International Journal of Reproduction, Contraception, Obstetrics and Gynecology

Mathews B et al. Int J Reprod Contracept Obstet Gynecol. 2018 Oct;7(10):4305-4308

www.ijrcog.org pISSN 2320-1770 | eISSN 2320-1789

DOI: http://dx.doi.org/10.18203/2320-1770.ijrcog20184173
Case Report

Second trimester rupture of an unscarred uterus following blunt

trauma: a case report
Basil Mathews*, Chitra T.

Department of Obstetrics and Gynecology, Jawaharlal Institute of Post Graduate Medical Education and Research
(JIPMER), Puducherry, India

Received: 21 July 2018

Accepted: 28 August 2018

*Correspondence:
Dr. Basil Mathews,
E-mail: [email protected]

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Uterine rupture is a life-threatening emergency in obstetrics carrying an increased risk of maternal and foetal
morbidity and mortality. Often, uterus ruptures during labour; however, scarred uterus may rupture before the onset of
contractions in the late third trimester. Uterine rupture in an unscarred uterus occurs extremely rare. Various aetiology
has been described in literature from anomalous uterus, uterine manoeuvres, and abnormal placentation to congenital
exposure to Diethylstilbestrol. Maternal outcome depends greatly on the early diagnosis, prompt management and
availability of emergency expert care and blood transfusion. However, the diagnosis is not always obvious with its
varied non-specific presentation. Most common presentation of rupture uterus is acute abdomen, which is often
mistaken for other causes like acute pancreatitis, appendicitis, cholecystitis, especially in the early pregnancy. Authors
report a case of grand multipara at 19 weeks of gestation presented as acute abdomen. She was referred as incomplete
abortion in need of blood transfusion, later diagnosed to be rupture of uterus. She had abdominal pain and vaginal
bleeding for 14hours duration prior to admission. On further inquiry, history of blunt trauma to abdomen, the day
prior was revealed.

Keywords: Maternal morbidity, Second trimester rupture, Unscarred uterine rupture, Uterus rupture

INTRODUCTION abdomen while spontaneous rupture is associated with

anomalous uterus and placenta accrete/percreta.7 Most
Rupture uterus is a catastrophic event and a surgical common presentation is acute abdomen and is mistaken
emergency associated with high mortality and morbidity.1 for acute pancreatitis, appendicitis, cholecystitis delaying
Non-labouring uterine rupture is rare and can be life- the diagnosis.6 Symptoms of acute abdomen in pregnancy
threatening.2 Most common cause for uterine rupture is is often atypical and it would be difficult to diagnose
previous caesarean section and these are comparatively based on clinical examination alone. Sonography aids in
associated with lesser morbidity being confined to lower the diagnosis, thus facilitating the decision making and
uterus. While the overall incidence of uterine rupture is 1 emphasising its role in modern obstetrics.2,8 Authors
in 2000 deliveries, in an unscarred uterus it is extremely report a case of second trimester rupture of an unscarred
rare. While Ofir et al reported an incidence of 1 in 17000- uterus in multiparous women who was referred to present
20000, study from south India including 32080 deliveries institute as a case of incomplete abortion. Although the
reported an incidence of 6.1/10,000.3,4 Unscarred uterine patient presented with bleeding and abdominal pain, the
rupture can be either traumatic or spontaneous.5,6 diagnosis of rupture was not suspected until the
Traumatic rupture is often associated with blunt trauma sonographic findings suggested the same.

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CASE REPORT Utero-vesical (UV) peritoneal fold was intact above the
foetus. Authors noted a rent between the foetus and
A 33 years old patient, gravida 6 para 3 at 19 weeks of uterus (Figure 2). No free fluid was demonstrable. On
gestation presented with complaints of lower abdominal further inquiry, history of blunt trauma on abdomen by
pain and vaginal bleeding for 14 hours duration. Patient being hit by a cow was revealed. Diagnosis of Rupture
was diagnosed to have incomplete abortion and in view uterus was made and the patient was immediately rushed
of need for blood transfusion, was referred to present for emergency laparotomy.
institute for further management. Patient gave history of
increasing pain abdomen, absent foetal movements and
vaginal bleeding. Her general medical history didn’t
reveal significant history or allergies. Her obstetrical
history showed three full term deliveries with one
postnatal death and two spontaneous abortions for which
check curettage was done. There was no history of
caesarean section or myomectomy. Current pregnancy
was booked and included four visits with one first
trimester ultrasound.

Figure 3: Intra operative image of bulging utero-

vesical fold filled with blood.

At the opening of abdominal wall, there was no

haemoperitoneum. The UV fold was filled with blood
and was bulging (Figure 3).

Figure 1: Ultrasound image showing empty uterus

foetus seen anteriorly between bladder and anterior
surface of uterine wall (intact utero-vesical fold).

Patient was haemodynamically stable with minimal

suprapubic tenderness. Uterus was just palpable per
abdomen and there were no peritoneal signs. Vaginal
examination revealed partially effaced open cervix and
bleeding from uterine cavity. Bi-manual examination
revealed a bulky uterus and boggy anterior fornix. Figure 4: Intra operative image showing foetus
Sonographic examination showed an empty uterine cavity between the uterus and bladder on opening the UV
with foetus seen between bladder and anterior surface of fold of peritoneum.
uterus (Figure 1).
An incision on the UV fold was given and extracted the
foetus along with placenta (Figure 4 and 5).

Figure 2: Rent between the foetus and uterus. Figure 5: Intra operative image showing fetus
between the uterus and bladder.

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 Mathews B et al. Int J Reprod Contracept Obstet Gynecol. 2018 Oct;7(10):4305-4308

On further inspection, a 5 cm rent in lower part of uterus increased risk of injury to other intra-abdominal organs
was noted and was repaired in two layers using vicryl and hysterectomy.9
(Figure 6). Bilateral uterine pedicles were intact. No other
complications were encountered during the surgery. Both Surgical procedure will depend on the patient condition,
fallopian tubes and ovaries were normal. Estimated blood site, size and extent of the tear. Total hysterectomy is the
loss was 1500mL and patient received one packed cell procedure of choice unless patient desire to preserve
transfusion. Patient received Antibiotics; Post-operative fertility or the patient condition warrants an immediate
haemoglobin was 8.9g/dL and was discharged after seven life-saving sub-total hysterectomy.9 Though Gibbins
days of hospitalization without any complication. concluded in his study involving 146 patients that the
women with primary rupture are more likely to undergo
hysterectomy as compared to scarred uterus (34% vs
2.4%), in this case, the patient was haemodynamically
stable and the rent was in the anterior surface not
involving uterine pedicles thus making it amenable to
repair.11 Subsequent pregnancies are at higher risk of
preterm deliveries, low birth weight, cervical tears and
subsequent rupture (4-19%).12

CONCLUSION

Uterine rupture can have a wide range of presentation

making it a clinical diagnosis. High index of suspicion is
needed at the first level of health care provider to prevent
delay in diagnosis and management. Survival of the
Figure 6: Rent in lower part of anterior uterus. patient depends on the time interval between rupture and
intervention. Timely diagnosis and prompt management
DISCUSSION can reduce the perinatal morbidity and mortality.

Uterine rupture is a life-threatening event, the risk of Funding: No funding sources

which depends mainly on whether uterus is scarred or Conflict of interest: None declared
not. Even though unscarred uterine rupture is the rarer Ethical approval: Not required
variety with an incidence of 1:17000 to 1:20000
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