Systematic review of the incidence and consequences of uterine rupture in women with previous caesarean section

Abstract

Objective To evaluate the incidence and consequences of uterine rupture in women who have had a delivery by caesarean section. Design Systematic review. Data sources Medline, HealthSTAR, Cochrane Database of Systematic Reviews, Cochrane Controlled Trials Register, National Centre for Reviews and Dissemination, reference lists, and national experts. Studies in all languages were eligible if published in full. Review methods Methodological quality was evaluated for each study by using criteria from the United States Preventive Services Task Force and the National Health Service Centre for Reviews and Dissemination. Uterine rupture was categorised as asymptomatic or symptomatic. Results We reviewed 568 full text articles to identify 71 potentially eligible studies, 21 of which were rated at least fair in quality. Compared with elective repeat caesarean delivery, trial of labour increased the risk of uterine rupture by 2.7 (95% confidence interval 0.73 to 4.73) per 1000 cases. No maternal deaths were related to rupture. For women attempting vaginal delivery, the additional risk of perinatal death from rupture of a uterine scar was 1.4 (0 to 9.8) per 10 000 and the additional risk of hysterectomy was 3.4 (0 to 12.6) per 10 000. The rates of asymptomatic uterine rupture in trial of labour and elective repeat caesarean did not differ significantly. Conclusions Although the literature on uterine rupture is imprecise and inconsistent, existing studies indicate that 370 (213 to 1370) elective caesarean deliveries would need to be performed to prevent one symptomatic uterine rupture.

Risk factors of uterine rupture with a special interest to uterine fundal pressure

“…Rupture in patients with previous uterine surgery was seen in 2.04% (15 of 737), compared to 0.9%-1% in other large retrospective studies [3,20]. Also in the subgroup of women with an unscarred uterus, in our collective a higher incidence of uterine rupture was observed as compared to the published incidence in other studies (0.067% vs. 0.02%-0.006%) [3][4][5]. The results in our study population allow three main conclusions: firstly and in accordance to many other publications, we found that the main risk factor for uterine rupture is previous uterine surgery [3,19,21].…”

“…The median incidence of uterine rupture based on studies in high-income countries is around 0.09% [3]. After previous cesarean section, the incidence varies between 0.4% and 0.9% [3,5] whereas in women without prior uterine surgery the incidence of uterine rupture is about 0.006%-0.02% [4,5]. In addition to previous cesarean section, postulated risk factors for uterine rupture are induction of labor, maternal age, multiparity, gestational age at delivery, vacuum-assisted birth, fetal birth weight, short inter pregnancy interval, prolonged second stage of labor, abnormal placentation, and uterine fundal pressure (UFP) [2,[6][7][8][9][10][11][12][13][14][15].…”

Maternal and neonatal morbidity: repeat Cesarean versus a trial of labour after previous Cesarean delivery

“…Though the overall risk of uterine rupture is low for both TOL after prior Cesarean delivery (<1%) and ERCD (0.03%) [8,33], the relative risk for women undergoing TOL is 20.47 (95% CI: 9.77 to 44.02, p < 0.001) as compared with ERCD [33]. Factors increasing the risk of uterine rupture after a prior Cesarean delivery include multiple gestation, BMI >30 kg/m 2 , a pregnancy interval shorter than 24 months, gestational age >40 weeks, estimated fetal weight >4,000 grams, and prostaglandin administration [33,34].…”

“…Prior Cesarean delivery is the most common cause of uterine rupture, though the frequency during TOL labour is <1% [8]. While uterine rupture is associated with severe maternal and perinatal morbidity, overall outcomes are generally favorable [9,10].…”

Prediction of scar integrity and vaginal birth after caesarean delivery

“…Uterine rupture is a rare but serious complication of a trial of vaginal birth after caesarean delivery (VBAC) [1][2][3]. Therefore, VBAC should be proposed only to women who are likely to have a low risk of uterine rupture.…”