signs of uterine rupture
Introduction
Introduction The rupture of the uterus or the lower uterus during pregnancy or childbirth is called rupture of uterus. It occurs mostly during childbirth and is associated with obstructive labor, inappropriate dystocia surgery, abuse of uterine contractions, uterine trauma in pregnancy, and poor healing of scars in uterine surgery. Individuals occur in late pregnancy. Uterine rupture is one of the most serious complications of obstetrics, often causing death in mothers and children. The incidence is one of the quality standards for obstetrics in a region. In recent years, with the increase in the quantity and quality of obstetric workers in China, the establishment and gradual improvement of the tertiary health care network for urban and rural maternal and child health has significantly decreased.
Cause
Cause
(1) Causes of the disease
Uterine rupture occurs mostly in dystocia, elderly and prolific women who have had surgery or have had damage to the uterus. According to the cause of the rupture, it can be divided into a scarless uterine rupture and a scar uterine rupture.
1. Reason:
(1) obstructive dystocia: obvious pelvic stenosis, head basin not called, soft birth canal malformation, pelvic tumor and abnormal fetal position and other factors hinder the decline of the first exposure of the fetus, the uterus overcomes the resistance to strengthen the contraction, the lower part of the uterus is forced to stretch and thin, Eventually the uterus ruptures. This uterine rupture is the most common type of uterine rupture, and the rupture occurs mostly in the lower uterus.
(2) uterine scar rupture: the main causes of uterine scar are cesarean section, uterine fibroids removal, uterine rupture or perforation repair, uterine malformation orthopedics; the cause of rupture is the mechanical traction of the uterus Pulling causes the rupture of the scar or the endometrium of the uterine scar, the placenta is implanted, and the penetrating placenta causes the uterus to rupture spontaneously. In recent years, cesarean section has increased rapidly. The uterine body longitudinal incision cesarean section is easy to be complicated with uterine rupture. The reason for the analysis is that the anatomical nature of the longitudinal incision and the lower transverse incision are different. Because the current cesarean section of the uterus longitudinal incision usually goes through a long period of labor, multiple vaginal examinations, the chance of infection increases.
(3) Abuse of uterine contractions: The uterotonics here should include a variety of substances that stimulate uterine contractions, including the most commonly used oxytocin (oxytocin) and misoprostol used in recent years, reported rice There are more and more cases of uterine rupture caused by sophora. The main reasons include excessive drug dosage or drug delivery rate, immature cervical cervix, malposition of the fetal position, dystocia of obstruction, and careful observation of the labor during the medication.
(4) vaginal midwifery surgery injury: the cervix is not open, forced forceps or hip traction, resulting in severe cervical laceration and extended to the lower uterus. Neglected transverse reversal, destructive surgery, partial artificial exfoliation, etc., due to improper operation, can cause uterine rupture.
(5) uterine malformation and uterine wall dysplasia: the most common is the double-horned uterus or the single-horned uterus.
(6) uterine lesions: multiple maternal, multiple curettage history, history of infectious abortion, history of intrauterine infection, history of artificially stripped placenta, history of hydatidiform mole. Due to the above factors, the endometrium or even the muscle wall is damaged, and the placenta is implanted or penetrated after pregnancy, eventually leading to uterine rupture. 2. Classification The classification of uterine rupture is mainly classified according to factors such as the cause of rupture, the time of rupture, the location of rupture and the degree of rupture.
(1) Classification by cause of rupture:
1 spontaneous uterine rupture occurs mostly in prenatal, common in scar uterus and uterine dysplasia such as double-horned uterus.
2 Traumatic uterine rupture occurs mostly at birth.
(2) Classification according to the time of occurrence of the rupture:
1 uterine rupture during pregnancy is common in scar uterus and uterine dysplasia.
2 uterine rupture during childbirth is more common in the mother, the cause is mostly obstructive dystocia or surgical trauma or oxytocin (oxytocin) improper use, most uterine rupture occurred in this period.
(3) Classification according to the location of uterine rupture:
1 uterine body rupture is more common in the body part of the scar, placental implantation and uterine dysplasia.
2 rupture of the lower uterus is more common in obstructive dystocia, inappropriate vaginal midwifery leads to cervical laceration and uplift.
(4) Classification according to the degree of uterine rupture:
1 Complete uterine rupture: the uterine wall is completely ruptured, the uterine cavity communicates with the abdominal cavity, the fetus and placenta can be invaded at the rupture of the uterus, and can also enter the abdominal cavity. If the gestational age is small, the placenta and amniotic sac encapsulate the fetus completely. Abdominal cavity.
2 incomplete uterine rupture: part or full layer of uterine muscle wall rupture, serosa layer intact. Common uterine segmental rupture, the formation of a wide ligament hematoma, also known as uterine rupture in the broad ligament.
(2) Pathogenesis:
The effects of uterine rupture include:
1. Bleeding: uterine rupture usually manifests as major bleeding, and bleeding is divided into internal bleeding, external bleeding or mixed bleeding. Internal bleeding indicates that blood accumulates in the broad ligament or in the abdominal cavity, resulting in a wide ligament hematoma or hemorrhage in the abdominal cavity; external bleeding indicates that blood is discharged from the vagina.
The site of bleeding of the uterus rupture usually includes uterine and soft birth canal rupture and placental septal bleeding; uterine and soft birth canal bleeding usually requires large blood vessels at the site of injury, if the soft birth canal injury does not damage the large blood vessels usually does not show major bleeding or activity Bleeding. The bleeding of the placental exfoliation surface is related to the degree of placental dissection and the strength of uterine contraction. If the placenta is not completely peeled off or exfoliated, the uterine cavity is not discharged, which affects the uterine contraction, which is characterized by massive hemorrhage. Conversely, if the placenta is completely stripped and has been discharged from the uterine cavity, the uterus contraction Very good, a small amount of active bleeding on the placenta peeling surface.
The above-mentioned bleeding refers to preoperative hemorrhage, and hemorrhage after surgery. The main cause is wound or DIC hemorrhage after clearing of the broad ligament hematoma, or conservative treatment of uterine bleeding.
In addition to causing hemorrhagic shock, bleeding also occurs due to hypercoagulability of the mother, excessive bleeding, and excessive shock time, resulting in DIC.
2. Infection: After the uterus ruptures, the parts that are prone to infection mainly include pelvic cavity, abdominal cavity, pelvic retroperitoneum and soft birth canal. The main causes of infection are: the pelvic cavity or the broad ligament is connected with the uterine cavity and the vagina. After the communication, bacteria enter; the uterus ruptures after hemorrhage, severe anemia or DIC, the resistance is decreased, and the infection is easy; the blood in the abdominal cavity or pelvis Or epidural hemorrhage, easy to infect; hysterectomy or repair after uterine rupture, all under bacteriological conditions; uterine rupture may have more vaginal operation during diagnosis; longer uterine rupture is more likely to lead to more Various infections of the site.
In addition, the infection that is worth mentioning is a respiratory infection. There are many factors that cause infection. The shock time is too long. The drainage and defense mechanisms of the normal respiratory tract are damaged, and the factors such as aspiration cannot be excluded.
3. Causes damage to the birth canal and other abdominal and pelvic organs: damage to the uterus rupture includes damage before and after surgical intervention. Injuries prior to surgical intervention include various injuries to the uterus, lower uterus, cervix, and vagina, as well as primary bladder damage due to fetal head compression. Patients with uterine rupture have many injuries during the diagnosis process and surgical treatment, sometimes even exceeding the primary damage. Excessive unnecessary vaginal operation or examination during the diagnosis process, resulting in increased birth canal injury; open exploration, clearing blood or cleaning the fetus, placenta and membrane, improper operation, leading to intestinal or omental damage; Ligament hematoma, causing pelvic floor blood vessels, ureters and bladder damage; uterine rupture time is too long, the damage to the abdominal organs is heavier.
4. Impact on the fetus: The impact on the fetus after uterine rupture is mainly caused by bleeding at different times and varying degrees of bleeding, and most fetuses die. Perinatal morbidity and mortality of surviving fetuses were significantly increased, and long-term complications were also significantly increased.
Examine
an examination
Related inspection
Obstetric B-ultrasound palpation
Clinical manifestations:
Uterine rupture can occur in the third trimester of pregnancy, but most of them occur when labor is difficult during labor, and the labor process is prolonged. The fetal head or the first exposed part cannot enter the basin or be blocked in the plane or above the ischial spine. Most uterine rupture can be divided into two stages: aura uterus rupture and uterine rupture.
1. Aura uterus rupture: In the process of labor, when the fetal first exposed part is blocked, the strong constriction makes the lower part of the uterus thinner and the uterus is thicker and shorter, forming a distinct annular depression between the two. This depression will gradually rise above the umbilical or umbilicus, called the pathologic retraction ring. Maternal self-reported lower abdomen pain, irritability, shortness of breath, difficulty urinating, pulse increased. Due to the excessive contraction of the uterus, the fetal blood supply is blocked, and the fetal heart changes or cannot be heard. Check the abdomen, a obvious depression can be seen on the abdominal wall, the lower part of the uterus is raised, the tenderness is obvious, the uterine round ligament is extremely tense, and it can be obviously touched and tender. Because the fetus incarcerated at the entrance of the pelvis first exposes the bladder, it damages the bladder mucosa, and hematuria can be seen during catheterization. If this condition is not immediately relieved, the uterus will soon rupture at and below the pathological constriction ring.
2, uterine rupture: according to the degree of rupture, can be divided into complete uterine rupture and incomplete uterine rupture.
(1) Complete uterine rupture: refers to the full-thickness rupture of the uterine wall, allowing the uterine cavity to communicate with the abdominal cavity. When the uterus is completely ruptured, the mother often feels severe tearing, and the uterus collapses, the pain is relieved, but as the blood, amniotic fluid and fetus enter the abdominal cavity, persistent abdominal pain occurs, and the woman appears pale and cold. Shock symptoms and signs such as superficial breathing, pulse breakdown, and blood pressure drop. During the examination, there is total abdominal tenderness and rebound tenderness. Under the abdominal wall, the carcass can be clearly seen. The uterus shrinks to the side of the fetus, the fetal heart disappears, and the vagina may have blood flowing out. The amount may be more or less. The first exposed part of the exposed or falling baby disappears (the fetus enters the abdominal cavity), and the uterus that has been expanded can be retracted. When the anterior wall of the uterus ruptures, the gap can extend forward to cause the bladder to rupture If there is more bleeding in the abdominal cavity, it can move out the mobile voiced sound. If the uterus has been diagnosed as ruptured, it is no longer necessary to vaginally examine the rupture of the uterus. If the uterus is broken due to oxytocin injection, the mother feels strong contraction of the uterus after injection, and suddenly it is severely painful. The first exposed part then rises and disappears, and the abdominal examination is as seen above.
(2) Incomplete uterine rupture: refers to the partial or partial rupture of the myometrium, the serosal layer has not been worn, the uterine cavity and the abdominal cavity are not connected, and the fetus and its appendages are still in the uterine cavity. Abdominal examination, there is tenderness in the incomplete rupture of the uterus. If the rupture occurs between the two lobes of the uterine wall, a hematoma can be formed in the broad ligament. At this time, the uterus body can be touched with a gradually increasing and tender bag. Piece. Fetal heart sounds are irregular. If the uterine artery is torn, it can cause severe extraperitoneal hemorrhage and shock. Abdominal examination of the uterus still maintains its original shape, tenderness after rupture, and can gradually increase the hematoma on the side of the abdomen. The broad ligament hematoma can also extend upwards to become a retroperitoneal hematoma. If bleeding does not stop, the hematoma can penetrate the serosa layer and form a complete uterine rupture.
Uterine rupture caused by uterine scar can occur in the late pregnancy, but most of the general aura is not obvious after labor, only mild abdominal pain, tenderness in the uterine scar, at this time should be alert to the possibility of scarring, but due to the membrane Has not broken, so the fetal position can be found, the fetal heart is good, if it can be found and processed in time, the maternal and child prognosis is good.
Because of the mild symptoms, it is easy to be ignored. When the gap is enlarged, amniotic fluid, fetus and blood enter the abdominal cavity to have symptoms and signs similar to complete rupture, but no tear-like pain. Some scars have little bleeding, and the maternal feels that the contraction stops, and the fetal movement disappears. There is no other discomfort. After 2 to 3 days, there may be symptoms of peritoneal inflammation such as abdominal distension and abdominal pain. The uterine rupture caused by improper use of oxytocin, the uterus strongly contracted after administration, the sudden sensation of tear-like abdominal pain, and the abdominal examination showed signs of uterine rupture.
diagnosis:
Comprehensive analysis should be based on medical history, clinical manifestations and signs, and diagnosis is generally not difficult. Anyone who carefully observes the maternal postpartum can confirm the diagnosis when the uterus is ruptured. If rupture has occurred, there is often inappropriate use of oxytocin history, severe pain in the labor process, patients with shock and obvious abdominal signs, the diagnosis can be immediately clear, the diagnosis of rupture of the posterior wall of the uterus is difficult, can do vaginal examination, Abdominal puncture can be used if necessary.
Where the original history of cesarean section is intended to be tender from the vaginal trial production in the original incision, it should be alert to the possibility of aura.
Very few, although the fetus is delivered from the vagina, but the uterus is still broken, this can be used for abdominal puncture and B-assisted examination, if necessary, laparoscopy can be used to clarify.
In short, the diagnosis of uterine rupture and the type, extent, location, nature of internal rupture, the amount of internal bleeding, fetal heart rate, complete or partial discharge of the placenta are closely related, light or atypical is easy to be ignored, such as uterine posterior wall rupture symptoms The signs and signs are often atypical and mild; the uterine rupture of the cesarean section in the lower uterus is usually located in the thin layer of the muscle layer, and there is no obvious symptoms and signs when there is no vascular area. Because of less bleeding, the uterine contractions often cover up. Symptoms of abdominal pain are only found during re-cesarean section or during routine vaginal exploration of the uterine cavity.
Diagnosis
Differential diagnosis
1. Differentiation from other causes of acute lower abdominal pain:
1 intra-abdominal hemorrhage: such as ectopic pregnancy;
2 tumor pedicle torsion, rupture or degeneration;
3 acute infection of pelvic organs;
4 blocked by blood discharge: such as congenital genital malformation or postoperative cervical, intrauterine adhesions;
5 abnormal uterine contractions: such as dysmenorrhea, adenomyosis and so on.
2. dystocia complicated infection: individual dystocia cases, after multiple vaginal examinations, found signs of abdominal pain and peritonitis stimulating signs, similar to signs of uterine rupture, due to long labor period during the vaginal examination, the lower part of the uterus is thin, double-checking the fingers to touch, Just like only the abdominal wall, it is easy to be misdiagnosed as uterine rupture, but in such cases, the cervix will not retract, the fetus will not rise first, and the carcass is not in the abdominal cavity, and the uterus will not shrink.
3. Early exfoliation of the placenta: often confused with symptoms such as acute onset, severe pain, internal bleeding, and shock.
