Maternal and fetal outcomes of uterine rupture and factors associated with maternal death secondary to uterine rupture

The prevalence of uterine rupture was found to be 2.24% (1 in 41 deliveries) in the study area. This finding is higher as compared to the studies from east and west Nigeria (0.4%) [12] and (1.2%) [13], Ghana(1 in 124) [15], Turkey (1 in 287) [8], Saudi Arabia (1 in 10011) [9], Nordic region (5.6 per 10 000) [16]. In addition, it is higher that the WHO systematic review for the causes of maternal mortality secondary to uterine rupture (0.053%) [5], Pakistan (0.41%) [17], Bangladesh (0.67%) [18] and North West Nigerian (0.61%) [19]. This difference could be partly explained by the high prevalence of home delivery service (57%), socioeconomic and cultural differences across countries, availability and accessibility of skilled maternal care. Moreover, 85.5% of the mothers who suffered uterine rupture are from rural areas which limit the access to improved maternal care. It was also higher when compared with the study in Adigrat hospital, Ethiopia (0.91%) [14]. This might be due to the improved medical documentation practice, demographic variation and low antenatal care service utilization in the study area.

However, the prevalence in the current study was lower when compared with studies in Angola (4.9%) [20] and Yergalem general hospital, Ethiopia (5%) [21]. This could be due to the time variation, improvement of health service infrastructure and quality of health service provision.

In this study, 57% (138) of the mothers labored at home. This finding is consistent with the study in Adigrat hospital, Ethiopia [14]. The possible explanation could be due to lack of accessibility of adequate hospitals in rural parts of Ethiopia and lack of awareness of institutional delivery service utilization in most parts of the country [22].

Obstructed labor accounted for 89.3% (216) of uterine rupture in this study, while previous uterine scar accounted for only 3.7% (9) cases. This figure is much higher than studies from Nigeria, 47.3% (scar = 22.1%), Adigrat in the northern Ethiopia 79.6% (scar = 11.2%) and Pakistan 12.5% (scar = 12.5%) [12, 14, 17]. This difference might be due to the variation in socio- economic factors and environmental factors, lack of transport for immediate shifting of patients to the referral hospital illiteracy in the community, lack of antenatal care, lack of screening for high-risk pregnancy, and unsupervised labor conducted in poorly equipped centers. It might also be due to the inadequacy of the health facilities to recognize and give definitive management for Cephalopelvic disproportion (CPD) and obstructed labor.

The current study shows, the majority of uterine rupture, 208 (86%) have a complete uterine rupture and 34(14%) had incomplete rupture. Similar to this, finding, a study from Turkey by Turgut and colleagues revealed that complete type of rupture is more likely to occur among mothers admitted for the management of uterine rupture [23]. Hysterectomy was performed for 73.9% of patients (Total Abdominal Hysterectomy = 57% (138) and Subtotal hysterectomy (STAH) =16.9% (41)). For 27% of the cases, uterine repair (23.3% repair with BTL and for 3.7% repair without BTL) was performed. This finding is higher than studies from Turkey(TAH 0 34%) [23] and Nigeria, where hysterectomy was performed for 31.6% of cases (TAH =7.4% STAH = 24.2%) and repair without BTL was done for 30% of cases of uterine rupture [24]. The possible explanation could be the difference in health care provider’s skill and the difference in health institution set up [25]. Ruptured uterus is the most common indication in performing hysterectomy [26‐28]. However, abnormal placentation was reported to be the most common indication for hysterectomy by a study from Turkey [8]. Although hysterectomy is considered as lifesaving procedure of obstetric emergency [26], it is invasive procedure [29]. Vaginal hysterectomy is rather minimally invasive and should be the first line of choice to consider before performing total hysterectomy [29]. If there is imminent uterine rupture around uterine fundal region, as Suhin and colleagues recommended, it might be essential to consider alternative second-line strategies (such as intrauterine balloon tamponade, uterine artery embolization and compression sutures) to minimize blood loss and preserve uterus [30]. However, identifying the site of uterine rupture without performing laparotomy is challenging in medical practice.

Comparable hysterectomy rate was reported from Pakistan where hysterectomy was done for 76.6% (TAH = 26.6%, STAH = 50%) [17]. This might be due to the similarity in obstetrics causes of uterine rupture. Comparable proportions of obstetric risk factors such as obstructed labor, prolonged labor and previous history of uterine scar were reported in the Pakistani study [17].

Blood availability and transfusion in catastrophic situations of uterine rupture is a lifesaving factor. As a result, this study shows 78% of the mothers who suffered from uterine rupture received blood transfusion which is comparable with the study conducted in Al-Batool Teaching Hospital, (83%) [7]. But in this study, more patients were transfused when compared with the study in Adigrat and in Yemen (57.1%), (59.3%) respectively [14, 31]. This could be probably due to the poor hemodynamic state in which patients arrived in health institutions.

The current study shows 50% of cases developed anemia postoperatively. Out of these, severe anemia accounts for 21.9% of cases, but this finding is lower than the finding from Nigeria (93.7%) [13]. The possible explanation might be due to the universal iron folate supplementation for all Ethiopian pregnant women by community health extension workers. Hence, this iron supplementation has a capacity to protect the occurrence of anemia after delivery whatever its complication level of labor would be [32]. In addition, low level of hemoglobin is associated with post-partum hemorrhage [33].

In 9.9% of the uterine rupture cases, there was associated bladder rupture which is comparable with a study from Yemen (8.6%) but lower than a study from Pakistan (21.1%) [10, 31]. Bladder rupture in association with uterine rupture reflects the presence of obstructed labor and late presentation of mothers to the hospital [34].

In this study, fourteen cases (5.8%) developed vesico-vaginal fistula and 0.4% of cases developed recto-vaginal fistula. This finding is slightly higher than the finding in Nigeria (4.2%) and Yirgalem (3%) [21, 24]. The possible explanation for this discrepancy could be due to the high occurrence of obstructed labor in this study and this is the main cause of rupture. But, the findings of uterine rupture in other studies may not be secondary to obstructed labor. The occurrence of bladder rupture and vesico-vaginal fistula suggest most of the rupture cases were attributed by prolonged and obstructed labor and late presentation of mothers to the Hospital [5, 7].

However, the proportion of vesico-vaginal fistula in this study is lower than the finding from Adigrat study (12.5%) [14]. The possible explanation is the occurrence of high prevalence of obstructed labor in the study area in association with uterine rupture and there was an association between bladder injury with obstructed labor [14].

From 2011 to 2014, 242 preventable cases of uterine rupture occurred in Debremarkos Hospital. Uterine rupture has been pointed out as a preventable tragedy of obstetric care in developing countries [35, 36]. It can, however, can be prevented by sustained ante-natal care institutional deliveries, early diagnosis, improved obstetric techniques [23, 34] and improving obstetric care to reduce the delay of women reaching obstetric clinics particularly for women with prolonged labor [35]. During the period between 2011 and 2014, 45 maternal deaths occurred in the hospital, 16(6.6%) of deaths include mothers managed for uterine rupture; this gave maternal mortality rate of 35.5%. This figure is comparable to the findings in Pakistan 7.8% and in Yirgalem 6% [17, 21]. However, it is higher than a study from Turkey (no maternal death was recorded) [23]. This is due to the difference in the infrastructure of hospitals and health care provider’s skill [25].

But, maternal mortality secondary to uterine rupture in this study was found to be lower than the study from Angola (13.6%), and Adigrat (11.1%) [14, 20]. The possible explanation for this might be an earlier presentation of mothers to the hospital set up, timely diagnosis of uterine rupture, adequate resuscitation of patients, availability of blood transfusion, absence of delay between diagnosis and definitive management and presence of experienced surgeon has effect decrement of maternal death after uterine rupture.

In this study, six (37.5%) patients died from hypovolemic shock, 4(25%) patients from severe anemia, 3 patients (18.7) from septic shock, 1 patient (6.3%) from acute renal failure and 1 patient (6.3%) from pulmonary edema. This figure is comparable to the study in Bangladesh where major causes of immediate death from uterine rupture were irreversible shock from severe hemorrhage and septicemia [18].

In addition, 87.5% maternal deaths were among a mother who labored at home and was found to be significantly associated with maternal death than laboring at a health facility. This study is similar to the study done in Angola where maternal death was higher among mothers who labored at home and referred from primary health unit [20]. This can be explained by mothers being in a more unstable condition are highly likely to die.