Uterine Rupture - Clinicals, Diagnosis, and Management

Obstetrics

Clinicals - History

Fact Explanation
History of previous cesarean section Uterine ruptures mostly occur due to previous cesarean sections. Risk of rupture in classical (vertical) incision is greater than transverse one in subsequent pregnancies..The incidence of uterine rupture has dropped significantly in developed countries and is most often encountered while attempting vaginal birth after caesarean section (CS).. Theoretically, any prior uterine insult, spanning from uterine perforation during curettage to myomectomy (laparoscopic or via laparotomy) or Caesarean section, can lead to a uterine wall weakness and an increased risk for uterine rupture in a subsequent pregnancy.. History of previous cesarean section
Uterine ruptures mostly occur due to previous cesarean sections. Risk of rupture in classical (vertical) incision is greater than transverse one in subsequent pregnancies..The incidence of uterine rupture has dropped significantly in developed countries and is most often encountered while attempting vaginal birth after caesarean section (CS).. Theoretically, any prior uterine insult, spanning from uterine perforation during curettage to myomectomy (laparoscopic or via laparotomy) or Caesarean section, can lead to a uterine wall weakness and an increased risk for uterine rupture in a subsequent pregnancy..
History of malpresentation, multiple pregnancy and multiparity Multiple pregnancy is a known causes of uterine rupture in unscarred uterus.. And assisted breech delivery and malpresentation also found to be significantly higher among women with UR.. Other Causes of uterine rupture in unscarred uterus are grand multiparity, injudicious use of oxytocin, neglected labour, uterine instrumentation and manipulation, labour induction, congenital abnormalities of uterus and uterine distension due to polyhydramnios, . History of malpresentation, multiple pregnancy and multiparity
Multiple pregnancy is a known causes of uterine rupture in unscarred uterus.. And assisted breech delivery and malpresentation also found to be significantly higher among women with UR.. Other Causes of uterine rupture in unscarred uterus are grand multiparity, injudicious use of oxytocin, neglected labour, uterine instrumentation and manipulation, labour induction, congenital abnormalities of uterus and uterine distension due to polyhydramnios, .
History of inadequate scar healing Uterine damage resulting from the use of electrocautery led to increased risk of adhesion formation.In addition to more adhesions, the inflammation and necrosis associated with electrocautery may lead to delayed healing and a weaker uterine scar, predisposing women in a subsequent pregnancy to an increased risk of uterine scar dehiscence or rupture.. Unhealthy tissue remaining after uterine repair may predispose to problems like infection, DIC, abscess formation and hemorrhage.And also increase the risk of recurrent rupture.. History of inadequate scar healing
Uterine damage resulting from the use of electrocautery led to increased risk of adhesion formation.In addition to more adhesions, the inflammation and necrosis associated with electrocautery may lead to delayed healing and a weaker uterine scar, predisposing women in a subsequent pregnancy to an increased risk of uterine scar dehiscence or rupture.. Unhealthy tissue remaining after uterine repair may predispose to problems like infection, DIC, abscess formation and hemorrhage.And also increase the risk of recurrent rupture..
Abdominal pain They experienced abdominal pain. It is a sharp pain between contractions.. A continuous abdominal pain with absence of contraction indicating UR has also been reported.. A complete uterine rupture cannot usually be predicted and it will suddenly occur during labor or delivery. Termination of pregnancy should be considered if any sudden pain is present.Onset of sharp pain at the site of previous scar also has also been reported.. Abdominal pain
They experienced abdominal pain. It is a sharp pain between contractions.. A continuous abdominal pain with absence of contraction indicating UR has also been reported.. A complete uterine rupture cannot usually be predicted and it will suddenly occur during labor or delivery. Termination of pregnancy should be considered if any sudden pain is present.Onset of sharp pain at the site of previous scar also has also been reported..
Vomiting Clinical signs of UR in early pregnancy are nonspecific and must be distinguished from acute abdominal emergencies. Abdominal pain, vaginal bleeding, and vomiting are classic findings.. Vomiting
Clinical signs of UR in early pregnancy are nonspecific and must be distinguished from acute abdominal emergencies. Abdominal pain, vaginal bleeding, and vomiting are classic findings..
Bleeding Vaginal bleeding is a classic finding of UR.. Even though in developed countries where fetal heart rate abnormalities are the first identified manifestations of uterine rupture, late signs like vaginal bleeding (43.9%) are common in developing countries.. Sometimes it may lead to life threatening severe uterine bleeding.. Unscared uterine rupture (UUR) usually occurs in the lower segment (the weakest part) of uterus. If the rupture part is fundus, the diagnosis is often delayed because the haemorrhage is not revealed immediately, as blood collects in the intraperitoneal space.. Bleeding
Vaginal bleeding is a classic finding of UR.. Even though in developed countries where fetal heart rate abnormalities are the first identified manifestations of uterine rupture, late signs like vaginal bleeding (43.9%) are common in developing countries.. Sometimes it may lead to life threatening severe uterine bleeding.. Unscared uterine rupture (UUR) usually occurs in the lower segment (the weakest part) of uterus. If the rupture part is fundus, the diagnosis is often delayed because the haemorrhage is not revealed immediately, as blood collects in the intraperitoneal space..
Vesicovaginal fistula Uterine rupture may leave surviving patients with term complications like vesicovaginal fistula and inability to deliver children.. Vesicovaginal fistula
Uterine rupture may leave surviving patients with term complications like vesicovaginal fistula and inability to deliver children..
Blood stained urine A rare presentation.UR can also leads to associated bladder rupture . Blood stained urine
A rare presentation.UR can also leads to associated bladder rupture .
DIC A complication of UR. One of the common cause of maternal death following UR is disseminated intravascular coagulation (DIC) or irreversible shock.. DIC
A complication of UR. One of the common cause of maternal death following UR is disseminated intravascular coagulation (DIC) or irreversible shock..
Acidosis A neonatal complication of UR. There are reported cases of acidosis needing admission in neonatal Intensive care unit (ICU).. Acidosis
A neonatal complication of UR. There are reported cases of acidosis needing admission in neonatal Intensive care unit (ICU)..
Birth asphyxia A fetal complication of uterine rupture. Birth asphyxia can occurred commonly in infants delivered after 17 minutes of onset of deceleration. Some of them undergone temporary neonatal intubation . Some developed severe birth asphyxia that needing neonatal intensive care.. Birth asphyxia
A fetal complication of uterine rupture. Birth asphyxia can occurred commonly in infants delivered after 17 minutes of onset of deceleration. Some of them undergone temporary neonatal intubation . Some developed severe birth asphyxia that needing neonatal intensive care..
Intrauterine death Rupture of the gravid uterus is an unexpected and devastating complication of pregnancy with high maternal and fetal mortality and morbidity. Even though it can be prevented in most cases, rates of maternal and perinatal morbidity and mortality are still high. Intrauterine death rate is high in rupture of the unscared uterus than the scared uterus.Rupture of the unscarred uterus carries more hazardous fetomaternal risks compared to scarred uterus.. Uterine rupture can lead to fetal brain injury or death.. Complete uterine rupture in which the fetus was already extruded into the peritoneal cavity was observed in most cases (88.4%). In these cases, majority of the fetus were dead, reflecting the high perinatal mortality rate. . Intrauterine death
Rupture of the gravid uterus is an unexpected and devastating complication of pregnancy with high maternal and fetal mortality and morbidity. Even though it can be prevented in most cases, rates of maternal and perinatal morbidity and mortality are still high. Intrauterine death rate is high in rupture of the unscared uterus than the scared uterus.Rupture of the unscarred uterus carries more hazardous fetomaternal risks compared to scarred uterus.. Uterine rupture can lead to fetal brain injury or death.. Complete uterine rupture in which the fetus was already extruded into the peritoneal cavity was observed in most cases (88.4%). In these cases, majority of the fetus were dead, reflecting the high perinatal mortality rate. .
Maternal death In the literature, maternal mortality rate can be as high as 13.5%, whereas several other studies from developing countries have reported lower rates.Death may have occurred prior to the admission to the hospital. Hypovolemic shock is claimed to be the main cause of death and rapid transfer of these patients to tertiary care centers. Maternal death
In the literature, maternal mortality rate can be as high as 13.5%, whereas several other studies from developing countries have reported lower rates.Death may have occurred prior to the admission to the hospital. Hypovolemic shock is claimed to be the main cause of death and rapid transfer of these patients to tertiary care centers.

Clinicals - Examination

Fact Explanation
Abdominal tenderness Uterine rupture usually occurs at the site of deficient cesarean scars. The majority of fenestrations or incomplete uterine ruptures are asymptomatic and may initially be quite subtle and may be seen during the process of future cesarean sections or laparotomies . The majority of cesarean uterine incisions are low-transverse and this type of incision has the lowest risk for rupture in subsequent pregnancies .The classical (vertical) scar at the upper part (body) of the uterus is more vulnerable to ruptures and can cause more serious complications both for the mother and her baby. Abdominal tenderness is a common finding in UR of a scarred uterus.. Abdominal tenderness
Uterine rupture usually occurs at the site of deficient cesarean scars. The majority of fenestrations or incomplete uterine ruptures are asymptomatic and may initially be quite subtle and may be seen during the process of future cesarean sections or laparotomies . The majority of cesarean uterine incisions are low-transverse and this type of incision has the lowest risk for rupture in subsequent pregnancies .The classical (vertical) scar at the upper part (body) of the uterus is more vulnerable to ruptures and can cause more serious complications both for the mother and her baby. Abdominal tenderness is a common finding in UR of a scarred uterus..
Fetal distress/ Bradicardia Abdominal tenderness and fetal distress are more common in the scarred uteri.. In developed countries fetal heart rate abnormalities are the first identified manifestations of uterine rupture.. Abnormalities in fetal heart rate were the most common sign of rupture, occurring in 55-87% of uterine rupture events. Fetal bradicardia and prolonged deceleration may occur. Usually no prolonged clinical morbidity (death, asphyxia, or intubation) occurred when delivery took place within 17 minutes of onset of deceleration. Fetal distress/ Bradicardia
Abdominal tenderness and fetal distress are more common in the scarred uteri.. In developed countries fetal heart rate abnormalities are the first identified manifestations of uterine rupture.. Abnormalities in fetal heart rate were the most common sign of rupture, occurring in 55-87% of uterine rupture events. Fetal bradicardia and prolonged deceleration may occur. Usually no prolonged clinical morbidity (death, asphyxia, or intubation) occurred when delivery took place within 17 minutes of onset of deceleration.
Hypovolemic shock Hypovolemic shock is claimed to be the main cause of death and rapid transfer of these patients to tertiary care centers is imperative.. The symptoms of incomplete rupture differ totally from those of complete rupture.In incomplete rupture, the symptoms can be minimal and so obscured as to lead us to almost inevitable diagnostic errors.In complete rupture, the symptoms are usually dramatic. To the primary shock due to the rupture are added the signs of an important internal hemorrhage.. Hypovolemic shock
Hypovolemic shock is claimed to be the main cause of death and rapid transfer of these patients to tertiary care centers is imperative.. The symptoms of incomplete rupture differ totally from those of complete rupture.In incomplete rupture, the symptoms can be minimal and so obscured as to lead us to almost inevitable diagnostic errors.In complete rupture, the symptoms are usually dramatic. To the primary shock due to the rupture are added the signs of an important internal hemorrhage..
Sudden increase in maternal pulse The most common presentation is intrapartum, but rupture can be diagnosed ante or postpartum. Intrapartum events are usually detected after a sudden increase in maternal pulse rate and a decrease in blood pressure together with vaginal bleeding and abdominal pain followed by fetal bradycardia.. Sudden increase in maternal pulse
The most common presentation is intrapartum, but rupture can be diagnosed ante or postpartum. Intrapartum events are usually detected after a sudden increase in maternal pulse rate and a decrease in blood pressure together with vaginal bleeding and abdominal pain followed by fetal bradycardia..
Palpable fetal parts The signs and symptoms of uterine rupture, largely depending on timing, site and extent of uterine defect, are severe hemorrhage, palpable fetal parts, recession of presenting fetal parts.. Palpable fetal parts
The signs and symptoms of uterine rupture, largely depending on timing, site and extent of uterine defect, are severe hemorrhage, palpable fetal parts, recession of presenting fetal parts..
Internal loops or parts of the greater omentum in the uterine cavity If there is sufficient cervical dilatation,
the vaginal examination may reveal intestinal loops or parts of the greater omentum in the uterine cavity..
Internal loops or parts of the greater omentum in the uterine cavity
If there is sufficient cervical dilatation,
the vaginal examination may reveal intestinal loops or parts of the greater omentum in the uterine cavity..
Cessation of contractions Uterine ruptures could be divided into complete and incomplete (dehiscence) ruptures. In incomplete uterine rupture or dehiscence, the myometrium is disrupted but the serosa is intact. Full thickness tears of uterine wall result in complete uterine ruptures. These ruptures mostly occur at the level of prior anterior low cesarean sections..The contractions cease and some part of the fetus can usually be palpated.. Cessation of contractions
Uterine ruptures could be divided into complete and incomplete (dehiscence) ruptures. In incomplete uterine rupture or dehiscence, the myometrium is disrupted but the serosa is intact. Full thickness tears of uterine wall result in complete uterine ruptures. These ruptures mostly occur at the level of prior anterior low cesarean sections..The contractions cease and some part of the fetus can usually be palpated..
Dyspnoea Considerable abdominal distension with dyspnoea, caused by the compression of the thoracic cavity.. Dyspnoea
Considerable abdominal distension with dyspnoea, caused by the compression of the thoracic cavity..
Hypotension Uterine ruptures mostly occur due to previous cesarean sections. Risk of rupture in classical (vertical) incision is greater than transverse one in subsequent pregnancies.. Modes of presentation in Uterine rupture (UR) may differ in scarred and unscarred uteri. Hypotension and intrauterine death occur frequently in the unscarred UR.. Hypotension
Uterine ruptures mostly occur due to previous cesarean sections. Risk of rupture in classical (vertical) incision is greater than transverse one in subsequent pregnancies.. Modes of presentation in Uterine rupture (UR) may differ in scarred and unscarred uteri. Hypotension and intrauterine death occur frequently in the unscarred UR..
Anemia Severe anemia and vaginal bleeding are also common presentations. Most women with uterine rupture required blood transfusion. That is probably due to the poor haemodynamic state and the high prevalence of anaemia in pregnancy.. Anemia
Severe anemia and vaginal bleeding are also common presentations. Most women with uterine rupture required blood transfusion. That is probably due to the poor haemodynamic state and the high prevalence of anaemia in pregnancy..
Recession of presenting fetal parts Recession of the fetal head can be seen. That means baby's head moving back up into the birth canal.. Recession of presenting fetal parts
Recession of the fetal head can be seen. That means baby's head moving back up into the birth canal..
Abdominal distension There will be a considerable abdominal distension together with uterine rupture.. Abdominal distension
There will be a considerable abdominal distension together with uterine rupture..
Bulging under the pubic bone Bulging under the pubic bone can be identified. Baby's head protrudes out of the uterine scar.. Bulging under the pubic bone
Bulging under the pubic bone can be identified. Baby's head protrudes out of the uterine scar..

Investigations - Diagnosis

Fact Explanation
CTG Continuous fetal cardiotocography (CTG) monitoring can performed. One of the first sign of posterior uterine rupture is a pathological CTG with persistent fetal bradycardia . CTG abnormalities are associated with 55–87% of uterine ruptures. Other recognised signs of uterine rupture include loss of station of presenting part and new inefficient contractility.. CTG
Continuous fetal cardiotocography (CTG) monitoring can performed. One of the first sign of posterior uterine rupture is a pathological CTG with persistent fetal bradycardia . CTG abnormalities are associated with 55–87% of uterine ruptures. Other recognised signs of uterine rupture include loss of station of presenting part and new inefficient contractility..
USS Ultrasonography is probably the safest and most useful imaging technique during pregnancy.Extra-peritoneal haematoma, intrauterine blood, free peritoneal blood, empty uterus, gestational sac above the uterus, and large uterine mass with gas bubbles have been reported as sonographic findings associated with uterine rupture.. An incomplete uterine rupture can be identified by sonographic evaluation of the isthmic uterine scar in late second trimester. High frequency transducer is preferred over a low frequency one for the diagnosis of anterior uterine wall rupture. It is recommended to look for continuous myometrial band and measure its thickness, especially, if the patient complains about pain or contractions. Besides, it is highly suggested to consider the diagnosis of uterine rupture in patients who have recently undergone cesarean section.. USS
Ultrasonography is probably the safest and most useful imaging technique during pregnancy.Extra-peritoneal haematoma, intrauterine blood, free peritoneal blood, empty uterus, gestational sac above the uterus, and large uterine mass with gas bubbles have been reported as sonographic findings associated with uterine rupture.. An incomplete uterine rupture can be identified by sonographic evaluation of the isthmic uterine scar in late second trimester. High frequency transducer is preferred over a low frequency one for the diagnosis of anterior uterine wall rupture. It is recommended to look for continuous myometrial band and measure its thickness, especially, if the patient complains about pain or contractions. Besides, it is highly suggested to consider the diagnosis of uterine rupture in patients who have recently undergone cesarean section..
CT scan CT and magnetic resonance
imaging also are used to diagnose uterine rupture. Computed tomography uses ionizing radiation and is better reserved for the evaluation of third trimester
trauma and in the postpartum period. The dose of ionizing radiation during CT is less than during pelvimetry..
CT scan
CT and magnetic resonance
imaging also are used to diagnose uterine rupture. Computed tomography uses ionizing radiation and is better reserved for the evaluation of third trimester
trauma and in the postpartum period. The dose of ionizing radiation during CT is less than during pelvimetry..
MRI MRI also used in diagnosis of uterine rupture. Even though Magnetic resonance imaging has demonstrated its usefulness as an alternative imaging modality, its high cost, complexity, lack of portability, and availability limits its usefulness.. MRI
MRI also used in diagnosis of uterine rupture. Even though Magnetic resonance imaging has demonstrated its usefulness as an alternative imaging modality, its high cost, complexity, lack of portability, and availability limits its usefulness..

Management - Supportive

Fact Explanation
Quick referral to a tertiary care center Uterine rupture (UR) is a serious, life-threatening emergency. A high index of suspicion and quick referral to a well equipped center may reduce the incidence of this condition. All patients with a history of cesarean section should deliver in hospitals with facilities for surgery and blood transfusion.. Quick referral to a tertiary care center
Uterine rupture (UR) is a serious, life-threatening emergency. A high index of suspicion and quick referral to a well equipped center may reduce the incidence of this condition. All patients with a history of cesarean section should deliver in hospitals with facilities for surgery and blood transfusion..
Close monitoring Close monitoring of maternal and fetal response to uterine stimulants is mandatory to avoid complications of obstructed labour and overuse of uterine stimulants. Application of external force, vacuum forceps and breech extraction are other possible causes of UR.. Close monitoring
Close monitoring of maternal and fetal response to uterine stimulants is mandatory to avoid complications of obstructed labour and overuse of uterine stimulants. Application of external force, vacuum forceps and breech extraction are other possible causes of UR..
Emergency exploratory laparotomy and delivery Emergency exploratory laparotomy and delivery are proposed for the treatment of ruptured uterus..The management of ruptured uterus is laparotomy as soon as possible, after resuscitation has been commenced. The correct surgical procedure is that which is the shortest, taking into consideration the surgeon's skill.. Successful repair of dehiscence with continuation of pregnancy have been reported by researchers too.. Emergency exploratory laparotomy and delivery
Emergency exploratory laparotomy and delivery are proposed for the treatment of ruptured uterus..The management of ruptured uterus is laparotomy as soon as possible, after resuscitation has been commenced. The correct surgical procedure is that which is the shortest, taking into consideration the surgeon's skill.. Successful repair of dehiscence with continuation of pregnancy have been reported by researchers too..
Total hysterectomy Hysterectomy whether total or subtotal was the main surgical procedure in case of UR. In circumstances where preservation of fertility is an issue to be remembered, suture repair can be considered. However, UR has a potential for mortality and cost-benefit ratio must be evaluated very well.The choice of the surgical procedure depends upon the type, location and extent of the tear as well as the patient’s condition and desire for future fertility. Total hysterectomy is the operative procedure of choice.. Total hysterectomy
Hysterectomy whether total or subtotal was the main surgical procedure in case of UR. In circumstances where preservation of fertility is an issue to be remembered, suture repair can be considered. However, UR has a potential for mortality and cost-benefit ratio must be evaluated very well.The choice of the surgical procedure depends upon the type, location and extent of the tear as well as the patient’s condition and desire for future fertility. Total hysterectomy is the operative procedure of choice..
Subtotal hysterectomy Even though total hysterectomy is the operation of choice,cardiovascular decompensation necessitates subtotal hysterectomy or simple suture repair and bilateral tubal ligation.. Subtotal hysterectomy
Even though total hysterectomy is the operation of choice,cardiovascular decompensation necessitates subtotal hysterectomy or simple suture repair and bilateral tubal ligation..
Suture repair Consider in case of where preservation of fertility is required.Unhealthy tissue remaining after uterine repair may predispose to problems like infection, DIC, abscess formation and hemorrhage. In circumstances where suture repair is undertaken to preserve fertility, the risk of recurrent rupture is always there.. Suture repair
Consider in case of where preservation of fertility is required.Unhealthy tissue remaining after uterine repair may predispose to problems like infection, DIC, abscess formation and hemorrhage. In circumstances where suture repair is undertaken to preserve fertility, the risk of recurrent rupture is always there..

Management - Specific

Fact Explanation
Regular antenatal care and family planing advice Regular antenatal care and meticulous screening of high-risk patients are very important for effective prevention.Family-planning advice to reduce grandmultiparity, improved access to maternal care, decentralization of obstetric services into peripheral units to prevent home deliveries and good supervision during labor can reduce the incidence of UR. Regular antenatal care and family planing advice
Regular antenatal care and meticulous screening of high-risk patients are very important for effective prevention.Family-planning advice to reduce grandmultiparity, improved access to maternal care, decentralization of obstetric services into peripheral units to prevent home deliveries and good supervision during labor can reduce the incidence of UR.

Concise, fact-based medical articles to refresh your knowledge

Access a wealth of content and skim through a smartly presented catalog of diseases and conditions.

  1. AHMADI F, SIAHBAZI S, AKHBARI F. Incomplete Cesarean Scar Rupture J Reprod Infertil [online] 2013, 14(1):43-45 [viewed 20 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3719360
  2. BISSON C. SPONTANEOUS UTERINE RUPTURE Can Med Assoc J [online] 1947 Dec, 57(6):583-585 [viewed 20 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1590711
  3. CADET JJ. Occult uterine rupture: role of ultrasonography. J Natl Med Assoc [online] 1998 Jun, 90(6):374-376 [viewed 20 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2568237
  4. FOFIE C, BAFFOE P. A Two-Year Review of Uterine Rupture in a Regional Hospital Ghana Med J [online] 2010 Sep, 44(3):98-102 [viewed 20 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2996838
  5. GUISE JM, MCDONAGH MS, OSTERWEIL P, NYGREN P, CHAN BK, HELFAND M. Systematic review of the incidence and consequences of uterine rupture in women with previous caesarean section BMJ [online] 2004 Jul 3, 329(7456):19-25 [viewed 20 August 2014] Available from: doi:10.1136/bmj.329.7456.19
  6. HASBARGEN U.. Uterine dehiscence in a nullipara, diagnosed by MRI, following use of unipolar electrocautery during laparoscopic myomectomy: Case report. [online] 2002 August, 17(8):2180-2182 [viewed 21 August 2014] Available from: doi:10.1093/humrep/17.8.2180
  7. IGWEGBE AO, ELEJE GU, UDEGBUNAM OI. Risk factors and perinatal outcome of uterine rupture in a low-resource setting Niger Med J [online] 2013, 54(6):415-419 [viewed 20 August 2014] Available from: doi:10.4103/0300-1652.126300
  8. JANG DG, LEE GS, YOON JH, LEE SJ. Placenta Percreta-Induced Uterine Rupture Diagnosed By Laparoscopy in the First Trimester Int J Med Sci [online] , 8(5):424-427 [viewed 20 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3149421
  9. KURDOGLU MERTIHAN, KOLUSARI ALI, YILDIZHAN RECEP, ADALI ERTAN, SAHIN HANIM GULER. Delayed diagnosis of an atypical rupture of an unscarred uterus due to assisted fundal pressure: a case report. Array [online] 2009 December [viewed 20 August 2014] Available from: doi:10.1186/1757-1626-2-7966
  10. NAVARATNAM K, ULAGANATHAN P, AKHTAR MA, SHARMA SD, DAVIES MG. Posterior Uterine Rupture Causing Fetal Expulsion into the Abdominal Cavity: A Rare Case of Neonatal Survival Case Rep Obstet Gynecol [online] 2011:426127 [viewed 20 August 2014] Available from: doi:10.1155/2011/426127
  11. OGBOLE G, OGUNSEYINDE O, AKINWUNTAN A. Intrapartum Rupture of the Uterus Diagnosed by Ultrasound Afr Health Sci [online] 2008 Mar, 8(1):57-59 [viewed 20 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2408536
  12. QAZI Q, AKHTAR Z, KHAN K, KHAN AH. Woman Health; Uterus Rupture, Its Complications and Management in Teaching Hospital Bannu, Pakistan Maedica (Buchar) [online] 2012 Jan, 7(1):49-53 [viewed 20 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3484796
  13. TOLA ESRA NUR. First Trimester Spontaneous Uterine Rupture in a Young Woman with Uterine Anomaly. Case Reports in Obstetrics and Gynecology [online] 2014 December, 2014:1-3 [viewed 20 August 2014] Available from: doi:10.1155/2014/967386
  14. TURGUT A, OZLER A, SIDDIK EVSEN M, ENDER SOYDINC H, YAMAN GORUK N, KARACOR T, GUL T. Uterine rupture revisited: Predisposing factors, clinical features, management and outcomes from a tertiary care center in Turkey Pak J Med Sci [online] 2013, 29(3):753-757 [viewed 20 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3809304