992; 44: 237-9.
 Wada S, Kudo M, Minakami H. Spontaneous uterine rupture of a twin pregnancy after a laparoscopic adenomyomectomy: a case report. J Minim Invasive
Gynecol. 2006; 13: 166-8.
 Lau S, Tulandi T. Conservative medical and surgical management of interstitial ectopic pregnancy. Fertil Steril. 1999; 72: 207-15.
 Hockstein S. Spontaneous uterine rupture in the early third trimester after laparoscopically assisted myomectomy. A case report. J Reprod Med. 2000; 45:
139-41.
 Ng S, Hamontri S, Chua I, Chern B and Siow A. Laparoscopic management of 53 cases of cornual ectopic pregnancy. Fertil Steril. 2009; 92: 448-52.