Spontaneous uterine rupture with primary epigastric pain in the second trimester: a case report on diagnostic challenges and multidisciplinary management.

Background: Uterine rupture during the second trimester is an exceptionally rare but life-threatening obstetric complication, presenting significant diagnostic and therapeutic challenges. Case summary: A 33-year-old woman, gravida 4, para 1, at 22 weeks and 3 days of gestation, was admitted due to a shortened cervical length. Four hours after admission, the patient developed acute, severe epigastric pain radiating to the back and shoulders. Her condition deteriorated with persistent hemoglobin decline. Abdominal and contrast-enhanced CT scans revealed perihepatic, perisplenic, and perienteric fluid accumulation, strongly suggesting intra-abdominal hemorrhage. Diagnostic paracentesis failed to yield non-coagulating blood. Following multidisciplinary consultation involving obstetrics, surgery, radiology, and anesthesiology, exploratory laparoscopy was performed to identify the bleeding site after obtaining informed consent, with conversion to laparotomy if necessary. Intraoperative findings revealed a full-thickness uterine rupture (4 cm × 1.5 cm) on the anterior wall. After further discussion with the family, cesarean delivery was performed, and the neonate was transferred to NICU. Postoperatively, the patient was admitted to ICU and received antibiotic therapy, fluid resuscitation, and thromboprophylaxis, achieving stable condition for discharge after 5 days. At the three-month postoperative follow-up, the patient recovered well. Conclusion: This case highlights the importance of multidisciplinary collaboration and timely laparoscopic exploration for acute abdominal pain during the second trimester, particularly in patients with intra-abdominal hemorrhage. Early identification and prompt surgical intervention remain critical for improving outcomes.