RUPTURE OF THE UTERUS IN EAST AFRICA

A Note on its Incidence and Aetiology in Women of the Kikuyu Tribe
BY

BRIAN P. HARRIS, M.D.
AND JAMES

0. W. ANGAWA, Dip.Med. (E.A.) The Mehcal Departmaat, Kenya *

Group 2. Shoulder presentation; 8 BETWEEN mid-September 1947 and October I950 33 cases of rupture of the cases. This group was subdivided as uterus were seen at the Government follows : African Hospital, Kiambu, Kenya, (I)Spontaneous rupture with shoulder presentation. (" Neglected transamongst women of the Kikuyu tribe. verse. ' ') The incidence of rupture of the uterus, (2) Rupture discovered after obstetric i.e., the ratio of cases of rupture to total live-births and stillbirths, for 1948 and manipulations in hospital. 1949is as follows: (3) Rupture discovered at autopsy, after obstetric manipulations in hospital.
Live-births

and
still-births
I948

Rupture of uterus
I1

Incidence
I

Groufi 3. After forceps delivery or craniotomy ; 3 cases.

I949

1023 I 188
2211

8
1 9

I

in 93 i n 148.5
--

G r o e 4. Associated with hydrocephalus; z cases.
Gqo@ 5. Rupture through scar of previous Caesarean section; z cases.

1948 and I949

I in

117.4

I n this series of 33 cases, a more detailed account of which has been submitted to the East African Medical Jozlnzal, rupture of the uterus presented itself as follows:

Groufi 6. Spontaneous rupture in vertex presentation; cases. This group was subdivided follows :
(I) Rupture before admission. (2) SPontaneous rupture in hospital.

Group I. Rupture of uterus discovered on admission; presentation before rupture not ascertainable; 11 cases. These patients were brought to hospital by ambulance, as emergencies occurring in the course of labour.
~ _ _ _

(3) SPontaneous rupture in hospital associated with subtertian malaria. (4)Spontaneous rupture causing V m P toms after normal delivery of live baby and placenta at home.
Two conclusions can be drawn, namely : incidence Of rupture of Uterus i n Kikuyu women is high, and (2)whilst the proportion of ruptures following Caesarean
(I) the

*We are indebted to Honourable Director of Medical Services, Kenya, for permission t o publish this paper.

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RUPTURE OF THE UTERUS IN 'EAST AFRICA

1031
through the scar of a previous Caesarean section of 6.8 per cent resembles in both features our East African series and differs from the Canadian and American series. Of 44 ruptures in the Chinese series, IZ were due to contracted pelvis and g of these were said to be due to osteomalacia. Ten of the 12 cases were spontaneous ruptures before admission to hospital. At least 7 of our East African series were known to be spontaneous. In other words, the presentation was vertex; delivery had not been attempted by forceps or craniatomy; nor had there been a previous Caesarean section. Further, the parity of these 7 strictly spontaneous cases lay between 3 and 9, and they gave previously normal obstetric histories. Why should spontaneous rupture occur during a short labour in a multipara with a previously normal history ? In seeking far the cause or causes of this high incidence of spontaneous rupture of the uterus amongst KikuYu women, we study their tribal customs and characteristics. First, are vegetarian; they seldom eat meat and milk is reserved for children- (In Passing, it may be mentioned suffer from a that their Young Severe form of Protein deficiency, known as malignant malnutrition or kwashiorkor "-1 Secondly,Preston (1942) basing his observations on a large number of height and pelvic measurements at Fort Hall, finds the average Kikuyu woman to be somewhat diminutive in height and to have a miniature or funnel-shaped pelvis which is likely to cause a delayed or obstructed labour. He is further of the opinion that most Kikuyu women have a more rapid labour than European women. He gives measurements based on the examination of 700 Kikuyu babies and considers that the moulding of the skull in the Kikuyu foetus is much greater than that of the European

section is low (6.1 per cent), the proportion of spontaneous rupture is high. In Canada and the United States, the incidence of rupture of uterus is far lower, viz., between I in 1,000 and I in 3,000 deliveries, in series recorded by Delfi and Eastman (1945), Morrison and Douglas (r945),Lynch (1g45), Fitzgerald, Webster and Fields (1949), Watt (1950) and Brierton (19.50): In fact, Brierton's 57 cases of rupture were ColIected during 14 Years from more than llo,ooo Broadly speaking the above authors found that rupture Of the Scar Of a previous Caesarean section was more common as a cause of rupture of uterus than in Our series; and spontaneous rupture a less common cause. Watt had I spontaneous and this rupture in his series Of '5 occurred in a woman who had been given pituitrin, and whose baby weighed I I B pounds and was described as a " moderate hydrocephalic ". Brierton found that rupture through the scar of a previous Caesarean section was the ccymmon& and next came in his series of 57 spontaneous rupture due to other causes. In the American series of rupture of uterus reported by Fitzgerald, Webster and Fields (1g4g), in 23 white and 19 coloured women, examination of their case-histories showed that obstetric trauma was a cornmoner antecedent cause in white women : but that vague antecedent causes, such a s " prolonged labour and probably &proportion ", " defect in fundus of uterus " and " unusually severe contractions and/ or rapid labour " appeared oftener in casehistories of coloured women. These vague antecedent causes probably mask spontaneous ruptures. Does rupture in fact differ in its causation in coloured and white women? In the series reported from Peiping by Whitacre and Fang (1942), the high incidence of rupture of uterus of I in 95 with the low proportion of rupture

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JOURNAL OF OBSTETRICS AND GYNRECOLOGY

and that there is a great deal of over-riding of bones of the foetal skull. Thirdly, Kikuyu girls at puberty undergo circumcision (removal of clitoris and labia minora). Our experience at Kiambu confirms Preston’s view that if circumcision scars give rise to delayed or obstructed labour the latter can generally be overcome by episiotomy. Fourthly, Preston emphasizes that Kikuyu women act as beasts of burden. A load is supported by means of a leather strap, passing over the skull in the region of the coronal suture, the load itself resting on the back, from the mid-dorsal to the lumbo-sacral region. They start carrying these loads at an early age and girls of 6 years and less may sometimes be seen carrying an infant by this method. The loads carried are often very heavy, consisting of big bundles of firewood, and prevent the women from maintaining the erect posture, especially when they are walking uphill. Further, when a woman’s scalp is shaved, it is often possible to see a furrow on the scalp, corresponding with a groove in the bony skull, which can f such stresses can alter the shape be felt. I of the skull, may they not do likewise to the bony pelvis? So much for their tribal customs and characteristics, We must now briefly examine the possible bearing of other factors in aetiology. First, parity: all our patients were multiparae, with the single exception of one of the two cases of hydrocephalus. Secondly, pituitrin: though some authors stress the misuse of pituitrin during labour, at this hospital pituitrin is never given until after delivery o f the placenta. Thirdly, toxaemias : established eclampsia is uncommon amongst the Kikuyu of this district, only one case having been treated in this hospital during the past 3 years, and toxaemias are rare. Fourthly, cervical tears : some authors mention the possibility of rupture of the uterus starting by upward extension

of a high cervical tear from a previous labour. Cases of high cervical tear have certainly occurred in Kiambu Hospital during the past 3 years. Three of these were fatal, because the tear was too high to be adequately sutured vaginally and packing did not control haemorrhage. Autopsy, however, was not performed on these 3 cases to determine whether the tear had extended into the lower uterine segment. On the other hand, the site of rupture of the uterus in our series was most often transverse, at the junction of upper and lower segments. Fifthly, rainfall : in this district, there are two rainy seasons, “long rains” from April to June and “ short rains ” from end of October to midDecember. During the rainy seasons there is an increased incidence of malaria. During the rainy seasons, too, women carry heavier loads of firewood on their backs. We failed, however, to find a relationship between monthly admissions for rupture of uterus and malarial case incidence or monthly rainfall figures. Admissions for rupture of uterus appear to “come in runs ”. Sixthly, pendulous abdomen : it is well known that Kikuyu women have a great tendency to anterior uterine obliquity with flabby abdominal musculature and pendulous abdomen. The anterior uterine wall lacks support and may be more vulnerable. I n our East African series, the lower anterior wall was the most favoured site for rupture of the uterus. Can load-carrying “ crowd ” the bones of the immature pelvis? Even so, why i t ha should trouble start in a woman w previously good obstetric history, unless load-carrying in some way in the intervals between pregnancies could diminish one of the internal diameters of the pelvis ? Or, can load-carrying lead to spondylolisthesis ? Dr. Hopkirk, the radiologist (1949)has not found a high incidence of spondylolisthesis amongst Africans in

I033 Nairobi. Only a radiological survey could uterus (with tuba1 sterilization, only if determine the importance of these factors. time allows) is a less shocking operation Alternatively, is the uterus unduly than removal of the puerperal uterus. friable? Mr. Victor Bonney used to preSUMMARY face his lecture on prolapse at the Middlesex Hospital, with the observation that The incidence of rupture of uterus everyone has " some shoddy in his or her amongst K i k u p WOmen at the Governmake-up," Even in our caxs of con- ment African Hospital, Kiambu, is I h ditiond rupture, e.g., i n neglected trans- II7.4. Thirb'-three cases have been vene presentations and following internal treated between mid-september 1947 and versions, we have the impression that October 1950. A high ProPhOn of Occur sPontaneouslY. the uterus ruptures more easily and after a shorter period from the onset The aetiology is discussed with particuof labour than in the European or lar reference to the Kikuyu method of Luo African. The uterus appears to be carrying loads. unduly friable and greater care has to REFERENCES be exercised when doing versions. The Gillmans (1947) produce experimental Brierton, J. F. (1950):Acmer. J . Obstet. Gylre~., 113. evidence that rats fed on certain deficiency DeLee,59, J. B., and Greenhill, J . p. (194,): diets become more liable to rupture of Principles and Practice of Obstetrics. 9th uterus. They think that nutritional factors edition, p. 690. Saunders. Philadelphia. may be Of importance in af uterus Delfs, E., and Eastman, N.J. (1945) : Canad. med. in some women. Ass. I., 52. 376. Further details, With case histories, Will Fitzgerald, J. E.,Webster. A., and Fields, J. E. (1949):Surg. Gynec. Obstet., 88, 652. be published in the East Africalz Medical JozcmaE. Twenty-one of the 33 cases were Gillman, J., Gilbert, G., and Gillman, T. S. (1947): S . Afr. J. med. Sci., 12, 153. submitted to laparotomy and repair o f Hopkirk, W. G. S. (1949):Personal communicauterus; of these, arec cove red, gdied. Four tion. were submitted to laparotomy and repair of uterus with tuba1 sterilization; of these, Lynch, F*J. (1945): Am''. J. ObStet. GYnec.0 4 9 s 514. to Morrison, 3 recovered, I died* six were J. H.,and Douglas, L. H. (1945) : sub-total hysterectomy; of these, 2 reAmer. J . Obstet. Gynec., 50, 330. 'Overed, 4 died* Two not submitted Preston, P. G.(1942) : E . Afr. med. ]., 9,223, 247. to operation for rupture died. Of total Watt, G.L. (1950):Amer. 1.Obstet. Gynec., 59. 33 cases, 17 recovered, 16 died. We are 490. of the opinion that, if blood is not available Whitacre, F . E., and Fang, L. Y. (1942): Arch. for transfusion, laparotomy and repair of Surg., 45, 213.

RUPTURE OF THE UTERUS I N EAST AFRICA

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