Ruptura uterina.
Justin E. Marmolejos Franco
10-0508
Ruptura uterina y vasa previa.
Justin E. Marmolejos Franco.
UNIBE.
Introducción
• La ruptura o rotura
uterina es la
soluci...
Ruptura uterina y vasa previa.
Justin E. Marmolejos Franco.
UNIBE.
Epidemiologia.
• Se reporta en alrededor de 0.03-0.08% ...
Ruptura uterina y vasa previa.
Justin E. Marmolejos Franco.
UNIBE.
Diagnostico.
• Síntomas:
- Dolor abdominal intenso y sú...
Ruptura uterina y vasa previa.
Justin E. Marmolejos Franco.
UNIBE.
Factores de riesgo.
• Estimulación
excesiva uterina.
• ...
Ruptura uterina y vasa previa.
Justin E. Marmolejos Franco.
UNIBE.
Manejo.
• Resucitación
intrauterina en
fetos con crisis...
Ruptura uterina y vasa previa.
Justin E. Marmolejos Franco.
UNIBE.
Prognosis.
• En un parto con
ruptura hay un 5%
de proba...
Vasa previa.
Ruptura uterina y vasa previa.
Justin E. Marmolejos Franco.
UNIBE.
Introducción.
• Anomalía hemorrágica obstétrica que ocu...
Ruptura uterina y vasa previa.
Justin E. Marmolejos Franco.
UNIBE.
Factores de riesgo.
• Placenta bilobular.
• Placenta pr...
Ruptura uterina y vasa previa.
Justin E. Marmolejos Franco.
UNIBE.
Placenta bilobal.
Fuente: Obstetrics Informational Modu...
Ruptura uterina y vasa previa.
Justin E. Marmolejos Franco.
UNIBE.
Placenta succenturiata.
Fuente: Obstetrics Informationa...
Ruptura uterina y vasa previa.
Justin E. Marmolejos Franco.
UNIBE.
Diagnostico.
• Se sospecha durante la palpación en
exám...
Ruptura uterina y vasa previa.
Justin E. Marmolejos Franco.
UNIBE.
Doppler en vasa previa.
Fuente: Williams Obstetrics, 23...
Ruptura uterina y vasa previa.
Justin E. Marmolejos Franco.
UNIBE.
Referencias:
• Adams, Jodi. Third Trimester Bleeding. E...
Fin de la presentacion.
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Ruptura uterina y vasa previa

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Breve presentacion acerca de la ruptura uterina y vasa previa. Complementos al tema de sangrados del tercer trimestre.

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  • Williams Obstetrics, 23rd Ed.

    Classification
    Uterine rupture typically is classified as either: (1) complete when
    all layers of the uterine wall are separated, or (2) incomplete when
    the uterine muscle is separated but the visceral peritoneum is intact.
    Incomplete rupture is also commonly referred to as uterine
    dehiscence. As expected, morbidity and mortality rates are appreciably
    greater when rupture is complete. The greatest risk factor
    for either form of rupture is prior cesarean delivery (see Fig. 26-3).
    In a review of all cases of uterine rupture in Nova Scotia between
    1988 and 1997, Kieser and Baskett (2002) reported that 92 percent
    were in women with a prior cesarean birth. Other causes of
    uterine rupture are discussed in Chapter 35 (see p. 784).
  • Obstetrics Informational Module 2004, Scott Ramshur, MD.
    Reported in 0.03-0.08% of all delivering women, but 0.3-1.7% among women with a history of a uterine scar (from a C/S for example)
    13% of all uterine ruptures occur outside the hospital
    The most common maternal morbidity is hemorrhage and subsequent anemia, requiring transfusion
    Fetal morbidity is more common with extrusion and includes respiratory distress, hypoxia, acidemia, and neonatal death

    Incomplete rupture is also commonly referred to as uterine
    dehiscence. As expected, morbidity and mortality rates are appreciably
    greater when rupture is complete. The greatest risk factor
    for either form of rupture is prior cesarean delivery (see Fig. 26-3).
    In a review of all cases of uterine rupture in Nova Scotia between
    1988 and 1997, Kieser and Baskett (2002) reported that 92 percent
    were in women with a prior cesarean birth. Other causes of
    uterine rupture are discussed in Chapter 35 (see p. 784).
  • Uterine rupture is characterized by intense abdominal pain and bleeding and occurs at higher rates in pt’s attempting a vaginal birth after caesarian section (VBAC) and with uterine over-stimulation during induction. Although other causes of antepartum hemorrhage should be considered, this diagnosis must be made promptly due to the risk to the patient and the necessity of surgical intervention.

    Diagnosis
    Prior to developing hypovolemic shock, symptoms and physical
    findings in women with uterine rupture may appear bizarre
    unless the possibility is kept in mind. For example, hemoperitoneum
    from a ruptured uterus may result in diaphragmatic
    irritation with pain referred to the chest—directing one to a
    diagnosis of pulmonary or amnionic fluid embolism instead of
    uterine rupture. The most common sign of uterine rupture is a
    nonreassuring fetal heart rate pattern with variable heart rate
    decelerations that may evolve into late decelerations, bradycardia,
    and death (American Academy of Pediatrics and American
    College of Obstetricians and Gynecologists, 2007). Contrary
    to older teachings, few women experience cessation of contractions
    following uterine rupture, and the use of intrauterine
    pressure catheters has not been shown to assist reliably in the
    diagnosis (Rodriguez and associates, 1989).
    In some women, the appearance of uterine rupture is identical
    to that of placental abruption. In most, however, there is remarkably
    little appreciable pain or tenderness. Also, because
    most women in labor are treated for discomfort with either narcotics
    or epidural analgesia, pain and tenderness may not be
    readily apparent. The condition usually becomes evident because
    of signs of fetal distress and occasionally because of maternal
    hypovolemia from concealed hemorrhage.
    If the fetal presenting part has entered the pelvis with labor, loss
    of station may be detected by pelvic examination. If the fetus is
    partly or totally extruded from the site of uterine rupture, abdominal
    palpation or vaginal examination may be helpful to identify the
    presenting part, which will have moved away from the pelvic inlet.
    A firm contracted uterus may at times be felt alongside the fetus.

    Classic presentation includes vaginal bleeding, pain, cessation of contractions, absence/ deterioration of fetal heart rate, loss of station, easily palpable fetal parts, and profound maternal tachycardia and hypotension

    Patients with a prior uterine scar should be advised to come to the hospital for evaluation of new onset contractions, abdominal pain, or vaginal bleeding
  • In the case of sudden change in fetal baseline heart rate or the onset of severe decelerations, the provider should initiate intrauterine resuscitation with maternal position change, IVF hydration, discontinuation of pitocin, O2 administration by re-breather mask, and consideration of subcutaneous terbutaline

    If the measures are ineffective, emergent laparotomy is indicated

    Hysterectomy versus Repair
    With complete rupture during a trial of labor, hysterectomy may
    be required. In the reports by McMahon (1996) and Miller
    (1997) and their colleagues, 10 to 20 percent of such women required
    hysterectomy for hemostasis. In selected cases, however,
    suture repair with uterine preservation may be performed. Sheth
    (1968) described outcomes from a series of 66 women in whom
    repair of a uterine rupture was elected rather than hysterectomy.
    In 25 instances, the repair was accompanied by tubal sterilization.
    Thirteen of the 41 mothers who did not have tubal sterilization
    had a total of 21 subsequent pregnancies, and uterine rupture
    recurred in four of these—approximately 25 percent. More
    recently, Usta and associates (2007) identified 37 women with a
    prior complete uterine rupture delivered over a 25-year period in
    Lebanon. Hysterectomy was performed in 11, and in the remaining
    26 women, the rupture was repaired. Twelve of these
    women had 24 subsequent pregnancies, of which one third were
    complicated by recurrent uterine rupture. Hysterectomy is described
    in Chapter 25 (see p. 556), and management of obstetrical
    hemorrhage is detailed in Chapter 35 (p. 791).
  • Prognosis
    With rupture and expulsion of the fetus into the peritoneal cavity,
    the chances for intact fetal survival are dismal, and reported mortality rates range from 50 to 75 percent. Fetal condition depends
    on the degree to which the placental implantation remains
    intact, although this can change within minutes. With rupture,
    the only chance of fetal survival is afforded by immediate delivery,
    most often by laparotomy. Otherwise, hypoxia from both
    placental separation and maternal hypovolemia is inevitable. If
    rupture is followed by immediate total placental separation, then
    very few intact fetuses will be salvaged. For example, in the August
    2008 issue of acog Today, the emergency team at Sharp
    Mary Birch Hospital for Women is described. After training, the
    “decision-to-incision” time was decreased to 14 5.6 minutes.
    Thus, even in the best of circumstances, fetal salvage will be impaired.
    In a study using the Swedish Birth Registry, Kaczmarczyk
    and colleagues (2007) found that the risk of neonatal death following
    uterine rupture was 5 percent—a 60-fold increase in the
    risk compared with pregnancies not complicated by uterine
    rupture. In the MFMU Network study, 7 of the 114 uterine
    ruptures—6 percent—associated with a trial of labor were complicated
    by the development of hypoxic ischemic encephalopathy
    (Spong and associates, 2007).
    Maternal deaths from rupture are uncommon. For example,
    of 2.5 million women who gave birth in Canada between 1991
    and 2001, there were 1898 cases of uterine rupture, and four of
    these—0.2 percent—resulted in maternal death (Wen and associates,
    2005). In other regions of the world, however, maternal
    mortality rates associated with uterine rupture are much higher.
    In a report from rural India, for example, the maternal mortality
    rate associated with uterine rupture was 30 percent (Chatterjee
    and Bhaduri, 2007).
  • Reported incidence varies, but most resources note occurrence in 1:3000 pregnancies

    Associated with a high fetal mortality rate (50-95%) which can be attributed to rapid fetal exsanguination resulting from the vessels tearing during labor
  • Vasa Previa. In some cases of velamentous insertion, placental
    vessels overlie the cervix, lie between the cervix and the
    presenting fetal part, and are supported only by membranes.
    As a result, vessels are vulnerable not only to compression,
    which may lead to fetal anoxia, but also to laceration, which
    can lead to fetal exsanguination. Fortunately, vasa previa is
    uncommon, and Lee and co-workers (2000) identified it in 1
    in 5200 pregnancies. Risk factors include bilobate or succenturiate
    placentas and second-trimester placenta previa, with
    or without later migration (Baulies and associates, 2007;
    Suzuki and Igarashi, 2008). It is also increased in pregnancies
    conceived by in vitro fertilization (IVF), and this is believed
    to stem from greater rates of abnormal cord insertion with
    pregnancies so conceived (Schachter and associates, 2003).
    Antepartum diagnosis results in improved rates of fetal survival
    compared with intrapartum diagnosis (Oyelese and associates,
    2004). Thus, vasa previa would ideally be identified
    early, and scheduled cesarean delivery planned.
  • Clinically, an
    examiner is occasionally able to palpate or directly see a tubular
    fetal vessel in the membranes overlying the presenting part.
    With endovaginal sonography, a vessel may be identified as
    echogenic, parallel or circular line near the cervix (Fig. 27-7).
    Because of a low sensitivity for imaging vasa previa with
    sonography, color Doppler examination is recommended
    when vasa previa is suspected. Canterino and colleagues
    (2005) have also described use of 3D-sonography with power
    Doppler angiography.
    Whenever there is hemorrhage antepartum or intrapartum,
    the possibility of vasa previa and a ruptured fetal vessel should
    be considered. Determination of bleeding as fetal or maternal is
    possible, and a variety of tests may be used. Each relies on the
    increased resistance of fetal hemoglobin compared with maternal
    to denaturing by alkaline reagents (Lindqvist and Gren, 2007; Oyelese and co-workers, 1999). Unfortunately, the
    amount of fetal blood that can be shed without killing the fetus
    is relatively small. Thus, in many cases, fetal death is virtually
    instantaneous.
  • Ruptura uterina y vasa previa

    1. 1. Ruptura uterina. Justin E. Marmolejos Franco 10-0508
    2. 2. Ruptura uterina y vasa previa. Justin E. Marmolejos Franco. UNIBE. Introducción • La ruptura o rotura uterina es la solución de continuidad no quirúrgica del útero, que ocurre por encima del cuello y en gestaciones avanzadas • Se puede clasificar en: • Completa: Cuando todas las capas del útero se separan. • Incompleta: Cuando el musculo uterino se separa pero el peritoneo visceral permanece intacto. Fuente: Williams Obstetrics, 23rd Ed.
    3. 3. Ruptura uterina y vasa previa. Justin E. Marmolejos Franco. UNIBE. Epidemiologia. • Se reporta en alrededor de 0.03-0.08% de todos los partos y en 0.3-1.7% con historia de cicatrización uterina. • El 13% de las rupturas uterinas ocurren afuera del hospital. Fuente: Obstetrics Informational Module, Scott Ramshur MD.
    4. 4. Ruptura uterina y vasa previa. Justin E. Marmolejos Franco. UNIBE. Diagnostico. • Síntomas: - Dolor abdominal intenso y súbito. - Dolor en el pecho. • Signos: - Sangrado vaginal. - Bradicardia fetal. - Cese de contracciones. - Partes fetales fácilmente palpables. - Taquicardia e hipotensión materna. Fuente: Obstetrics Informational Module, Scott Ramshur MD.
    5. 5. Ruptura uterina y vasa previa. Justin E. Marmolejos Franco. UNIBE. Factores de riesgo. • Estimulación excesiva uterina. • Historia de cesárea. • Trauma. • Ruptura previa. • Cirugía uterina previa. • Multípara. • Presentación fetal no cefálica. • Distocia del hombro. • Parto con fórceps. Fuente: Williams Obstetrics, 23rd Ed.
    6. 6. Ruptura uterina y vasa previa. Justin E. Marmolejos Franco. UNIBE. Manejo. • Resucitación intrauterina en fetos con crisis. • Hidratación IV. • Descontinuó de pitocina. • Oxigeno. • Laparotomía cuando no hay mejora. • En rupturas completas durante el parto se realiza una histerectomía con el fin de crear hemostasis. • En caso de reparación, un tercio de las mujeres continuaran teniendo rupturas. Fuente: Williams Obstetrics, 23rd Ed.
    7. 7. Ruptura uterina y vasa previa. Justin E. Marmolejos Franco. UNIBE. Prognosis. • En un parto con ruptura hay un 5% de probabilidad de muerte fetal. • Cuando hay expulsión del feto al peritoneo hay un rango de mortalidad de 50 al 75%. • La muerte materna por ruptura en países desarrollados es raro, mientras que en otras partes del mundo es de alrededor de 30%. Fuente: Williams Obstetrics, 23rd Ed.
    8. 8. Vasa previa.
    9. 9. Ruptura uterina y vasa previa. Justin E. Marmolejos Franco. UNIBE. Introducción. • Anomalía hemorrágica obstétrica que ocurre cuando los vasos fetales (cordón umbilical) cruzan la entrada del canal de parto. • Se estima que ocurre en uno de cada cinco mil embarazos (1:5200) • Se asocia a una alta mortalidad fetal (50- 95%) atribuido a la rápida exanguinacion. Fuente: Obstetrics Informational Module, Scott Ramshur MD.
    10. 10. Ruptura uterina y vasa previa. Justin E. Marmolejos Franco. UNIBE. Factores de riesgo. • Placenta bilobular. • Placenta previa. • Embarazo in vitro. • Placenta con lóbulos accesorios. • Embarazo multiple. • Implantacion placentaria baja. Fuente: Obstetrics Informational Module, Scott Ramshur MD.
    11. 11. Ruptura uterina y vasa previa. Justin E. Marmolejos Franco. UNIBE. Placenta bilobal. Fuente: Obstetrics Informational Module, Scott Ramshur MD.
    12. 12. Ruptura uterina y vasa previa. Justin E. Marmolejos Franco. UNIBE. Placenta succenturiata. Fuente: Obstetrics Informational Module, Scott Ramshur MD.
    13. 13. Ruptura uterina y vasa previa. Justin E. Marmolejos Franco. UNIBE. Diagnostico. • Se sospecha durante la palpación en exámenes rutinarios. • Usualmente se diagnostica con una sonografia vaginal o un doppler a color. Fuente: Obstetrics Informational Module, Scott Ramshur MD.
    14. 14. Ruptura uterina y vasa previa. Justin E. Marmolejos Franco. UNIBE. Doppler en vasa previa. Fuente: Williams Obstetrics, 23rd Ed.
    15. 15. Ruptura uterina y vasa previa. Justin E. Marmolejos Franco. UNIBE. Referencias: • Adams, Jodi. Third Trimester Bleeding. E-medicine website 2004 p1-9 • Andre, FL and Brady J. Vasa Previa Diagnosis and Management J AM Board Fam Pract 16 (6): p543-548 2003 • Advanced Life Support in Obstetrics (ALSO) Course 2003-2004 “Vaginal Bleeding in Late Pregnancy” • Callahan et al. Blueprints in Obstetrics and Gynecology 2nd ed. 2001 p39-47 • Toppenberg KS. and Block, WA. Uterine Rupture: What Family Physicians Need to Know. AAFP September 1, 2002
    16. 16. Fin de la presentacion.

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