Chapter
Rupture of the Uterus
24 Ana Pinas Carrillo and Edwin Chandraharan
Introduction
Uterine rupture is an obstetric emergency that arises
due to the disruption of the uterine wall, which occurs
most frequently during labour and delivery but, rarely,
may also occur during pregnancy. It is a catastrophic
emergency, associated with high rates of both maternal
and neonatal morbidity and mortality. The incidence
of uterine rupture in an unscarred uterus is 1 in 10 000
deliveries; however, it increases up to 1% in women
with previous caesarean section (CS). It can have dra-
matic consequences from infertility due to irreparable
damage to the uterus that may necessitate hysterec-
tomy, to maternal or neonatal death if diagnosis and
surgical treatment are delayed.
Although uterine rupture is a rare event in mod-
ern obstetric practice, progressively increasing CS
rates, especially in Western countries, could poten-
tially increase its incidence. Uterine rupture can hap-
pen during the antenatal period, especially in the pres-
ence of a previous classical CS scar. However, it occurs
most commonly during labour after the onset of uter-
ine contractions. It is also more common in a scarred
uterus, but in some parts of the developing world with
poor healthcare, it can occur in an unscarred uterus
often due to grand multiparity and adverse intra-
partum factors such as prolonged or obstructed labour,
especially associated with undiagnosed cephalo-pelvic
disproportion.
Epidemiology
Uterine rupture is rare in developed countries. The
prevalence for women with previous CS is around 1%,
while on an unscarred uterus it is extremely rare (1
per 10 000). The World Health Organization (WHO)
undertook a systematic review to obtain data on preva-
Best Practice in Labour and Delivery, Second Edition, ed. Sir Sabaratnam Arulkumaran. Published by Cambridge University
Press. 
C Cambridge University Press 2016.
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lence/incidence of maternal mortality and morbid-
ity from uterine rupture. They included 86 groups of
women and concluded that the prevalence of uterine
rupture tended to be lower for countries defined as
developed than those classified as less or least devel-
oped. For women with a previous CS, the prevalence of
uterine rupture was reported to be approximately 1%.
Only one group from a developed country reported
data for women with an unscarred uterus and the
prevalence was extremely low (0.006%) [1].
Classification and Risk Factors
There are two types of uterine rupture. Complete
uterine rupture is defined as a full-thickness separa-
tion of the uterine muscle and the overlying visceral
peritoneum; it can be associated with the extrusion
of the fetus, placenta or both into the abdominal
cavity. It is a dramatic life-threatening emergency
for both the mother and the baby. An incomplete
rupture is a disruption of the uterine muscle, but
the visceral peritoneum remains intact, which is fre-
quently due to a dehiscence of the CS scar. It is usu-
ally uncomplicated. Figure 24.1a shows a complete
rupture and Figure 24.1b shows a partial rupture or
dehiscence.
The most important risk factor for uterine rupture
is the presence of a previous scar. Other causes are
shown in Table 24.1.
Previous Caesarean Section
Antepartum rupture is rare and imaging studies of
the previous caesarean scar are unreliable to predict
the likelihood of intrapartum uterine rupture [2].
A systematic review that analysed 59 full-text arti-
cles including one randomized controlled trial (RCT)
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 Chapter 24: Rupture of the Uterus
(a) Total myometrial (b)
and serosal
disruption
Table 24.1 Classification of causes of uterine rupture
Uterine injury or anomaly sustained before current
pregnancy
1. Surgery involving the myometrium
Caesarean section or hysterotomy
Previously repaired uterine rupture
Myomectomy
Deep cornual resection
Metroplasty
2. Coincidental uterine trauma
Abortion
Sharp or blunt trauma
3. Congenital anomaly
Pregnancy in undeveloped uterine horn
reported that the prevalence of rupture ranged from
0.5% to 1% [3].
There is no clear evidence on the effectiveness
and safety of the agents used for induction of labour
in women with a previous uterine scar. A Cochrane
review [4] concluded that there was insufficient evi-
dence available on which to base clinical decisions
regarding management. It is, however, widely accepted
that the use of misoprostol for induction of labour is
contraindicated in the presence of a scarred uterus.
One large study (20 095 cases) which analysed women
who delivered a second singleton following a previ-
ous CS reported a uterine rupture rate of 5.2 per 1000
for spontaneous labour and 24.5 per 1000 for labour
induced with prostaglandins [5]. Oxytocin used for
induction and augmentation remains an option. How-
ever, it has been reported that doses exceeding 20
mU/min increase the risk of uterine rupture at least
four-fold [3].
Previous Uterine Surgery
Despite the lack of evidence, the vast majority of obste-
tricians recommend an elective CS after myomectomy
if the cavity has been entered into (i.e. breached) [6].
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Figure 24.1 Types of scar rupture: (a)
complete rupture; (b) scar dehiscence.
Serosa intact
Uterine injury or abnormality during current
pregnancy
1. Before delivery
Induction or augmentation of labour
External trauma
External cephalic version (ECV)
2. During delivery
Internal podalic version
Difficult forceps
Breech extraction
3. Acquired in pregnancy
Placenta increta or percreta
Adenomyosis
Sacculation of entrapped retroverted uterus
The location of the fibroid, the surgical technique and
the occurrence of postoperative infection are other fac-
tors that can contribute to uterine rupture in subse-
quent pregnancy [7].
A comparison of the rates of uterine rupture
between women with prior myomectomy (176) or
prior classical caesarean delivery (455) with women
with a prior low transverse caesarean (13 273) showed
no statistical difference in the frequency of uterine
rupture between the group with a prior myomectomy
and the one with low transverse CS [8].
However, this study unfortunately does not state
how many patients with a previous myomectomy
delivered vaginally.
Laparoscopic myomectomies appear to be safe.
A study reviewed 47 pregnancies in 40 patients
after laparoscopic myomectomy. Vaginal delivery was
attempted in 72% and was achieved in 83% in those
who attempted a vaginal delivery with no cases of rup-
ture. The authors advised that vaginal birth can be
safely achieved provided they are managed as patients
with previous CS [9].
Advances in the subspecialty of fetal medicine have
resulted in an increasing number of intrauterine fetal

surgeries. Fetoscopic procedures and open procedures
such as ex utero intrapartum treatment (EXIT) pro-
cedure or mid-gestation open maternalfetal surgery
(OMFS) involve injury to a pregnant uterus and, sub-
sequently, an increased risk of uterine rupture. Wilson
et al. [10] reviewed the reproductive outcomes of 97
women undergoing maternalfetal surgery. The num-
ber of subsequent pregnancies was 47, with a uterine
dehiscence rate of 14% and rupture rate of 14%. These
outcomes in a subsequent pregnancy should form part
of counselling prior to OMFS.
Obstructed Labour
This represents an important cause of spontaneous
rupture in the developing world, especially in women
labouring outside hospital. There is a high incidence
of cephalo-pelvic disproportion in Black African
women. A retrospective review of 82 cases of uter-
ine rupture in a Nigerian hospital (incidence 0.85%)
showed that obstructed labour was the third com-
monest cause (18.7%) and occurred only in unbooked
patients [11].
Multiparity is an independent risk factor for uter-
ine rupture and it is considered to be due to the pres-
ence of a greater proportion of collagen compared to
smooth muscle.
Congenital Uterine Malformations and
Connective Tissue Disorders
In the presence of uterine congenital malformations,
the walls are likely to be thinner and tend to dimin-
ish in thickness as gestation advances. Moreover, addi-
tional thinning can occur in the presence of uter-
ine contractions [12]. Overall, uterine malformations
complicate 1 in 594 pregnancies and the greatest risk
of uterine rupture occurs during labour.
Disorders of connective tissue can also affect the
structure and function of the uterus. There are cases
described of uterine rupture associated with Ehlers
Danlos syndrome [13].
Induction of Labour and Termination
of Pregnancy
There are only a few RCTs of induction of labour in
women with a previous CS. Different methods have
different incidence of uterine rupture. Ophir et al. [14]
reviewed the existing evidence and concluded that the
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Chapter 24: Rupture of the Uterus
lowest rate of uterine rupture occurred with oxytocin
(1.1%), then dinoprostone (2%), and the highest rate
was with misoprostol (6%).
Trauma
Trauma contributes to only a minority of cases of uter-
ine rupture. It usually occurs in the context of a road
traffic accident or a history of assault. It is important
to optimize education in trauma prevention in preg-
nancy and exclude uterine rupture in cases of domestic
violence [15].
Mechanisms
It is well known that the risk of uterine rupture in-
creases with the use of prostaglandins for induction
of labour. However, the exact pathophysiology is not
completely clear. Although one of the contributing fac-
tors is increased uterine contractility, it is believed that
there may also be some biochemical changes within
the collagen component of the scar tissue. This is illus-
trated by the observation that women treated with
prostaglandins are more likely to experience rupture
at the site of the old scar, whereas women treated with
oxytocin experience uterine rupture on sites remote
from the old scar [16]. Prostaglandins may induce
changes in the collagen and ground substance (gly-
cosaminoglycans) of the uterine scar, predisposing to
an increased incidence of scar dehiscence or rupture.
Clinical Features
Uterine rupture can manifest with a wide spectrum
of symptoms and signs depending on the site, extent
and timing of rupture. While a scar dehiscence can
be asymptomatic, a complete rupture can represent a
dramatic emergency with fatal consequences for the
mother, the fetus or both. Classical symptoms and
signs include sudden onset of abdominal pain which is
continuous and persistent between contractions, fresh
vaginal bleeding, scar tenderness, evidence of fetal
compromise (changes in fetal heart rate (FHR)) and
alteration in the shape of the abdomen with the pres-
ence of easily palpable fetal parts. It is rare to observe
all classical features in a single patient and a high index
of clinical suspicion is required.
Abnormal FHR patterns can be detected on a
cardiotocograph (CTG). These include cessation of
uterine contractions often preceded by tachysystole
or hypertonia, reduced baseline variability, variable
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 Chapter 24: Rupture of the Uterus

or late decelerations or a single prolonged decelera-

tion. The mechanisms underlying these CTG features
include cord prolapse through the ruptured scar show-
ing variable decelerations and abruption leading to late
or prolonged decelerations.
Other symptoms include haematuria and bladder
tenderness, especially with a previous lower segment
uterine scar, as well as maternal tachycardia and signs
of hypovolaemic shock and collapse that can lead to
fetal demise or even maternal death, if immediate
resuscitation and surgical treatment are delayed.
Uterine rupture presents most commonly as an
intrapartum event but it can also occur in the antepar-
tum period and very rarely in the immediate post-
partum period. Figure 24.2 Uterine scar dehiscence during second stage of
labour with a haematoma under the visceral peritoneum during
laparotomy. See the colour plate section for a colour version of this
figure.
Antepartum Rupture
Antepartum uterine rupture is characterized by ab- Continuous FHR monitoring is recommended
dominal pain as the most important clinical symp- in all women aiming for vaginal delivery after CS
tom. Vaginal bleeding may be present, but haemor- (VBAC). Several studies report the association be-
rhage may be intra-abdominal, resulting in irritation tween FHR changes and uterine rupture. Prolonged
of the diaphragm and causing pain referred to chest deceleration, reduced baseline variability and uterine
or to the shoulder. Antepartum rupture can occur in tachysystole were found to be common patterns with
early pregnancy in patients with previous upper seg- uterine rupture [18,19].
ment scars and not associated with contractions [17]. A receding presenting part (loss of station) may
The patient can present with signs of shock, mainly also be a sign of uterine rupture, if the fetal presenting
due to hypovolaemia, although it can also have a neu- part had already entered the pelvis prior to the rupture.
rogenic component. There may be abdominal tender- Abdominal and vaginal examination can identify the
ness, especially if associated with haemoperitoneum or presenting part rising above the pelvic inlet.
presence of fetal parts into the abdominal cavity; how-
ever, uterine scar tenderness is not a reliable sign of Postpartum Rupture
uterine rupture.
This is an extremely rare event that usually presents
with abdominal pain and postpartum haemorrhage.
Intrapartum Rupture On vaginal examination, it is sometimes possible to
palpate a dehiscence in the uterine wall and if the rup-
This is the most common presentation of uterine rup-
ture is complete the fingers can be passed into the peri-
ture. Abdominal pain is also a common symptom, clas-
toneal cavity. However, studies have shown that sys-
sically presenting as constant acute pain that doesnt
tematic manual uterine exploration after VBAC does
subside between contractions. Parallel to this, it is
not improve the outcomes. Moreover, it can increase
possible to observe a loss of contractions on the CTG,
the risk of manual uterine rupture [20], and there-
usually preceded by tachysystole or hypertonia. It can
fore this practice should be avoided. Figure 24.2 shows
be difficult to interpret in the context of labour, but
uterine scar dehiscence that occurred during active
should raise the suspicion of uterine rupture or abrup-
pushing which was followed by maternal collapse in
tion. Scar tenderness, changes in uterine shape and
the immediate postpartum period.
palpation of fetal parts are other signs suggestive of
rupture. They have high sensitivity but low specificity
and are frequently unreliable. Vaginal bleeding may or Findings on Laparotomy
may not occur. Haematuria might be present if there is Low uterine segment (LUS) is the part most commonly
bladder involvement. involved in rupture, with some studies reporting

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up to 92% of cases [21]. However, other parts may
be involved, especially on previous classical CS, or
involvement of the cervix among patients with an
unscarred uterus. Rupture of the lower segment can
also extend anteriorly towards the bladder, laterally
towards the uterine arteries and into the broad liga-
ment. It is important to perform a systematic exam-
ination of the uterus and other abdominal organs to
ensure appropriate identification of all areas involved.
Posterior rupture is rare but it can occur associ-
ated with uterine malformations, obstructed labour or
instrumental delivery.
Diagnosis
There have been several attempts to predict the risk of
uterine rupture in patients with a previous CS using
ultrasound antenatally. A recent review included 21
articles that described LUS thickness in relation to the
occurrence of a uterine dehiscence or rupture during
labour. They found an LUS thickness cut-off of 3.1
5.1 mm and a myometrium thickness cut-off of 2.1
4.0 mm provided a strong negative predictive value for
the occurrence of a uterine rupture during VBAC. A
myometrial thickness between 0.6 and 2 mm provided
a strong positive predictive value for the occurrence of
a rupture. However, they could not determine an ideal
cut-off to aid clinical practice [22].
The use of magnetic resonance imaging has also
been described, but results are still inconclusive [23].
Clinical parameters include extension of uterine inci-
sion to the upper segment, uterine tears and very
preterm CS.
Management
When uterine rupture is diagnosed, immediate deliv-
ery should be expedited to improve maternal and
neonatal outcome. Initially, maternal vital signs need
to be assessed, if the woman presents with signs of
haemorrhagic shock, she needs to be resuscitated and
stabilized. Fluid resuscitation and blood transfusion
are vital to correct hypovolaemia, hypoxia and aci-
dosis. Complete uterine rupture is an obstetric emer-
gency that can lead to fetal demise and even mater-
nal death if there is delayed intervention. The gravid
uterus receives 12% of the cardiac output and thus
uterine haemorrhage can lead to rapid hypovolaemic
shock, which may pose an anaesthetic challenge.
This is because inducing anaesthesia in patients who
are hypovolaemic and hypotensive and maintaining
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Chapter 24: Rupture of the Uterus
haemodynamic status before haemostasis is achieved
could be challenging. Moreover, these patients can fre-
quently develop coagulopathy and require blood prod-
ucts. The presence of an experienced obstetrician as
well as an anaesthetist is essential. Senior neonatal
input is also needed as the neonate is often born in
poor condition.
Immediate laparotomy is essential and delivery of
the fetus should be achieved within 15 min (cate-
gory 1 CS). Occasionally the fetus may be completely
extruded in the abdominal cavity and this is associated
with worse outcomes.
Once the fetus and placenta are delivered, it is rec-
ommended to exteriorize the uterus in order to help
arrest the bleeding and give a better view of the pos-
terior aspect, the broad ligament and uterine angles to
identify the site(s) of the rupture and associated lac-
erations. Once this has been done, the surgeon should
decide on the most appropriate surgery depending on
the patients general condition, type and extent of the
rupture, facilities available, previous obstetric history
and own experience.
In case of a simple laceration or scar rupture, repair
is appropriate, after ensuring that there are no lat-
eral extensions or involvement of the broad ligament,
parametrial vessels, ureters and bladder.
In cases of dehiscence of lower segment CS scars,
it is advisable to trim the edges and suture the most
viable parts [24].
Tubal sterilization could be considered, provided
the circumstances have allowed to discuss this with the
patient. However, if the rupture is simple and unin-
fected and the patient has a strong desire to preserve
fertility, this can be omitted.
Hysterectomy should be considered in a life-
threatening situation when the patient is haemody-
namically unstable and it is not possible to achieve
haemostasis. It may also be considered in cases of
extensive laceration. A subtotal hysterectomy is the
advisable procedure if the cervix and paracolpos are
not involved and if there is no associated sepsis. Uter-
ine artery embolization is generally not feasible due to
accompanying haemodynamic instability.
Insertion of a drain should be considered if there
is evidence of continuous bleeding due to coagulopa-
thy. Perioperative care includes appropriate admin-
istration of prophylactic antibiotics and thrombo-
prophylaxis.
Appropriate documentation of the sequence of
events that led to the uterine rupture along with
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 Chapter 24: Rupture of the Uterus
the subsequent management plan is very important.
Umbilical cord gases are mandatory.
An adverse incident report should be completed
to inform the risk management team. In developed
countries, uterine rupture is one of the most common
clinical causes of medical litigation in obstetrics and
gynaecology. In most cases, it is driven by poor clinical
outcomes. Injudicious use of oxytocin is indefensible.
An appropriate debrief to the patient to discuss the
sequence of events and consequences is very impor-
tant. If the uterus has been preserved and no tubal
ligation was performed, it is advisable to recommend
contraception for a minimum of two years. Any future
pregnancy should be closely monitored and an early
elective CS should be considered after 37 weeks.
Differential Diagnosis
The main symptoms that present on uterine rupture
are abdominal pain, hypovolaemia and fetal compro-
mise. In the presence of these symptoms it is impor-
tant to exclude placental abruption that may or may
not present with vaginal bleeding. The obstetric his-
tory and clinical picture can help differentiate these
two emergencies. Other less common conditions that
can present with similar symptoms include subcapsu-
lar liver haematoma with or without rupture, splenic
rupture, rupture of the broad ligament uterine vein
and uterine torsion. All of these conditions require
urgent surgical intervention and immediate laparo-
tomy is generally indicated in patients presenting with
these symptoms.
Complications
Maternal
Maternal morbidity and mortality very much depend
on the extent of the rupture, the timeliness of
diagnosis and intervention, and the availability of
resources. Haemoperitoneum, the subsequent haem-
orrhagic shock and the complications derived from the
interventions are responsible for the maternal compli-
cations.
In developed countries, maternal death is ex-
tremely rare but morbidity is significant. Complica-
tions secondary to the emergency intervention includ-
ing bladder and ureteric injuries are not uncommon,
especially during peripartum hysterectomy. Other
complications include acute renal failure due to the
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hypovolaemia, adverse effects derived from the mas-
sive blood transfusion and postoperative complica-
tions such as infection and thromboembolism. In
more dramatic cases of massive haemorrhage, patients
can develop renal, pituitary or liver failure that expe-
dite transfer to the intensive care unit.
Long-term sequelae include renal failure and Shee-
hans syndrome and psychological disorders secondary
to the permanent loss of fertility in cases of hysterec-
tomy, and post-traumatic stress disorder when there is
a poor neonatal outcome.
The rare cases of maternal death in the devel-
oped world may be due to haemorrhage, shock, sep-
sis, disseminated intravascular coagulation and pul-
monary embolism [25]. There is also an important
human factor; failure to recognize the clinical condi-
tion and institute timely and appropriate intervention,
failure to seek timely senior help and failure in effec-
tive multidisciplinary communication are some of the
factors that may increase the likelihood of maternal
mortality.
In less developed countries uterine rupture repre-
sents an important cause of mortality accounting for
as many as 9.3% of maternal deaths as reported by
one Indian study [26]. In the Second Report on Confi-
dential Enquiries into Maternal Deaths in South Africa
19992001, ruptured uterus was responsible for 6.2%
of deaths due to direct causes and 3.7% of all deaths
(1.9% due to rupture of an unscarred uterus and 1.8%
due to a scarred uterus) [1]. This increase is believed
to be due to the use of misoprostol in uncontrolled
dosages for induction of labour.
Perinatal
Disruption of uteroplacental circulation, secondary
to placental abruption, results in fetal hypoxia and
metabolic acidosis. This may result in neurological
sequelae. If severe and not acted on in time it may
result in perinatal death. The median umbilical cord
gases reported are 6.80, median base excess 22 and
median five minute Apgar score 4 [27]. Approximately
6% of uterine ruptures will result in perinatal death.
The risk of hypoxic-ischaemic encephalopathy with
long-term disability ranges from 0.5% to 19% [3]. In
addition, short-term complications such as neonatal
seizures and multiple organ failure requiring intu-
bation and ventilation may ensue. Long-term impli-
cations include impaired motor development, learn-
ing difficulties and cerebral palsy. Neurological injury

is rare if the infant is delivered within 18 min and
good outcomes have been reported when delivered
within 30 min [3]. Severe complications are more likely
to occur in more dramatic cases of uterine rupture
with placental or fetal extrusion into the abdominal
cavity as the hypoxic insult is more acute in these
cases [27].
Reproductive Outcome
Pregnancy after uterine rupture can be successfully
managed with good antenatal, intrapartum and post-
partum surveillance. There is no clear evidence on the
course of action to be taken but there is a general con-
sensus that delivery should be by elective CS as the risk
of uterine rupture is too high. The timing of delivery
will be assessed individually according to the gesta-
tional age of presentation of uterine rupture in the pre-
vious pregnancy, type of scar and individual obstetric
history.
Recurrent uterine ruptures are associated with a
high incidence of maternal and perinatal morbidity. It
has been reported that recurrences are frequent, espe-
cially after longitudinal ruptures and short intervals
between pregnancies.
Conclusion
Uterine rupture can occur at any gestational age. In
developed countries uterine rupture is most com-
monly related to the presence of previous CS. The
key steps to improve the outcomes are anticipation of
uterine rupture and early diagnosis. Continuous elec-
tronic fetal monitoring in high-risk patients such as
women undergoing trial of labour with the aim of vagi-
nal delivery with a scarred uterus and recognition of
cephalo-pelvic disproportion or malposition prior to
augmentation of labour, especially with prolonged sec-
ond stage of labour, will help to reduce uterine scar
rupture.
In low-resource settings, primary precautions are
the most important. These include health education
such as recommendation of contraception in high-risk
women, improving the access to healthcare services
and provision of resources to deal with obstetric emer-
gencies.
Although it is not currently possible to predict
the occurrence of uterine rupture, early diagnosis
and establishment of appropriate interventions are the
key to improve the outcome for mothers and their
babies.
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Chapter 24: Rupture of the Uterus
References
1. Hoffmeyr GJ, Say L, Gulmezoglu AM. WHO
systematic review of maternal mortality and
morbidity: the prevalence of uterine rupture. BJOG.
2005; 112: 12218.
2. Varner M. Cesarean scar imaging and prediction of
subsequent obstetric complications. Clin Obstet
Gynecol. 2012; 55: 53341.
3. Scott JR. Intrapartum management of trial of labour
after caesarean delivery: evidence and experience.
BJOG. 2014; 121: 15762.
4. Jozwiak M, Dodd JM. Methods of term labour
induction for women with a previous caesarean
section. Cochrane Database Syst Rev. 2013; 3:
CD009792.
5. Lydon-Rochelle M, Holt VL, Easterling TR, Martin
DP. Risk of uterine rupture during labour in patients
with a prior caesarean delivery. N Engl J Med. 2001;
345: 38.
6. Weibel HS, Jarcevic R, Gagnon R, Tulandi T.
Perspectives of obstetricians on labour and delivery
after abdominal or laparoscopic myomectomy. J Obstet
Gynaecol Can. 2014; 36(2): 12832.
7. Walsh CA, Baxi LV. Rupture of the primigravid uterus:
a review of the literature. Obstet Gynecol Surv. 2007;
62(5): 32734.
8. Gyamfi-Bannerman C, Gilbert S, Landon MB, et al.
Risk of uterine rupture and placenta accreta with prior
uterine surgery outside of the lower segment. Obstet
Gynecol. 2012; 120(6): 13327.
9. Hurst BS, Matthews ML, Marshburn PB. Laparoscpic
myomectomy for symptomatic uterine myomas. Fertil
Steril. 2005; 12: 2416.
10. Wilson RD, Lemerand K, Johnson MP, et al.
Reproductive outcomes in subsequent pregnancies
after a pregnancy complicated by open maternalfetal
surgery (19962007). Am J Obstet Gynecol. 2010;
203(3): e16. doi: 10.1016/j.ajog.2010.03.029.
11. Akaba GO, Onafowokan O, Offiong RA, Omonua K,
Ekele BA. Uterine rupture: trends and feto-maternal
outcome in a Nigerian teaching hospital. Niger J Med.
2013; 22(4): 3048.
12. Nahum GG. Uterine anomalies, induction of labour
and uterine rupture. Obstet Gynecol. 2005; 106(5 Pt 2):
11502.
13. Murray ML, Pepin M, Peterson S, Byers PH.
Pregnancy-related deaths and complications in women
with vascular EhlersDanlos syndrome. Genet Med.
2014; 16(12): 87480. doi: 10.1038/gim.2014.53.
14. Ophir E, Odeh M, Hirsch Y, Bornstein J. Uterine
rupture during trial of labor: controversy of
inductions methods. Obstet Gynecol Surv. 2012;
299
 Chapter 24: Rupture of the Uterus
67(11): 73445. doi: 10.1097/OGX.0b013e318273
feeb.
15. El Kady D, Gilbert WM, Xing G, Smith LH. Maternal
and neonatal outcomes of assaults during pregnancy.
Obstet Gynecol. 2005; 105(2): 35763.
16. Buhimschi CS, Buhimschi IA, Patel S, Malinow AM,
Weiner CP. Rupture of the uterine scar during term
labour: contractility or biochemistry? BJOG. 2005;
112(1): 3842.
17. Turner MJ. Uterine rupture. Best Pract Res Clin Obstet
Gynaecol. 2002; 16: 6979.
18. Ridgeway JR, Weyrich DL, Benedetti TJ. Fetal heart
rate changes associated with uterine rupture. Obstet
Gynecol. 2004; 103: 50612.
19. Sheiner E, Levy A, Ofir K, et al. Changes in fetal heart
rate pattern and uterine patterns associated with
uterine rupture. J Reprod Med. 2004; 49: 3738.
20. Dinglas C, Rafael TJ, Vintzileos A. Is manual palpation
of the uterine scar following vaginal birth after
cesarean section (VBAC) helpful? J Matern Fetal
Neonatal Med. 2015; 28(7): 83941. doi: 10.3109/
14767058.2014.935326
21. Ofir K, Sheiner E, Levy A, Katz M, Mazor M. Uterine
rupture: differences between a scarred and an
300
Downloaded from https://www.cambridge.org/core. Stockholm University Library, on 02 Sep 2017 at 16:46:39, subject to the Cambridge Core terms of use, available at
https://www.cambridge.org/core/terms. https://doi.org/10.1017/9781316144961.026
unscarred uterus. Am J Obstet Gynecol. 2004; 191(2):
4259.
22. Kok N, Wiersma IC, Opmeer BC, et al. Sonographic
measurement of lower uterine segment thickness to
predict uterine rupture during a trial of labor in
women with previous Cesarean section: a meta-
analysis. Ultrasound Obstet Gynecol. 2013; 42(2):
1329. doi: 10.1002/uog.12479.
23. Murphy DJ. Uterine rupture. Curr Opin Obstet
Gynecol. 2006; 18(2): 13540.
24. Rameez MFM, Goonewardene M. Uterine rupture. In
Chandraharan E, Arulkumaran S (eds), Obstetric and
Intrapartum Emergencies (pp. 528). Cambridge:
Cambridge University Press; 2012.
25. Nagarkatti RS, Ambiye VR, Vaidya PR. Rupture
uterus: changing trends in etiology and management.
J Postgrad Med. 1991; 37(3): 1369.
26. Rajaram P, Agarwal A, Swain S. Determinants of
maternal mortality: a hospital based study from
South India. Indian J Matern Child Health. 1995; 6(1):
710.
27. Bujold E, Gauthier RJ. Neonatal morbidity associated
with uterine rupture: what are the risk factors? Am J
Obstet Gynecol. 2002; 186: 31114.