UTERINE RUPTURE &

VVF
Prepared by: Metti Melkamu
Modulator: Dr. Hailegebrel
April 21/2021
Uterine rupture
• Is when the uterus layers tears during later weeks of pregnancy or
during childbirth.
• INCIDENCE:
0.05% for all pregnancy's
0.8% after previous lower segment CS
>5% after classical CS
Basis of clas-
Classifications
sification

-Complete uterine rupture- rupture of myometrium and serosa (entire thickness)

Extent
-Incomplete uterine rupture- rupture of myometrium with intact uterine serosa

-Spontaneous uterine rupture- uterine rupture without any external trauma or rup-
ture of unscarred uterus following obstructed labour
Etiology -Traumatic uterine rupture- uterine rupture following iatrogenic or accidental
trauma
-Scar rupture
Antepartum uterine rupture- uterine rupture before the onset of labor – usually
Timing scar dehiscence
Intrapartum uterine rupture- uterine rupture during labor
Fundal uterine rupture
Lower segment uterine rupture
Anatomic
Posterior uterine rupture
Uterine rupture with vaginal extension
 Based on the etiology
1)Spontaneous rupture

During pregnancy During labor

• Previous damage to the uterine walls fol- • Obstructive labor
lowing dilatation and curettage operation
or manual removal of placenta •Grand multiparaous are usually
affected and rupture usually oc-
• grand multiparae due to thin uterine
walls curs in early labor. Its due to
weakening of the walls through
• congenital malformation of the uterus
repeated previous births .
• abruptio placentae
• oxytosin and prostaglandins
• perforating mole
• collagen disorder
2) Scar rupture

During pregnancy During labor

•Due to Classical cesarean or •The classical or hysterectomy scar

is more vulnerable to rupture dur-
hysterectomy scar which likely ing labor.
to give way during later
months of pregnancy
 3) Iatrogenic or traumatic
During pregnancy
• Careless administration of oxy-
tocin
• Use of prostaglandins for induc-
tion of abortion or labor
• Forcible external cephalic ver-
sion specially under general
anesthesia
• Abdominal blunt trauma
During labor
• Internal cephalic version—specially
following obstructed labor
• Destructive operation on fetus
• Manual removal of placenta
• Application of forceps or breech ex-
traction through incompletely dilated
cervix
• Unmonitored administration of oxy-
tocin for augmentation of labor.
 Symptoms
•Severe abdominal pain
•Symptoms of hypovolemia and shock –
dizziness, weakness etc
•In labor- cessation of typical labor pains
and replacement with diffuse generalized
abdominal pain
•Vaginal bleeding
•Cessation of fetal movement
•Respiratory difficulty
•Fever, chills, rigors
•late - subdiaphragmatic and shoulder pain
• •Variable abdominal + bowl
Signs
•Hypovolemia and shock
•Acute cardio respiratory distress
•Pallor
•Dry mucosal surfaces
•Tender abdomen
•Easily palpable fetal parts
•Fetal distress or death
•Evidence of fluid in abdomen
•Features of obstructed labor on
vaginal exam
•Bloody vaginal discharge
distension
•Offensive vaginal discharge
•FHB usually absent unless a recent
rupture
 Management
Resuscitation
• Administer oxygen by face mask
• Open wide bore IV access
• Administration of broad spectrum an-
tibiotics
• Type and cross match blood for possible
transfusion
• Catheterize bladder and monitor input-
output
• Insert NG tube if food ingested recently
or labor prolonged for days to avoid as-
piration
• Administer antacids
• Prepare for emergency surgery
Surgical
• Immediate Laparotomy
• Type of surgery performed depends on:
1) Parity and future fertility needs
2)Hemodynamic status and ability to
withstand prolonged anesthesia
3) Site and extent of rupture
4) Presence or absence of over uter-
ine and intra abdominal infection
 VVF
• Is one of the genitourinary fistual related to labour and
delivery.
• VVF is an abnormal connection b/n bladder & vagina which
leakage of urine via vagina occurs. Its the commonest type
of genitourinary fistula.
• Incidence; 0.2% - 1% gynacological addmission
-classified -juxta-urethral, mid-vaginal, juxta-cervical
a) juxta-urethral
-near or at urethro-vesical junction
-commonest type of VVF
b) Mid-Vaginal
-hole in the mid-vagina
-easy to repair
c) Juxta-Cervical
-common where high incidence of C/S
-results from complicated C/S-extensions, bladder injury
-excellent prognosis
Cause of VVF
1)Obstetrical (95%)
PROLONGED OBSTRUCTED LABOUR -results from prolonged
compression effect on the vagina and the bladder which comes
against the pubis syphysis by the fetal head leading to cutting of
blood flow to vesicovaginal wall
• Ischemic necrosis infection sloughing fistula.
•Instrumental vaginal delivery such as destructive operations or
forceps or bony spicule of the fetal skull in craniotomy operation.
• Thus, it takes few days (3–5) following delivery to produce
such type of fistula.
 2)Gynecological:(0.5%-1%)
• Operative injury- like abdominal hysterectomy for benign or
malignant lesions, vaginal hysterectomy, caesarean section,
hysterectomy for
rupture uterus
• The injury may be direct or ischemic following a part of the
bladder wall being caught in the suture.
• This type of direct traumatic fistula usually soon after delivery
• Repair of Anterior Vaginal wall prolapse
Other causes
• Radiation induced fistula (associated with Rx for cervix
cancer or other pelvic malignancies)
• Vaginal foreign bodies
• Direct trauma from masturbation or automobile accidents
• Congenital cause
 Clinical Features
• VVf usually presents with constant/ contionous leakage of urine per
vagina(true incontinence)
• Most commonly recognized in the first 10 days after operation and less
commonly bn 10 - 20th day of post operative days.
• Post pelvic radiation fistula- delayed onset of leakage, takes months to
years
• Small fistula- leakage in certain positions and can also pass urine
normally
• large fistula- patient may not void at all, but leak
• Menouria- cyclical hematuria at the time of menestruayion
• Pruritis vulvae, perineal skin irritaion: to constant wetness
• Recurrent cystitis and UTI
Diagnosis
• Special test
1. Catheter test: comes out from the vaginal orifice of vagina
2. Click test: metal catheter in bladder gives click with a metal
probe passes through vaginal orifice of fistula.
3. Methylene blue dye test
4. Modified methylne blue test- no pads but sye seen directly
Diagnosis cont.
 MANAGEMENT
• Conservative Managemet
• Medical Therapy
• Surgical Therapy
• Nonsurgical Intervention
 TIMING OF REPAIR
• Dictum is that best time to repair fistula is
at its first closure during index surgery
• Obstetric fistula- 3 months following
delievery
• Surgical fistula
- if recognized within 48 hrs- immediate
repair
- otherwise repair after 10 - 12 wks
• Radiation fistula - after 12 months
• If repar fails, reattempt after 3 months
COMPLICATION
• Incontinence • Bladder stones

• Failed repair • Contractures

• Stress incontinence • Malnutrition
• Urethral Stricture • Infertility
• Mental health
• Sexual difficulties
 PREVENTION
1.Adequate childhood nutrition
2.Delay in child bearing until full pelvic growth is completed.
3.Provision of family life education.
4.Supervision of labor of every pregnant woman by trained birth attendant
5.Monitoring of every labor with partograph
6.Universal basic education for women
7.Education of men concerning women's reproductive health
8. Avoiding use of high forceps, rotational forceps on undilated cervix, pro-
longed trial in CPD or contracted pelvis
Referrences
• Dc Duttatxt book of gynecology 6th edition
• current diagnosis and treatment obstetrics and gynacology
• Internet