Spontaneous rupture of the uterus during pregnancy and childbirth

While existing in our country the organization of obstetric care have all the opportunities to prevent rupture of the uterus; meanwhile breaks fibroids occur, unfortunately, not only in the practice of medical rural area, but also the Clinician with undoubtedly more obstetric experience and all the possibilities for timely recognition threatening uterine rupture, and his warnings. The analysis of gaps cancer occurring in practice experienced clinicians, shows that the bulk of them are the result of neglect of childbirth, when the symptoms threatening uterine rupture visible, or insufficient to properly considered.
Rupture of the uterus to find nowadays much less frequently than in the past 50 years ago, namely in 0,01-0,09%. Rupture of the uterus can be observed in pregnant women (90%) and less frequently in pregnant women (10%), prior to the labor or poorly expressed labor activity.
Rupture of the uterus during childbirth is more common among multiparous (95-98%)had post-abortion and post-partum inflammatory diseases of the sexual system, tumours, etc.
Avtomobilnye give birth larger children, the head of which can not be significant configuration; they are more common abnormal position of the fetus and the extensor inserting head, like frontal presentation.
In nulliparous, even elderly, rupture of the uterus are extremely rare.
Breaks may reside anywhere in the uterus, but usually they are in the lower segment, where the muscles are weak. Break lower segment for the most part has a cross or slanting direction and is located on the front or rear. Side breaks the uterus often secondary origin (by the extension of the lateral surface of the uterus front or rear of the gap) and are generally caused by a brute and technically they are often inappropriate surgical intervention.
Rupture of the uterus are often so vast that the body of the uterus is almost separated from the lower segment. In some cases the gap, starting at the bottom segment, transferred to the body of the uterus and almost reaches its bottom.
There are comprehensive, that is, penetrating, breaks with infringement of an integrity of the peritoneum and incomplete, non-invasive, when is broken only muscle (sometimes imperfectly), and the peritoneum remains undamaged (Fig. 66 and 67).


Fig. 66. Complete rupture of the uterus (de).
Fig. 67. Partial rupture of the uterus. Education retroperitoneal hematoma.

The prediction of a woman's life and especially to the fetus when rupture of the uterus is extremely serious, it depends on many factors, among which are the essential nature of the gap (complete or incomplete), its size, location, degree of blood loss, etc.
According to the Sverdlovsk scientific research Institute of maternity and infancy, when rupture of the uterus kill nearly 47% of mothers and 85% of fetuses (C. K. Doseeva), and with the full breaks the prognosis is worse than incomplete.
The cause of death of women is most often traumatic shock associated with Central nervous system in the result of pererazbiyeniya its impulses coming from the uterus; the second reason is acute anemia because of blood loss, which, by the way, only in separate cases, it is massive, and, finally, the third reason is peritonitis or sepsis in the result of infection.
The fruit die from asphyxia, resulting from the detachment of the placenta, which happens when any form of uterine rupture.
Timely detection of uterine rupture, fast and strictly deliberate surgical care greatly increase the chances of a woman in recovery. Belated intervention is the cause of increasing the frequency of deaths.
Among the complications of uterine rupture was particularly widespread damage to the broad ligaments, peritoneum in fossa iliaca, and on the lateral wall of the belly; much less is detachment and rupture of the bladder, loss of intestinal loops and seal through the gap in the vagina. Especially serious complication are gallbladder-vaginal fistula arising on 9-10-th day after birth, when the fall of the dead tissue. The accession of these complications burdens and over, and the outcome of the uterine rupture, which in itself is the worst suffering.
During pregnancy in the uterus happen two kinds of processes. Until the end of the 8th (or the beginning of the 9th month of pregnancy is the increase of the uterus in connection with the development of the ovum. In connection with the existence of plastic tone inherent in the smooth muscle of the uterus, increasing intrauterine pressure still does not reach the extent that it causes severe contraction of smooth muscle fibers. Device muscles of the uterus to a gradual increase intrauterine pressure caused by biological properties typical of smooth muscle fibers, and their ability to actively extending and maintaining that state for a certain period of time; this process is regulated by a special neurohumoral (including hormonal) mechanisms that reduce the excitability of the uterine muscles and maintain it in the condition necessary tonic voltage (tone).
By the end of the 9th month of pregnancy growth of the uterus usually stops. From this moment begins to increase dramatically, especially intrauterine pressure, which reaches its maximum by the end of pregnancy. The increase intrauterine pressure is accompanied by periodic contractions of the uterine muscles, sometimes even are felt by the woman herself. These contraction of the uterine muscles, seems to be connected with the deployment of the lower uterine segment.
The muscles of the uterus, is a full functional relationship can easily cope with the increase intrauterine pressure, as well as easily cope with the increased volume of the uterus. Pathologically as amended muscles often not withstand significant fluctuations in the volume of the uterus and intrauterine pressure and can easily be broken if a relatively small voltages. The gap in such cases may occur without clear of previous symptoms. In the literature described the numerous cases of rupture of the uterus in various stages of pregnancy, since four months. The immediate cause for the break served as the slight physical strain, for example: dancing, lifting small weights, emotional, loud laughter and so on
The inferiority of the muscles of the uterus may be due to underdevelopment (infantilism, hypoplasia) or malformations of the uterus (one - or two-horned, double) or result from previous inflammatory diseases (metroendometrit) after complicated abortion or childbirth, may depend on rubrofasciata changes after surgery (caesarean section and others). Known predisposing role deep ingrown villi in the uterine wall and violations of neurotrophic processes related to changes in the properties of muscle protein fibrils of the uterus (sharp degree hydrophilicity, leading to the spread of muscle tissue).
However, in some cases in the tissues of ruptured uterus no histological changes cannot be found. Apparently, sometimes in smooth muscle fibers occur complicated biochemical processes that affect contractile uterine activity, and creating conditions for the spread and even rupture of the uterine wall.
About this there are indications in the work of L. I. Chernysheva. It was studied in detail the changes net-fibrous structure of the uterus in women during pregnancy and childbirth in physiological and pathological conditions.
All this allows us to consider erroneous opinion of those who do not attach due importance in the etiopathogenesis of rupture of the uterus to the fallopian muscles and hold the view that the rupture of the uterus occurs exclusively due to mechanical reasons.
Clinicians well known that in some cases protracted childbirth in the presence of spatial mismatch between the head of the foetus and the size of the pelvis of the mother of uterine rupture can occur. Therefore, the cause of the rupture of the uterus are not only mechanical factors, such as the spatial mismatch between the value of predlagay part and the size of the pelvis (narrow pelvis, hydrocephalus, the correct position of the fetus, incorrect insertion of the head and other), and the inferiority of the uterus muscles. According to HP Persianinova, 50.7% of the cause of uterine rupture were only tissue changes walls of the latter, without other relevant factors. However, in the pathogenesis of rupture of the uterus during childbirth cannot ignore the importance and mechanical factors, especially given its inferiority of uterine muscles; pressure or hyperextension disadvantaged muscle tissue is quite sufficient to have occurred sprawling or tearing of the muscle tissue. In the literature there are known cases of uterine rupture occurring during the initiation of preterm delivery by injection of large doses of pituitrin, and in these cases, the state net-fibrous structure of the uterus is essential.


All the above requires a midwife to be especially attentive to the management of delivery when: 1) anatomically or clinically (functionally) narrow pelvis; 2) extension ustawieniach head (FWD-head, forehead, face previa); 3) high direct standing swept seam head; 4) hydrocephalus; 5) the cervical fibroids; 6) tumors of the ovary, impacted in the pelvis. These complications typically cause a delay in discharge of amniotic fluid, difficult inserting head in the entrance to the pelvis and the slow progress last through the birth canal, despite strong tribal activities. In such cases it is easy to get infringement edges uterine throat (often the front of his lips) between the head of the fetus and the wall of the pelvis. In the result of such infringement, pulling up the fallopian Zev becomes impossible, there is a hyperextension of the lower segment, and therefore creates conditions for uterine rupture.
In addition to the mismatch between the size of the pelvis and the size of the fruit, a significant role in the emergence of gaps is the rigidity of the tissues of the cervix, her scar or Sardinia external OS. Rupture of the uterus often come as a result of improper management of labour when running the transverse position of the fetus, placenta previa, and so on
Spontaneous rupture at the inferiority of the uterus muscles can occur without clear of previous symptoms, nerezko expressed fights and even without any mechanical obstacles to the promotion of fruit. More often, however, the emergence of uterine rupture is preceded by excessive stretching of tissues of the lower segment of the uterus, which is usually at late departed waters due to vigorous, continuous contractive activity of uterine muscles in the presence of mechanical obstacles to the promotion of fruit.
In most cases, the hyperextension generic tube prevent, on the one hand, ligaments of the uterus (round, wide and Sacro-uterine ligaments), and on the other hand, abdominals. The effect of these factors is that the ligaments holding the edge roller or so-called contraction ring at the level close to the plane of the entrance to the pelvis and abdominal nastavovat all the uterus in the direction to the entrance to the pelvis.
As soon as there is a violation in the work of this mechanism, the retraction of the upper section of the uterus tops limit and the lower uterine segment is stretched to capacity (this is confirmed by lifting up the edge of the cushion or contraction rings), there is a favourable time for uterine rupture.
The possibility of rupture of the uterus, not only in childbirth, but in pregnancy obliges doctors to consider not only the mechanical factors (spatial mismatch between the head and the pelvis, the correct position of the fetus, incorrect insertion of the head, cancer in the pelvis and so on), but also reminded of the possible existence of pathological changes in the tissues of the uterus.
In this regard, the physician should pay serious attention to history and thoroughly examined the woman during pregnancy, to be able to recommend it to the correct mode, to organize the active patronage and promptly deliver to the hospital, noting in exchange the map all the features of anamnesis data and objective examination.
Prevention of uterine rupture during pregnancy is a major challenge. No less complex prevention gaps in the unfolding of labor activity, because the symptoms threatening rupture are often not clearly expressed.
The symptoms of the coming (threatening) uterine rupture pronounced in cases where there is a mechanical obstacle for progressive movement of the fetus in the presence of rapid labor activity. However, rupture of the uterus, often in the absence of mechanical obstacles, under normal and sometimes poorly expressed labor activity.
The clinical course and symptoms of rupture of the uterus during childbirth are separated or three (threatening occurring or occurred), or in two stages - threatening and accomplished. We adhere to the latest classification, considering practically very difficult to draw a clear distinction between the second and third stages (with the first classification). A clearer distinction in symptomatology may be detected between threatened and accomplished rupture of the uterus. The presence of pronounced convulsive pain, extremely restless behavior of the woman and a number of other features that indicate the hyperextension of the uterus, and so on, is an indication of the possibility of rupture of the uterus, or even at the beginning and requires a physician emergency measures to eliminate the revealed pathology in childbirth.