Talat J. Hassan  ( PMRC Research Centre, Institute of Urology and Transplantation, Karachi. )

Rupture of the uterus is seen in two forms, separation of previous surgical scar or rupture of an intact uterus. These two entities differ greatly in In­cidence and severity; the latter being exclusively a problem of developing countries^1-7. Sequelae of rupture of previous scars vary according to location of scar. Surgical scars may be due to previous caesarean section or other procedures like myomectomy, injury by perfora­non (as during curettage), cornual resection or plastic procedures for double uterus. Rupture of an intact uterus usually occurs in lower segment as a result of iatrogenic trauma, which may be pharmacological, instrumental or manual. Oxytocin is well known to contribute to uterine rupture and Hassan et al1 found it to be the second commonest cause of uterine tears. Spontaneous rupture of intact uterus may also occur as a result of neglected labour usually in undeveloped countries^1,2. Groen⁸ reported an incidence of 1 rupture per 112 deliveries in rural Nigeria. In 46.4% of cases the cause was cephalopelvic disproportion. Undoubtedly this type of situation occurred all over the world at an earlier time but has declined considerably in the Western World. In developed countries rupture is mainly due to dehiscence of previous caesarean section scar as a large proportion of women requesting pregnan­cy termination in the second trimester can be expected to have had previous caesarean section due to increasing use of abdominal delivery⁹. Although rupture of a previous low- transverse cervical scar during succeeding labour is a rare occurrence, an association of previous uterine surgery, invasive placenta (accreta, increta or percreta) and uterine rupture is well recognized¹⁰. Incidence of uterine rupture in United States is 1/2500 deliveries¹¹. Grand multiparity, although considered as a causa­tive factor in spontaneous rupture, is not encountered in developed countries¹² whereas in developing countries main victims of uterine rupture are grand multipara in third decade of life¹. They probably have a false sense of security about the ease of vaginal delivery and avoid hospital facilities for ante-natal and intra-natal care. The traditional birth attendants (TBAs) attending them are also unaware of their being high risk patients and refer them to hospitals late in labour (as seen by their position on partogram at the time of their admission to the hospital¹). If pregnant mothers and TBAs are made aware of the risks of this condition, a large number of uterine tears and their resultant morbidity and mortality can be avoided in our country. In our country the basic problem, besides unawareness and malnutrition⁶, ap­pears to be non availability of standard obstetric services to middle and low socioeconomic groups, for over 80% of mothers sustaining uterine tears had no ante-natal care^1,13, a situation prevalent for the last 20 years¹⁴. Maternal mortality of 3.9% in a 7-year series appearing in this issue is not very discouraging. Only mothers with lateral uterine ruptures and ruptures of broad ligament and those admitted moribund, died, rest were saved due to timely and appropriate aggressive management. Maternal mortality of 8.9%¹⁵ and foetal mortality above 50% in most of the series have been reported from U.S. Foetal mortality of 17.6% has been reported from Karachi in cases sustaining injury within the hospital¹. Significantly low maternal and foetal mortality, in cases admitted early in labour in general hospital, are ample proof that good obstetric services are present but they are not used by the middle and low socioeconomic groups either due to unawareness of their importance or due to social customs, or they are not available to them for different reasons, including transport difficulty. Possibly, all above factors operate collectively to maintain a high frequency of this obstetric catastrophe in our country which varies from 1 in 71” to 1 in 189 deliveries¹.

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