Journal of the Royal Society of Medicine Volume 72 June 1979
415
Rupture of the pregnant uterus in Eastern Libya' Mohammad Sayedur Rahman MB MRCOG Associate Professor of Obstetrics and Gynaecology, University of Garyounis, Benghazi, Libya
Roger J Fothergill MB FRCOG Consultant Obstetrician, Good Hope Maternity Hospital, Sutton Coldfield, and Visiting Professor, University of Garyounis, Benghazi, Libya Uterine rupture in obstetric practice has always been a subject of compelling interest. Obstetricians working nowadays in developed countries find their interest is unfailingly drawn to the dramatic obstetric emergencies still taking place in underdeveloped areas. Rupture of the uterus in recent years in developed countries has often been due to unwise obstetric interference and has frequently taken place in patients who have had previous caesarean sections. Murphy (1 976a, b) compared events in ten recent years at the Rotunda Hospital, Dublin, with O'Driscoll's 1966 review of fourteen years' experience in Dublin Hospitals. He gave a renewed warning about the risks of grand-multiparity and oxytocin in relation to uterine ruptures. Groen (1974) contrasted uterine ruptures in rural Nigeria with those in the USA. The causes of uterine rupture in America, he thought, 'seem to be shifting because of more aggressive management of labour'. Brudenell & Chakravarti (1975), who reviewed 5 cases of uterine rupture in Kings College Hospital, London, also gave warnings against overenthusiastic obstetric management. From 1968-70, in the West Midlands of England, 4 ruptures of the uterus were encountered in 6490 deliveries at Good Hope Maternity Hospital, Sutton Coldfield (Fothergill, unpublished). None of these occurred after previous lower segment caesarean sections, but 2 cases followed previous classical operations; one case was due to obstetric trauma and one to oxytocin. Eighty-six cases of previous caesarean section had been studied during that period, 15 of which had been classical operations. In the last five years, far fewer patients with previous classical caesarean sections have presented and only 2 cases of uterine rupture have occurred, one of which followed a previous lower segment operation (19 247 deliveries). In 1976 in the Birmingham Maternity Hospital there was only one uterine rupture in 3972 deliveries (Annual Report 1976). Rupture of the uterus in England then is rather uncommon and it has been the cause of fewer and fewer deaths in successive reports of confidential enquiries into maternal mortality (Arthure et al. 1975). In underdeveloped countries the situation is quite different. In Khartoum Civil Hospital, for instance, the incidence of uterine rupture was 1:376 deliveries in 1968-71 (Modawi 1974, Abdalla & Modawi 1974). This prevalence in the Sudan has not diminished recently (S S Modawi, 1977, personal communication), and is attributed to lack of obstetric care of abnormal cases. Uterine ruptures in Libya The report which follows is based on 46 cases treated by the first author, MSR, in 1974-77 at the General Hospital, Benghazi, and the records which could be traced of 100 patients who were treated at the same hospital from 1967-73. This hospital, which since 1974 has become the main teaching hospital of the University in Benghazi, delivers about 10 000 patients each year; 95% of these women are admitted in labour, having had no previous antenatal care. 1 Accepted 7 July 1978
0 141-0768/79/060415-06/$O 1.00/0
'."
1979 The Royal Society of Medicine
416
Journal of the Royal Society of Medicine Volume 72 June 1979
Table 1. Age distribution of 146 cases of rupture of the uterus in Benghazi Age (years)
No. of cases
%
18-20 21-25 26-30 3 1-35 36-40 40 and over
5 35 54 37 10 5
3.4 24 37 25.4 6.8 3.4
Complicated obstetric cases are admitted directly as well as being transferred from all the other, smaller maternity hospitals in Benghazi. Patients also come to the hospital from distant towns and villages even as far away as 500 kilometres. Libya is a vast country with a population of only 2.5 million in an area of approximately 1.76 million square kilometres. The majority of Libyans are relatively affluent and have been strongly motivated to bear large families to populate their country; Libya has one of the world's fastest population growth rates. Recently the influence of education has produced some changing attitudes, but the traditional culture-pattern leads to childbearing throughout the reproductive life of Libyan women. This has brought about a prevalence of high parity, and the incidence of grand-multiparity in the hospital is 18%. (Grand multiparae are defined in this study as women who have carried 7 or more pregnancies beyond 28 weeks.) All the patients were Arab; they were mostly Libyan but there were a few from neighbouring countries. The average age was 30.4 years, with a range from 18 to 43 (Table 1). The parity ranged from 0 to 21 with an average of 10.5 (Table 2). Table 2. Parity in 146 cases of rupture of the uterus in Benghazi
Parity 0 1 2 3 4
No. of cases 2 2
10 10 23
5
19
6 7 8
17 12 10
10
12 9 10
11 12+
% 9.6% J
47.3% 43
1 r
43.1%
J
Incidence of uterine rupture From 1966-77 approximately 98 000 deliveries took place in the General Hospital, Benghazi, and the incidence of uterine rupture was 1:671 (1.5 per thousand deliveries). In 1974 the incidence in King Edward VIII Hospital, Durban (Mokgokong & Marivate 1976) was double this and in rural Nigeria in 1972 it was as much as 1: 112 (Groen 1974). In Uganda, Rendle Short (1960) reported a figure of 1:93. In the Rotunda Hospital, Dublin, however, a recent figure was 0.8 per thousand deliveries (Murphy 1976a, b), and in the Clinical Report of the Royal Maternity Hospital, Belfast, in 1973-75, the figure was 0.69 per thousand, an incidence of 1:1439.
Journal of the Royal Society of Medicine Volume 72 June 1979
417
Table 3. Causes of rupture of the unscarred uterus in 118 cases in Benghazi Causes Maternal: Contracted pelvis Grand multiparity only Pelvic tumour Concealed accidental haemorrhage Stenosis of the birth canal Induced: Oxytocin infusion Shirodkar stitch in place Fetal: Shoulder presentation Brow presentation Hydrocephaly Compound presentation Mentoposterior face presentation
No. of cases
%
29 26 3 2 1
24.6 22 2.5 1.7 0.8
3 1
2.5 0.8
26
22 6 4.2 3.4 2.5
7 5 4 3
Table 4. Sixteen cases of traumatic rupture of the uterus in Libya Causes
No. of cases
Internal version Kielland's forceps rotation Shoulder dystocia Arrested after-coming head Manual removal of placenta Packing of the uterus
7 3 2 2 1 I
Causes In Tables 3 and 4 the aetiology for the present series is given, but in many cases more than one cause was responsible. Spontaneous rupture of an unscarred uterus occurred during active labour in 118 patients (80.8% of all our cases). Grand-multiparity on its own is listed as the cause for 26 patients (22% of the spontaneous group), but also contributed to two-fifths of the ruptures in the remaining cases (i.e. 37 ruptures in 92 remaining cases) in which other factors were the principal causes. Even small doses of oxytocin proved to be very dangerous to grand multiparae. Obstructed labour was very frequently due to malpresentation but pelvic contraction needs special emphasis (Fothergill 1973). Pelvic contraction was diagnosed clinically as the cause in 29 patients. Increased fetal size in successive pregnancies adds to the problem. The average fullterm birth weight in the hospital is approximately 4.1 kg. In Libyan patients great obesity is quite frequent and 3% of the female population of Benghazi city are known to have diabetes; very large birth weights are common. Shoulder presentations and other malpresentations and malpositions featured prominently. Hydrocephalus was the cause in 5 patients; major CNS malformations are present in almost 1% of the deliveries at the hospital. Ovarian cysts caused rupture of the uterus in 2 cases; in one case of obstructed labour due to a pelvic mass the tumour was a calcified hydatid cyst.
418
Journal of the Royal Society of Medicine Volume 72 June 1979
Traumatic rupture: Sixteen women (11% of the series) suffered rupture of the uterus from internal version (7 patients) forceps rotation (3) and other obstetric manipulations (Table 4). In one case the cause was thought to be packing of the uterus for post-partum haemorrhage.
Rupture of uterine scars: This occurred in only 12 women in the series (8.2%). There were 2 previous classical scars and 8 scars from previous lower segment caesarean sections. In 2 patients the uterus had ruptured in a previous pregnancy, had been repaired and then had broken again. Clinical features Eighty per cent of the patients came into the hospital as emergencies and uterine rupture was diagnosed on admission, but 29 women (20%) sustained rupture of the uterus during labour in the hospital. About 60% of the patients were severely shocked. The symptoms and signs which occurred were very variable (Table 5). The diagnosis was most easily made when the fetus was Table 5. Clinicalfeatures shown by the 146 cases at the General Hospital, Benghazi (1967-77)
Symptoms and signs
No. of cases
Proportion of total (0)
Signs of shock Abnormal uterine contour Easily palpable fetal parts Cessation of uterine contractions Tenderness Pain Vaginal bleeding Abdominal distension
128 117 109 105 102 80 47 26
88 80 75 72 70 55 32 18
partly or wholly extruded into the abdominal cavity. When the fetus remained in utero a presumptive diagnosis was made which was confirmed at laparotomy. In 87 patients (60%), the lower segment ruptured anteriorly. The fundus of the uterus was involved in 18 cases (12.3%). There was a lateral tear in 22 (15%), posterior in 12 (18.2%), and circumferential in 7 cases (4.8%). Anterior and lateral tears often extended to the fundus or to the vaginal vault; multiple lacerations occurred in 18 cases. The urinary bladder was also ruptured in 8 women (one of whom later developed a vesicovaginal fistula, but this was repaired successfully). In 77.4% of the cases (113 mothers) the fetus died. Anaemia About one half of the pregnant patients in the practice of the hospital had a haemoglobin concentration of less than 9 g/dl. Quite a number of patients were severely anaemic before rupture of the uterus took place, so that when admitted they were reduced to an extremely poor condition. Blood transfusions were necessary for all the cases in this series; half the patients needed up to one litre and the other half required more than this. Although before 1972 blood for transfusion was not readily available in Benghazi, it seemed from the hospital records that maternal deaths in this series were not due to undertransfusion. This finding contrasts with the experience of Boulle & Crichton (1964) who found that inadequate replacement of blood at operation was a contributory cause of death in 3 of their patients.
Treatment During the period 1967-74, irqdividual surgeons acted according to their own preferences in the treatment of these cases, but from 1974-77 the first author (MSR) personally undertook the management of all patients with rupture of the uterus (Table 6). Hysterectomy was then chosen for everyone with 5 or more living children. Repair of the rent in the uterus was usually thought
Journal of the Royal Society ofMedicine Volume 72 June 1979
419
Table 6. Methods of treatment of 146 cases of rupture of the uterus at the General Hospital, Benghazi
Hysterectomy
1967-73 inclusive 1974-77 inclusive Total
Total
Repair
Subtotal
510
49
0
20
18
26
53 (36%)
93 (64%)
* 'Sterilization' was not done in 7 cases * A para 2 and a para 3, with rupture of scars from previous lower segment caesarean sections; 'sterilization' was not done
to be a much less satisfactory method of treatment. Part of the reason for adopting this policy was that several grand multiparae had been asking at the hospital for restoration of fertility after previous repairs of uterine ruptures accompanied by 'sterilization'. Regrettably these patients were eventually submitted to restorative surgery in private clinics abroad. After the policy in favour of hysterectomy was adopted, 26 patients were treated by total hysterectomy and 18 by subtotal hysterectomy. Dehiscence of previous lower segment caesarean section scars in a para 2 and a para 3 were treated by repairs alone. The mortalities associated with different methods of treatment are shown in Table 7. There were 12 maternal deaths in the series (8.2%); 10 of these occurred in the first hundred cases, and 3 in the 46 cases treated from 1974-77. The recent improvement in the maternal mortality figure can be attributed to improved transport facilities, availability of blood for transfusions, and early diagnosis with prompt treatment by a surgeon with a special interest in these disasters. Interpretations of Table 7 must take into account that repair operations were commonly done for less serious cases and that hysterectomy was often necessary for more dangerous conditions. Three patients died from septicaemia, 3 from pulmonary embolism, 2 from renal failure and 4 apparently just from haemorrhage. Table 7. Mortality from uterine rupture, General Hospital Benghazi
(1967-77) Treatment
Numbers of
operations
Numbers of deaths
Total hysterectomy Subtotal hysterectomy Repair and tubal ligations Repair only
26 67 44 9 146
2 6 1 3 12 (8.2%)
Maternal morbidity More than 12 hours delay before operation brought greater morbidity as well as a higher mortality. Four patients had a subphrenic abscess (3 after a repair, one after a subtotal hysterectomy), and 3 had a pelvic abscess needing drainage (after repairs). In 6 cases who had a repair, secondary post-partum haemorrhages took place requiring exploration of the uterus. Intestinal obstruction necessitating another laparotomy occurred four times after repair operations. Four cases had to have postoperative dialysis for renal failure (2 died). Despite generous antibiotic treatment, fevers above 39°C, for up to ten days, occurred in 20 patients who had uterine repairs and 3 who had hysterectomies (but the abdominal wounds healed equally well in the repair and the hysterectomy groups).
420
Journal of the Royal Society of Medicine Volume 72 June 1979
Discussion 'High multiparity', Feeney observed in 1953, 'carries with it certain inherent risks .. it can be very unforgiving of any carelessness, incapacity or neglect.' Our experience in Libya confirms the wisdom of this statement and corresponds with the findings of Israel & Blazar (1964). We were surprised that Boulle & Crichton (1964) found that 'fewer ruptures occurred among grande multiparae then among those who had had from to 5 children'. Our series .
1
emphatically demonstrates the predisposition of grand multiparae to uterine rupture. In Libya there are very many 'dangerous multiparae' (Solomons 1934). Many of these women are at a further disadvantage through being in their late 30s or over 40 years of age, through being
grossly overweight, and through anaemia. In 1932 Mahfouz urged conservative treatment whenever possible, but nowadays the choice in treatment lies between hysterectomy and suture of the rent with sterilization (Menon 1962). Several authors recommend repair of the uterus rather than hysterectomy (e.g. Groen 1974), but in all Murphy's cases (1976a) of spontaneous rupture a hysterectomy was considered necessary. Yussman & Haynes (1970) undertook total hysterectomy in three-quarters of their patients because of the severity of the trauma or because 'sterilization' was considered advisable. Mokgokong & Marivate (1976) reviewed 335 uterine ruptures in Durban. We agree with their advice that repair of the uterus should generally be restricted to cases where the tear is simple, transverse in the lower segment and in the absence of infection. Our present policy in Benghazi is governed, of course, by the character of the tear, condition of the patient and her previous obstetric history, but in the majority of our patients hysterectomy is best. Many patients coming to the hospital have neglected themselves. Obviously our paramount problem is prevention; at present we are defeated by ignorance. Restricted facilities play their part but the patients are to a great extent unwilling to make good use of the services available. Doubtless education will put things right one day. Summary forty-six cases of rupture of the uterus during labour are reported and obstetric practice is described in Eastern Libya, where these disasters took place. The incidence and the causes of uterine rupture in Libya differ greatly from those in developed countries; high multiparity is a frequent cause. Hysterectomy is very often the best treatment. More than
One hundred and
three-quarters of the children were lost, but 92%
of the mothers were saved.
References
Abdalla M A & Modawi 0 (1974) Proceedings of the Third Congress of Obstetrics and Gynaecology. Ed. 0 Modawi, A R Musa & F A Aziz. Khartoum University Press, Khartoum;
p
152
J, Organe G, Lewis E M, Adelstein A M & Weatherall J A C (1975)
Confidential enquiries into maternal deaths in England and Wales 1970-72. HMSO, London Boulle P & Crichton D (1964) Lancet i, 360 Brudenell M & Chakravarti S (1975) British Medical Journal ii, 122 Feeney J K (1953) Journal of the Irish Medical Association 32, 36 Fothergill R J (1973) Update 7, 915 Groen G P (1974) Obstetrics and Gynecology 44, 682 Israel S L & Blazar A S (1965) American Journal of Obstetrics and Gynecology 91, 327 Mahfouz N (1932) Journal of Obstetrics and Gynaecology of the British Empire 39, 743 Menon K (1962) Journal of Obstetrics and Gynaecology of the British Commonwealth 69, 18 Modawi 0 (1974) Proceedings of the Third Congress of Obstetrics and Gynaecology. Ed. 0 Modawi, A R Musa & F A Aziz. Khartoum University Press, Khartoum; p 133 Mokgokong E T & Marivate M (1976) South African Medical Journal 50, 1621 Murphy (1976a) H Irish Medical Journal 69, 531 Murphy (1976b) H Irish Medical Journal 69, 533 O'Driscoll K (1966) Proceedings of the Royal Society of Medicine 59, 65 Rendle Short C (1960) American Journal of Obstetrics and Gynecology 79, 1114 Solomons B (1934) Lancet ii, 8 Yussman M A & Haynes D M (1970) Obstetrics and Gynecology 36, 115
Arthure H, Tomkinson
415
Rupture of the pregnant uterus in Eastern Libya' Mohammad Sayedur Rahman MB MRCOG Associate Professor of Obstetrics and Gynaecology, University of Garyounis, Benghazi, Libya
Roger J Fothergill MB FRCOG Consultant Obstetrician, Good Hope Maternity Hospital, Sutton Coldfield, and Visiting Professor, University of Garyounis, Benghazi, Libya Uterine rupture in obstetric practice has always been a subject of compelling interest. Obstetricians working nowadays in developed countries find their interest is unfailingly drawn to the dramatic obstetric emergencies still taking place in underdeveloped areas. Rupture of the uterus in recent years in developed countries has often been due to unwise obstetric interference and has frequently taken place in patients who have had previous caesarean sections. Murphy (1 976a, b) compared events in ten recent years at the Rotunda Hospital, Dublin, with O'Driscoll's 1966 review of fourteen years' experience in Dublin Hospitals. He gave a renewed warning about the risks of grand-multiparity and oxytocin in relation to uterine ruptures. Groen (1974) contrasted uterine ruptures in rural Nigeria with those in the USA. The causes of uterine rupture in America, he thought, 'seem to be shifting because of more aggressive management of labour'. Brudenell & Chakravarti (1975), who reviewed 5 cases of uterine rupture in Kings College Hospital, London, also gave warnings against overenthusiastic obstetric management. From 1968-70, in the West Midlands of England, 4 ruptures of the uterus were encountered in 6490 deliveries at Good Hope Maternity Hospital, Sutton Coldfield (Fothergill, unpublished). None of these occurred after previous lower segment caesarean sections, but 2 cases followed previous classical operations; one case was due to obstetric trauma and one to oxytocin. Eighty-six cases of previous caesarean section had been studied during that period, 15 of which had been classical operations. In the last five years, far fewer patients with previous classical caesarean sections have presented and only 2 cases of uterine rupture have occurred, one of which followed a previous lower segment operation (19 247 deliveries). In 1976 in the Birmingham Maternity Hospital there was only one uterine rupture in 3972 deliveries (Annual Report 1976). Rupture of the uterus in England then is rather uncommon and it has been the cause of fewer and fewer deaths in successive reports of confidential enquiries into maternal mortality (Arthure et al. 1975). In underdeveloped countries the situation is quite different. In Khartoum Civil Hospital, for instance, the incidence of uterine rupture was 1:376 deliveries in 1968-71 (Modawi 1974, Abdalla & Modawi 1974). This prevalence in the Sudan has not diminished recently (S S Modawi, 1977, personal communication), and is attributed to lack of obstetric care of abnormal cases. Uterine ruptures in Libya The report which follows is based on 46 cases treated by the first author, MSR, in 1974-77 at the General Hospital, Benghazi, and the records which could be traced of 100 patients who were treated at the same hospital from 1967-73. This hospital, which since 1974 has become the main teaching hospital of the University in Benghazi, delivers about 10 000 patients each year; 95% of these women are admitted in labour, having had no previous antenatal care. 1 Accepted 7 July 1978
0 141-0768/79/060415-06/$O 1.00/0
'."
1979 The Royal Society of Medicine
416
Journal of the Royal Society of Medicine Volume 72 June 1979
Table 1. Age distribution of 146 cases of rupture of the uterus in Benghazi Age (years)
No. of cases
%
18-20 21-25 26-30 3 1-35 36-40 40 and over
5 35 54 37 10 5
3.4 24 37 25.4 6.8 3.4
Complicated obstetric cases are admitted directly as well as being transferred from all the other, smaller maternity hospitals in Benghazi. Patients also come to the hospital from distant towns and villages even as far away as 500 kilometres. Libya is a vast country with a population of only 2.5 million in an area of approximately 1.76 million square kilometres. The majority of Libyans are relatively affluent and have been strongly motivated to bear large families to populate their country; Libya has one of the world's fastest population growth rates. Recently the influence of education has produced some changing attitudes, but the traditional culture-pattern leads to childbearing throughout the reproductive life of Libyan women. This has brought about a prevalence of high parity, and the incidence of grand-multiparity in the hospital is 18%. (Grand multiparae are defined in this study as women who have carried 7 or more pregnancies beyond 28 weeks.) All the patients were Arab; they were mostly Libyan but there were a few from neighbouring countries. The average age was 30.4 years, with a range from 18 to 43 (Table 1). The parity ranged from 0 to 21 with an average of 10.5 (Table 2). Table 2. Parity in 146 cases of rupture of the uterus in Benghazi
Parity 0 1 2 3 4
No. of cases 2 2
10 10 23
5
19
6 7 8
17 12 10
10
12 9 10
11 12+
% 9.6% J
47.3% 43
1 r
43.1%
J
Incidence of uterine rupture From 1966-77 approximately 98 000 deliveries took place in the General Hospital, Benghazi, and the incidence of uterine rupture was 1:671 (1.5 per thousand deliveries). In 1974 the incidence in King Edward VIII Hospital, Durban (Mokgokong & Marivate 1976) was double this and in rural Nigeria in 1972 it was as much as 1: 112 (Groen 1974). In Uganda, Rendle Short (1960) reported a figure of 1:93. In the Rotunda Hospital, Dublin, however, a recent figure was 0.8 per thousand deliveries (Murphy 1976a, b), and in the Clinical Report of the Royal Maternity Hospital, Belfast, in 1973-75, the figure was 0.69 per thousand, an incidence of 1:1439.
Journal of the Royal Society of Medicine Volume 72 June 1979
417
Table 3. Causes of rupture of the unscarred uterus in 118 cases in Benghazi Causes Maternal: Contracted pelvis Grand multiparity only Pelvic tumour Concealed accidental haemorrhage Stenosis of the birth canal Induced: Oxytocin infusion Shirodkar stitch in place Fetal: Shoulder presentation Brow presentation Hydrocephaly Compound presentation Mentoposterior face presentation
No. of cases
%
29 26 3 2 1
24.6 22 2.5 1.7 0.8
3 1
2.5 0.8
26
22 6 4.2 3.4 2.5
7 5 4 3
Table 4. Sixteen cases of traumatic rupture of the uterus in Libya Causes
No. of cases
Internal version Kielland's forceps rotation Shoulder dystocia Arrested after-coming head Manual removal of placenta Packing of the uterus
7 3 2 2 1 I
Causes In Tables 3 and 4 the aetiology for the present series is given, but in many cases more than one cause was responsible. Spontaneous rupture of an unscarred uterus occurred during active labour in 118 patients (80.8% of all our cases). Grand-multiparity on its own is listed as the cause for 26 patients (22% of the spontaneous group), but also contributed to two-fifths of the ruptures in the remaining cases (i.e. 37 ruptures in 92 remaining cases) in which other factors were the principal causes. Even small doses of oxytocin proved to be very dangerous to grand multiparae. Obstructed labour was very frequently due to malpresentation but pelvic contraction needs special emphasis (Fothergill 1973). Pelvic contraction was diagnosed clinically as the cause in 29 patients. Increased fetal size in successive pregnancies adds to the problem. The average fullterm birth weight in the hospital is approximately 4.1 kg. In Libyan patients great obesity is quite frequent and 3% of the female population of Benghazi city are known to have diabetes; very large birth weights are common. Shoulder presentations and other malpresentations and malpositions featured prominently. Hydrocephalus was the cause in 5 patients; major CNS malformations are present in almost 1% of the deliveries at the hospital. Ovarian cysts caused rupture of the uterus in 2 cases; in one case of obstructed labour due to a pelvic mass the tumour was a calcified hydatid cyst.
418
Journal of the Royal Society of Medicine Volume 72 June 1979
Traumatic rupture: Sixteen women (11% of the series) suffered rupture of the uterus from internal version (7 patients) forceps rotation (3) and other obstetric manipulations (Table 4). In one case the cause was thought to be packing of the uterus for post-partum haemorrhage.
Rupture of uterine scars: This occurred in only 12 women in the series (8.2%). There were 2 previous classical scars and 8 scars from previous lower segment caesarean sections. In 2 patients the uterus had ruptured in a previous pregnancy, had been repaired and then had broken again. Clinical features Eighty per cent of the patients came into the hospital as emergencies and uterine rupture was diagnosed on admission, but 29 women (20%) sustained rupture of the uterus during labour in the hospital. About 60% of the patients were severely shocked. The symptoms and signs which occurred were very variable (Table 5). The diagnosis was most easily made when the fetus was Table 5. Clinicalfeatures shown by the 146 cases at the General Hospital, Benghazi (1967-77)
Symptoms and signs
No. of cases
Proportion of total (0)
Signs of shock Abnormal uterine contour Easily palpable fetal parts Cessation of uterine contractions Tenderness Pain Vaginal bleeding Abdominal distension
128 117 109 105 102 80 47 26
88 80 75 72 70 55 32 18
partly or wholly extruded into the abdominal cavity. When the fetus remained in utero a presumptive diagnosis was made which was confirmed at laparotomy. In 87 patients (60%), the lower segment ruptured anteriorly. The fundus of the uterus was involved in 18 cases (12.3%). There was a lateral tear in 22 (15%), posterior in 12 (18.2%), and circumferential in 7 cases (4.8%). Anterior and lateral tears often extended to the fundus or to the vaginal vault; multiple lacerations occurred in 18 cases. The urinary bladder was also ruptured in 8 women (one of whom later developed a vesicovaginal fistula, but this was repaired successfully). In 77.4% of the cases (113 mothers) the fetus died. Anaemia About one half of the pregnant patients in the practice of the hospital had a haemoglobin concentration of less than 9 g/dl. Quite a number of patients were severely anaemic before rupture of the uterus took place, so that when admitted they were reduced to an extremely poor condition. Blood transfusions were necessary for all the cases in this series; half the patients needed up to one litre and the other half required more than this. Although before 1972 blood for transfusion was not readily available in Benghazi, it seemed from the hospital records that maternal deaths in this series were not due to undertransfusion. This finding contrasts with the experience of Boulle & Crichton (1964) who found that inadequate replacement of blood at operation was a contributory cause of death in 3 of their patients.
Treatment During the period 1967-74, irqdividual surgeons acted according to their own preferences in the treatment of these cases, but from 1974-77 the first author (MSR) personally undertook the management of all patients with rupture of the uterus (Table 6). Hysterectomy was then chosen for everyone with 5 or more living children. Repair of the rent in the uterus was usually thought
Journal of the Royal Society ofMedicine Volume 72 June 1979
419
Table 6. Methods of treatment of 146 cases of rupture of the uterus at the General Hospital, Benghazi
Hysterectomy
1967-73 inclusive 1974-77 inclusive Total
Total
Repair
Subtotal
510
49
0
20
18
26
53 (36%)
93 (64%)
* 'Sterilization' was not done in 7 cases * A para 2 and a para 3, with rupture of scars from previous lower segment caesarean sections; 'sterilization' was not done
to be a much less satisfactory method of treatment. Part of the reason for adopting this policy was that several grand multiparae had been asking at the hospital for restoration of fertility after previous repairs of uterine ruptures accompanied by 'sterilization'. Regrettably these patients were eventually submitted to restorative surgery in private clinics abroad. After the policy in favour of hysterectomy was adopted, 26 patients were treated by total hysterectomy and 18 by subtotal hysterectomy. Dehiscence of previous lower segment caesarean section scars in a para 2 and a para 3 were treated by repairs alone. The mortalities associated with different methods of treatment are shown in Table 7. There were 12 maternal deaths in the series (8.2%); 10 of these occurred in the first hundred cases, and 3 in the 46 cases treated from 1974-77. The recent improvement in the maternal mortality figure can be attributed to improved transport facilities, availability of blood for transfusions, and early diagnosis with prompt treatment by a surgeon with a special interest in these disasters. Interpretations of Table 7 must take into account that repair operations were commonly done for less serious cases and that hysterectomy was often necessary for more dangerous conditions. Three patients died from septicaemia, 3 from pulmonary embolism, 2 from renal failure and 4 apparently just from haemorrhage. Table 7. Mortality from uterine rupture, General Hospital Benghazi
(1967-77) Treatment
Numbers of
operations
Numbers of deaths
Total hysterectomy Subtotal hysterectomy Repair and tubal ligations Repair only
26 67 44 9 146
2 6 1 3 12 (8.2%)
Maternal morbidity More than 12 hours delay before operation brought greater morbidity as well as a higher mortality. Four patients had a subphrenic abscess (3 after a repair, one after a subtotal hysterectomy), and 3 had a pelvic abscess needing drainage (after repairs). In 6 cases who had a repair, secondary post-partum haemorrhages took place requiring exploration of the uterus. Intestinal obstruction necessitating another laparotomy occurred four times after repair operations. Four cases had to have postoperative dialysis for renal failure (2 died). Despite generous antibiotic treatment, fevers above 39°C, for up to ten days, occurred in 20 patients who had uterine repairs and 3 who had hysterectomies (but the abdominal wounds healed equally well in the repair and the hysterectomy groups).
420
Journal of the Royal Society of Medicine Volume 72 June 1979
Discussion 'High multiparity', Feeney observed in 1953, 'carries with it certain inherent risks .. it can be very unforgiving of any carelessness, incapacity or neglect.' Our experience in Libya confirms the wisdom of this statement and corresponds with the findings of Israel & Blazar (1964). We were surprised that Boulle & Crichton (1964) found that 'fewer ruptures occurred among grande multiparae then among those who had had from to 5 children'. Our series .
1
emphatically demonstrates the predisposition of grand multiparae to uterine rupture. In Libya there are very many 'dangerous multiparae' (Solomons 1934). Many of these women are at a further disadvantage through being in their late 30s or over 40 years of age, through being
grossly overweight, and through anaemia. In 1932 Mahfouz urged conservative treatment whenever possible, but nowadays the choice in treatment lies between hysterectomy and suture of the rent with sterilization (Menon 1962). Several authors recommend repair of the uterus rather than hysterectomy (e.g. Groen 1974), but in all Murphy's cases (1976a) of spontaneous rupture a hysterectomy was considered necessary. Yussman & Haynes (1970) undertook total hysterectomy in three-quarters of their patients because of the severity of the trauma or because 'sterilization' was considered advisable. Mokgokong & Marivate (1976) reviewed 335 uterine ruptures in Durban. We agree with their advice that repair of the uterus should generally be restricted to cases where the tear is simple, transverse in the lower segment and in the absence of infection. Our present policy in Benghazi is governed, of course, by the character of the tear, condition of the patient and her previous obstetric history, but in the majority of our patients hysterectomy is best. Many patients coming to the hospital have neglected themselves. Obviously our paramount problem is prevention; at present we are defeated by ignorance. Restricted facilities play their part but the patients are to a great extent unwilling to make good use of the services available. Doubtless education will put things right one day. Summary forty-six cases of rupture of the uterus during labour are reported and obstetric practice is described in Eastern Libya, where these disasters took place. The incidence and the causes of uterine rupture in Libya differ greatly from those in developed countries; high multiparity is a frequent cause. Hysterectomy is very often the best treatment. More than
One hundred and
three-quarters of the children were lost, but 92%
of the mothers were saved.
References
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Arthure H, Tomkinson
