|Year : 2016 | Volume
| Issue : 1 | Page : 1-4
A 10-year review of uterine rupture and its outcome in the University of Benin Teaching Hospital, Benin City
Patricia A Osemwenkha, James A Osaikhuwuomwan
Department of Obstetrics and Gynaecology, University of Benin Teaching Hospital, Benin City, Nigeria
|Date of Acceptance||09-May-2016|
|Date of Web Publication||20-Dec-2016|
Patricia A Osemwenkha
Department of Obstetrics and Gynaecology, University of Benin Teaching Hospital, Benin City
Source of Support: None, Conflict of Interest: None
Objective: Uterine rupture is one of the major obstetric complications of labour which contributes significantly to maternal and perinatal mortality in the low resource and developing countries This study determined the incidence, predisposing factors and feto-maternal outcome of ruptured uterus. Methods: A 10-year retrospective study of all cases of uterine ruptures that were managed in University of Benin Teaching Hospital, Benin City, Nigeria between 1st January, 2005 and 31st December, 2014 was undertaken. Data collected from maternity records were transferred to a data sheet. The data were entered and analyzed using SPSS statistical software, version 15.0. Results: Out of 15,818 deliveries over the study period, 92 had uterine rupture, giving a prevalence of 0.58% or 1 in 172 deliveries. The majority of the patients 56, (60.8%) were Para 1 and 2. Majority (77.2%) were unbooked. Of the 92 patients with uterine rupture, 73 (85.9%) had emergency caesarean section. Fourteen patients had prolonged labour: 2 were primigravidas and 12 were multigravidas. Case fatality rate was 2.2% while the perinatal mortality rate was 61.9%. Conclusion: Uterine rupture constituted a major obstetric emergency in the study hospital and its environs. An "unbooked" status was a key associated factor. The incidence and perinatal mortalities were high. There is therefore a need for education of women on health-related issues, utilization of available health facilities, adequate supervision of labour and provision of facilities for emergency obstetric care.
Keywords: Fetomaternal outcome, perinatal mortality, unbooked, uterine rupture
|How to cite this article:|
Osemwenkha PA, Osaikhuwuomwan JA. A 10-year review of uterine rupture and its outcome in the University of Benin Teaching Hospital, Benin City. Niger J Surg Sci 2016;26:1-4
|How to cite this URL:|
Osemwenkha PA, Osaikhuwuomwan JA. A 10-year review of uterine rupture and its outcome in the University of Benin Teaching Hospital, Benin City. Niger J Surg Sci [serial online] 2016 [cited 2019 Dec 12];26:1-4. Available from: http://www.njssjournal.org/text.asp?2016/26/1/1/196256
| Introduction|| |
Ruptured uterus is a hazardous complication of pregnancy and labor, and it carries a high risk both to the mother and the fetus. , Worldwide, every year, between 340,000 and half a million women die due to complications of pregnancy and child birth, the majority of these occurring in low-income countries. , Sub-Saharan Africa bears over 90% of the burden. Uterine rupture, one of the major obstetric complications of labor, contributes significantly to maternal and perinatal mortality. The occurrence of uterine rupture varies in different parts of the world. 
While it is rare in high-income countries, it remains a public health problem in low-income countries, particularly in Africa and mainly occurring as a consequence of prolonged, obstructed labor.  In the developing countries where obstetric services are either poor or nonexistent coupled with high parity, cephalopelvic disproportion, and an increasing incidence of previous uterine scars, it remains a common and major cause of maternal and perinatal morbidity and mortality. Secondary factors in the developing world include poverty, ignorance, illiteracy, traditional practices, aversion to abdominal delivery, and nonutilization of available health services. 
Ruptured uterus is a serious obstetric emergency with a high maternal and perinatal mortality. It is a preventable obstetric problem common in developing countries with poor obstetric services. Inadequate obstetric services coupled with the reluctance of the illiterate masses to accept even the limited services available have made ruptured uterus an ever-present obstetric problem in the third world countries. Furthermore, most women are averse to cesarean delivery regarding it as a sign of reproductive failure. , Consequently, most would like to avoid hospital care, especially where a previous cesarean operation was performed, no matter the extent of the risk involved. A reduction in the incidence can be achieved through the provision of adequate obstetric services, health education, and counseling as well as antenatal screening to detect those at risk. 
Uterine rupture during pregnancy is an obstetric emergency. It is most commonly associated with a scar on the uterus followed by multiparous patients with inadvertent use of oxytocics or obstructed labor.  Congenital uterine anomalies, fetopelvic disproportion, multiparity, previous myomectomy and cesarean scars, fetal macrosomia, labor induction or augmentation, neglected labor, abnormal lie, and uterine instrumentation, are all predisposing factors to uterine rupture. The signs and symptoms of uterine rupture depend on the timing, site, and extent of uterine defect.  Immediate maternal complications of ruptured uterus are hypovolemic shock, infection, and death while for the fetus, hypoxia, shock, anemia, and death may ensue. 
In Nigeria, the incidence of uterine rupture remains high and continues to increase because of poverty, illiteracy, unavailability of human power, poor supply of medical equipment and consumables, and dwindling health-care funding as a result of bad governance.  As poverty and illiteracy multiply with high hospital bills in these poorly-equipped and staffed government hospitals, more women seek care at primary health centers, traditional birth attendants, mission (faith) centers, and home deliveries, which are more affordable, but more risky.  This study, therefore, explored the factors and feto-maternal outcomes associated with uterine rupture in the University of Benin Teaching Hospital (UBTH), Nigeria.
| Materials and Methods|| |
A 10-year retrospective study of all cases of rupture uterus in the UBTH between January 2005 and December 2014 was carried out. Records of the labor wards and theater were searched and the folder numbers of the patients with uterine rupture were retrieved. The names and hospital number of all the cases of uterine rupture in the hospital were obtained from the labor ward and operating theater registers. Relevant information was extracted, namely, sociodemographic variables, booking status, clinical presentation, points of referral, type of delivery, complications, and fetal and maternal outcome.
The data were entered and analyzed using SPSS statistical software, version 15.0 (SPSS, Chicago, IL, USA). Descriptive statistics was obtained through frequencies and cross tabulations. Results were presented using percentages, tables, and charts.
| Results|| |
During the study, there were a total of 92 cases of uterine rupture out of 15,818 deliveries, giving a prevalence of 0.58% or 1 in 172 deliveries. The yearly trend showed a range of 0.43-0.83%. Prevalence was higher in 2007 (0.83%; 1 in 119 deliveries) and a gradual decline to a prevalence of 0.43% (1 in 231 deliveries) in 2014 [Figure 1]. The age range of patients was 20-44 years with a mean of 30.8 ± 5.2 years while the majority (72, 78.3%) were ≥34 years. The majority of the patients (56, 60.8%) were Para 1 and 2. Four patients were grand multiparous (parity ≥5) and nulliparous (parity = 0). Majority (66.7%) belonging to parity 1 and 2 had previous cesarean section scars. Only 21 (22.8%) patients were registered for antenatal care (booked) while majority (71, 77.2%) were unbooked.
|Figure 1: Line graph showing the yearly trend of uterine rupture from 2005 to 2014|
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More than half (51.8%) of the patients had previous spontaneous vaginal delivery while 43.5% had previous emergency cesarean section.
Of the 92 patients with uterine rupture, 73 (85.9%) had emergency cesarean section. Fourteen patients had prolonged labor: 2 were primigravidas and 12 were multigravidas. Eighteen (19.6%) had intra-partum care and delivery in UBTH, 23.9% delivered in private hospitals, while the place of delivery for 55.4% of the patients were unknown. Thirteen patients had laparotomy during their cesarean section [Table 1].
For fetal outcomes, 14 (15.2%) had Apgar scores of <6 in 1 min and 21 (22.8%) had Apgar score of 7 or above. Ten (11.1%) infants weighed below 2.5 kg while 19 (21.1%) were macrosomic. There were 43 fresh stillbirths and 14 macerated stillbirths, giving a perinatal mortality rate of 61.9%. Two women died, out of which one was postoperative. The cause of death was associated with blood loss [Table 2].
| Discussion|| |
Uterine rupture has remained a significant cause of maternal and perinatal mortality in developing countries where there is inadequate obstetric services coupled with poor health-seeking behavior. An incidence of 1 in 172 deliveries reported in this study is low compared with an incidence of 1 in 131 reported in Uganda.  This incidence is high when compared with another Nigerian study with an incidence of 1 in 258.  In addition, skilled obstetric care is limited and relatively expensive. Furthermore, a woman with previous cesarean delivery would prefer attempted vaginal delivery with an unskilled attendant to undergo another cesarean section regardless of the inherent health threat. ,,, Ignorance and poor socioeconomic status are the major factors associated with the high incidence of uterine rupture in this setting.
Majority (77.2%) of the patients in this study were unbooked. The occurrence of uterine rupture among mostly unbooked patients has also been noted in other studies. ,,,,, The differences in the level of obstetric practices, availability, and utilization of the essential obstetric care services would account for the persistent high rate of uterine rupture in our environment and its rare occurrence in the developed economies. Other contributing factors include transportation difficulties and poor attitude of health-care providers. , Thus, there is an urgent need for good communication network between the tertiary health institutions and the peripheral health units to ensure proper referral of the complicated cases.
There were two maternal deaths in this study giving a mortality of 2.2%. Both were unbooked and due to blood loss. Late presentation to the hospital is a major cause of this poor prognosis. This late presentation could be as a result of poverty, delayed referral, poor transport network, and poor ambulance services. The high perinatal mortality rate recorded in this study supports the preposition that uterine rupture is a major cause of maternal and perinatal morbidity and mortality in our environment.  Similar high perinatal mortality rate has also been reported in other studies. ,
| Conclusion|| |
Uterine rupture still constitutes a major obstetric complication, and inadequate utilization of antenatal services is a major contributory factor. Thus, efforts need to be made to improve proper utilization of limited health facilities, by increasing socioeconomic status of woman, providing easy access to emergency obstetrics care as well as improving the communication and transportation systems. There is also a need for proper education of females about the associated risk after a previous cesarean section if pregnancy and labor are unsupervised in the next confinement. Health education and counseling of potential and expectant mothers would be of immense significance.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Nagarkatti RS, Ambiye VR, Vaidya PR. Rupture uterus: Changing trends in etiology and management. J Postgrad Med 1991;37:136-9.
Agu O, Yakasai I, Muhammad Z, Saidu A. Uterine rupture: A major contributor to obstetric morbidity in Kano, Northern Nigeria. Int J Gynecol Obstet 2009;107:S39-96.
Mukasa PK, Kabakyenga J, Senkungu JK, Ngonzi J, Kyalimpa M, Roosmalen VJ. Uterine rupture in a teaching hospital in Mbarara, Western Uganda, unmatched case - Control study. Reprod Health 2013;10:29.
Souza JP, Cecatti JG, Parpinelli MA, de Sousa MH, Serruya SJ. Systematic review of near miss maternal morbidity. Cad Saude Publica 2006;22:255-64.
Esike CO, Umeora OU, Eze JN, Igberase GO. Ruptured uterus: The unabating obstetric catastrophe in South Eastern Nigeria. Arch Gynecol Obstet 2011;283:993-7.
Ebeigbe PN, Enabudoso E, Ande AB. Ruptured uterus in a Nigerian community: A study of sociodemographic and obstetric risk factors. Acta Obstet Gynecol Scand 2005;84:1172-4.
Ekpo EE. Uterine rupture as seen in the University of Calabar Teaching Hospital, Nigeria: A five-year review. J Obstet Gynaecol 2000;20:154-6.
Mbamara SU, Obiechina N, Eleje GU. An analysis of uterine rupture at the Nnamdi Azikiwe University Teaching Hospital Nnewi, Southeast Nigeria. Niger J Clin Pract 2012;15:448-52.
Ekele BA, Audu LR, Muyibi S. Uterine rupture in Sokoto, Northern Nigeria - Are we winning? Afr J Med Med Sci 2000;29:191-3.
Ezechi OC, Mabayoje P, Obiesie LO. Ruptured uterus in South Western Nigeria: A reappraisal. Singapore Med J 2004;45:113-6.
Nyengidiki TK, Allagoa DO. Rupture of the gravid uterus in a tertiary health facility in the Niger delta region of Nigeria: A 5-year review. Niger Med J 2011;52:230-4.
Ezechi OC, Fasubaa OB, Dare FO. Socioeconomic barriers to safe motherhood among booked patients in rural Nigerian communities. J Obstet Gynaecol 2000;20:32-4.
Ezegwui HU, Nwogu-Ikojo EE. Trends in uterine rupture in Enugu, Nigeria. J Obstet Gynaecol 2005;25:260-2.
Igwegbe AO, Eleje GU, Udegbunam OI. Risk factors and perinatal outcome of uterine rupture in a low-resource setting. Niger Med J 2013;54:415-9.
Onwudiegwu U, Ezechi OC. Emergency obstetric admission, case referral, misdiagnosis and consequences. J Obstet Gynaecol 2001;21:570-5.
[Table 1], [Table 2]