Spontaneous fundal rupture of an unscarred uterus in the second trimester of twin gestation, presenting with sepsis: a case report.

backgroundSpontaneous rupture of the uterus during the early weeks of gestation is rare. When it occurs, it is a life-threatening obstetric emergency. Most uterine ruptures happen in scarred uteri and during the late third trimester. This case is unique because it involves a spontaneous rupture in an unscarred uterus during the second trimester. Identified risk factors include antepartum hemorrhage in a previous pregnancy, history of retained placenta, prior manual vacuum aspiration for incomplete abortion, and use of herbal medicine. This case adds to the limited global literature indicating that spontaneous rupture of an unscarred uterus in the second trimester can occur owing to the combined effect of uncommon risk factors. CASE PRESENTATION: A 30-year-old ethnically Amhara, gravida IV, para II, and abortion I mother presented at Debre Tabor Comprehensive and Specialized Hospital with severe abdominal pain lasting 2 weeks. The patient reported using unspecified herbal medicine, a history of manual vacuum aspiration for incomplete abortion, retained placenta, and antepartum hemorrhage in a previous pregnancy. On physical examination, she appeared acutely ill, pale, and tachycardic. Her abdomen was distended and tender. Ultrasound results revealed two dead fetuses, one outside and one partially inside a ruptured uterus. A large intraabdominal fluid collection was also observed. An exploratory laparotomy confirmed a 10-cm transverse rupture of the uterine fundus with necrotic margins. No gross uterine congenital anomalies were detected during exploration. After stabilizing the patient, a hysterectomy with bilateral salpingectomy was performed. She received broad-spectrum antibiotics and recovered gradually with supportive care. Following psychological counseling, she was discharged after 1 week with a smooth postoperative course.

conclusionThis case report demonstrates that spontaneous rupture of the uterus in the second trimester can occur even in an unscarred uterus. Unusual risk factors such as a history of antepartum hemorrhage, retained placenta, manual vacuum aspiration for incomplete abortion, and use of herbal medicine might have acted together to contribute to uterine rupture in an already overdistended uterus. Clinicians should have a high index of suspicion for uterine rupture in pregnant women presenting with unusual abdominal pain during pregnancy, even in the absence of classical risk factors.