Norwegian National Advisory Unit on Women's Health, Rikshospitalet, Oslo University Hospital, Oslo, Norway; Women and Children's Division, Rikshospitalet, Oslo University Hospital, Oslo, Norway.
Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway; Medical Birth Registry of Norway, Norwegian Institute of Public Health, Bergen, Bergen, Norway.
Am J Obstet Gynecol. 2018 Jul;219(1):109.e1-109.e8. doi: 10.1016/j.ajog.2018.04.010. Epub 2018 Apr 12.
Complete uterine rupture is a rare peripartum complication often associated with a catastrophic outcome for both mother and child. However, little has been written based on large data sets about maternal and infant outcome after complete ruptures. This is partly due to the rarity of the event and the serious maternal and infant outcome; it is also partly due to the use of international diagnostic codes that do not differentiate between the less catastrophic partial rupture and more catastrophic complete uterine rupture. As uterine rupture is expected to increase due to increased cesarean delivery rates worldwide, it is important to know more completely about the outcome following complete uterine rupture.
We sought to explore risk factors associated with poor infant outcome in cases of complete uterine rupture.
This population-based study used data from the Medical Birth Registry of Norway, the Patient Administration System, and medical records. We included births with complete uterine rupture after start of labor in all maternity units in Norway during the period 1967 through 2008 (n = 244 births), identified among 2,455,797 births. Uterine ruptures were identified and further studied through a review of medical records. We estimated the associations between infant outcomes and demographic and labor risk factors using logistic regression analyses. Odds ratios with 95% confidence intervals for each risk factor were determined after adjustment for demographic factors and period of birth. The main outcome measure was infant outcome: healthy infant, intrapartum/infant deaths, hypoxic ischemic encephalopathy, and admission to the neonatal intensive care unit.
We identified 109 (44.7%) healthy infants, 56 (23.0%) infants needing neonatal intensive care unit admission, 64 (26.2%) intrapartum/infant deaths, and 15 (6.1%) infants with hypoxic ischemic encephalopathy. The highest number of intrapartum/infant deaths occurred in 1967 through 1977 (51.6%) and the fewest in 2000 through 2008 (15.0%). Unscarred uterine ruptures did not significantly increase intrapartum/infant deaths compared to scarred uterine ruptures. Placental separation and/or fetal extrusion had the highest odds ratio for intrapartum/infant deaths (odds ratio, 17.9; 95% confidence interval, 7.5-42.4). Time-to-delivery interval <20 minutes resulted in fewest intrapartum/infant deaths (9.9%), although there were 2 deaths at 10-minute interval. Time to delivery >30 minutes vs <20 minutes increased risk of death (odds ratio, 16.7; 95% confidence interval, 6.4-43.5).
Intrapartum/infant death after complete uterine rupture decreased significantly over the decades. Time to delivery >30 minutes and placental separation and/or fetal extrusion had the highest association with intrapartum/infant deaths after complete uterine rupture. Time to delivery <20 minutes limited the incidence of intrapartum/infant deaths.
完全性子宫破裂是一种罕见的围产期并发症，常导致母婴灾难性后果。然而，由于事件的罕见性以及母婴严重后果，基于大型数据集的相关研究很少；此外，由于国际诊断代码并未区分不太严重的部分性破裂和更严重的完全性子宫破裂，这也在一定程度上限制了相关研究。随着全球剖宫产率的上升，完全性子宫破裂的发生率预计会增加，因此，全面了解完全性子宫破裂后的母婴结局非常重要。
探讨与完全性子宫破裂后婴儿不良结局相关的危险因素。
本研究基于人群，使用了挪威医学出生登记系统、患者管理系统和病历中的数据。研究纳入了挪威所有分娩中心在 1967 年至 2008 年期间出现的、在开始分娩后发生的完全性子宫破裂病例（n=244 例），总计 2455797 例分娩。通过病历回顾识别出子宫破裂病例，并进一步进行研究。我们使用逻辑回归分析估计了婴儿结局与人口统计学和分娩风险因素之间的关系。在调整了人口统计学因素和分娩时期后，确定了每个风险因素与婴儿结局之间的优势比及其 95%置信区间。主要结局指标为婴儿结局：健康婴儿、分娩期/婴儿死亡、缺氧缺血性脑病和新生儿重症监护病房入住。
研究共识别出 109 例（44.7%）健康婴儿、56 例（23.0%）需要入住新生儿重症监护病房的婴儿、64 例（26.2%）分娩期/婴儿死亡和 15 例（6.1%）患有缺氧缺血性脑病的婴儿。1967 年至 1977 年期间的分娩期/婴儿死亡发生率最高（51.6%），而 2000 年至 2008 年期间的分娩期/婴儿死亡发生率最低（15.0%）。未剖宫产的子宫破裂与剖宫产的子宫破裂相比，并不会显著增加分娩期/婴儿死亡的风险。胎盘分离和/或胎儿排出的发生与分娩期/婴儿死亡的关联度最高（比值比，17.9；95%置信区间，7.5-42.4）。分娩时间<20 分钟时分娩期/婴儿死亡的发生率最低（9.9%），但有 2 例发生在 10 分钟时。与分娩时间<20 分钟相比，分娩时间>30 分钟时死亡风险增加（比值比，16.7；95%置信区间，6.4-43.5）。
过去几十年中，完全性子宫破裂后的分娩期/婴儿死亡显著减少。分娩时间>30 分钟以及胎盘分离和/或胎儿排出与完全性子宫破裂后的分娩期/婴儿死亡关系最密切。分娩时间<20 分钟可降低分娩期/婴儿死亡的发生率。
