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

A 30-year-old ethnically Amhara, gravida IV, para II and abortion I woman presented to the obstetrics and gynaecology emergency triage at Debre Tabor Comprehensive and Specialised Hospital with severe abdominal pain lasting more than 2 weeks. Upon arriving at the hospital, she appeared critically ill, lethargic and in considerable discomfort. Before being referred to the hospital on 15 September 2025, the patient suffered abdominal pain, nausea, and widespread malaise. She initially obtained care from a traditional healer and was given an unnamed oral herbal medication. The oral herbal syrup offered brief alleviation. She went to a local health clinic where an ultrasound test was performed, and she was reassured that the findings were normal. After 2 weeks (on 30 September 2025), she experienced a recurrence of similar symptoms, including abdominal pain, malaise, easy fatigue, light-headedness, and nausea. She returned to the health center, underwent repeat investigations and an ultrasound. At the health center, she was diagnosed with malaria. She received antimalarial treatment (artemether–lumefantrine) along with cimetidine and tramadol and was discharged with reassurance. She had taken only two doses of artemether–lumefantrine. However, her condition subsequently worsened, prompting a return to the health center, where she spent the night. She was then referred to Debre Tabor Comprehensive and Specialized Hospital on 1 October 2025, with the preliminary assessment of “second-trimester pregnancy, dyspepsia, rule out congestive heart failure.” She denied the use of any uterotonic agents. Her earlier deliveries were normal vaginal deliveries. The patient’s first pregnancy occurred 13 years ago and resulted in a vaginal delivery at home following 9 months of amenorrhea. After delivery, she was taken to a local health center owing to a retained placenta, which was removed easily without difficulty and without the need for anaesthesia. Her second pregnancy was 9 years ago. She was admitted to Felegehiwot Specialized Comprehensive Hospital for 1 week owing to APH. Despite the bleeding episode, she delivered vaginally, and the labor and delivery process was smooth and uncomplicated. The third pregnancy occurred 5 years ago and ended in spontaneous abortion at approximately 5 months of gestation. MVA was performed for an incomplete abortion. Besides this, she had no history of uterine surgery or trauma. Vital signs revealed hypotension with a blood pressure of 80/40 mmHg and tachycardia, with a pulse rate ranging from 120 to 140 beats per minute. The patient was febrile with a temperature of 37.8 °C and had a respiratory rate of 24 breaths per minute. On general examination, she appeared pale with a paper-white conjunctiva, suggestive of significant anemia. Abdominal examination showed a distended (protuberant) abdomen with diffuse tenderness and signs of intraabdominal fluid accumulation. Pelvic examination revealed a closed cervix and a bulging posterior fornix. There was no active vaginal bleeding at the time of examination. Fetal heart tones were absent on auscultation. The ultrasound examination showed a significant free intraperitoneal fluid collection (deepest pocket 8 cm) (Fig.  1 ). The uterine fundus was distorted. The two dead fetuses were visible, one completely outside the uterus and the other partly in the uterus and partly in the peritoneal cavity. Gestational age by femur length (FL) for the first twin was 19 weeks, and for the other, 19 + 4 weeks. Laboratory findings showed severe anemia (hemoglobin (Hb) 5.2 g/dL, hematocrit (Hct) 14.7%) and leucocytosis (white blood cell (WBC) 21.7 × 10⁹/L). Creatinine level was normal (0.9 mg/dL), and the malaria test was negative. Fig. 1 Ultrasound image showing free peritoneal fluid. A Hemoperitoneum. B A fetus in the peritoneal cavity. C Maternal kidney Ultrasound image showing free peritoneal fluid. A Hemoperitoneum. B A fetus in the peritoneal cavity. C Maternal kidney A team of healthcare specialists, including obstetricians, anesthesiologists, and critical care specialist nurses, collaborated to manage the patient. Before the surgery, we took comprehensive consent. All prospective scenarios, including hysterectomy and anticipated surgical outcomes, were discussed with the patient. After getting informed consent, the patient was transferred to the operating theater for exploratory laparotomy and hysterectomy.

Uterine rupture is one of the devastating consequences of pregnancy. It leads to adverse effects for the mothers and the foetus, including morbidity and mortality [ 1 , 2 ]. Most typically, uterine rupture is associated with previous caesarean scars, trauma, instrumental delivery, or the use of uterotonics medications [ 3 , 4 ]. Despite the grave consequences of uterine rupture, the spontaneous rupture of an unscarred uterus is a rare obstetric emergency. It occurs in 1 in 5700 to 1 in 50,000 pregnancies [ 5 – 7 ]. Particularly, the spontaneous rupture of an unscarred uterus in the second trimester is very rare [ 8 , 9 ]. Several case reports on spontaneous second-trimester uterine rupture have been published [ 8 , 10 – 13 ]. In most of the published case reports, the rupture is assumed to be associated with past scars [ 10 , 14 ], bicornate uterus [ 11 , 13 ], or adenomyosis [ 12 , 15 ]. This case report is unique because the uterine rupture occurred spontaneously in an unscarred uterus during the second trimester, related to unusual risk factors. The incident happened in remote areas of Ethiopia, where diagnostic services are scarce. This highlights the diagnostic challenges, atypical presentation, and potential uncommon risks associated with early spontaneous uterine rupture. It also underscores the importance of maintaining a high level of clinical suspicion, even if women do not have the usual risk factors for uterine rupture.

This case demonstrates the complexity of spontaneous uterine rupture during the second trimester in the unscarred uterus. It could highlight the synergistic effect of multiple unusual and subtle risk factors, such as a previous history of APH, retained placenta, MVA for incomplete abortion, and herbal medicine use, on spontaneous rupture of the unscarred uterus. Clinicians should have a high index of suspicion for pregnant women presenting with abdominal pain, even in the absence of classical risk factors. Community education on the dangers of unregulated herbal remedies during pregnancy is needed. Furthermore, the provision of capacity-building training on obstetric ultrasound and emergency triage could facilitate the early identification and referral of high-risk pregnant women. Addressing such system-level weaknesses is crucial to prevent similar maternal near-miss and mortality cases in resource-limited settings.

We did an abdominal hysterectomy and bilateral salpingectomy. The patient was given three units of cross-matched blood and broad-spectrum antibiotics (ceftriaxone and metronidazole). We intended to conduct blood coagulation tests and a histological analysis of the uterine edge and placental tissue. Nonetheless, these examinations are unavailable at the hospital, and the patient lacked the financial means to afford them at alternative private or referral hospitals. The patient recovered without any complications. We prescribed her oral iron supplements for a period of 3 months. She was discharged on the seventh day after surgery. Before discharge, she received individualized psychosocial support and counseling focused on grief processing, adjustment to loss of fertility, and facilitation of postoperative emotional and physical recovery. We also involved her spouse in the discussion to enhance family support. The patient was referred to the nearest health facility for ongoing psychological care as well as monitoring of wound healing and hematological recovery. The overall timeline of the patient’s clinical course and management is presented in Table  1 . Table 1 Timeline of the patient’s clinical course and management Time Event Diagnosis Management Outcome Early September/2025 • Abdominal pain, nausea and malaise • Undiagnosed/self-treatment • Took an unknown herbal medicine • Alleviation of symptoms 15 September 2025 • Worsening symptoms • Went to the health center • Normal ultrasound • Discharge with reassurance • Worsening of symptoms 30 September 2025 • Further worsening of symptoms • Returned to the health center • Patient diagnosed with malaria • Artemether–lumefantrine and cimetidine • Worsening of symptoms 1 October 2025 • Patient referred to Debre Tabor Comprehensive and Specialized Hospital • “Second-trimester pregnancy, dyspepsia, rule out congestive heart failure” • Referral • Arrival at the hospital 1 October 2025 • Emergency triage and initial evaluation at the hospital • Lab investigation showed severe anemia (Hb 5.2 g/dL) • Ultrasound investigation showed hemoperitoneum, a distorted uterus • Spontaneous fundal uterine rupture • Emergency exploratory laparotomy • Abdominal hysterectomy with bilateral salpingectomy • 3 units of blood transfused • Broad-spectrum antibiotics started • Bleeding controlled • Vital signs stabilized From 2 to 7 October 2025 • Recovery (postoperative) • Postoperative course • Continued antibiotics • Supportive and psychosocial care • Gradual and smooth recovery 8 October 2025 • Discharged from the hospital • Recovered • Discharge with follow-up plan • Discharged in stable condition Timeline of the patient’s clinical course and management • Worsening symptoms • Went to the health center • Further worsening of symptoms • Returned to the health center • Emergency triage and initial evaluation at the hospital • Lab investigation showed severe anemia (Hb 5.2 g/dL) • Ultrasound investigation showed hemoperitoneum, a distorted uterus • Emergency exploratory laparotomy • Abdominal hysterectomy with bilateral salpingectomy • 3 units of blood transfused • Broad-spectrum antibiotics started • Bleeding controlled • Vital signs stabilized • Continued antibiotics • Supportive and psychosocial care

A spontaneous rupture of the uterus is a rare event during the early weeks of gestational age [ 5 – 7 ]. However, if it occurs, it poses severe repercussions for the mother and fetus, leading to morbidity and mortality [ 1 , 2 ]. Several studies have demonstrated that the spontaneous rupture of the uterus is associated with a previously scarred uterus [ 10 , 14 ] and anomalies such as bicornate uteri, didelphys, septate, and arcuate uterus [ 11 , 16 , 17 ]. Several authors have reported abnormal placental invasions, such as placenta percreta and accreta, as potential risk factors for spontaneous uterine rupture [ 18 ]. In this case, we could not identify a single independent risk for the spontaneous uterine rupture. The case suggests a multifactorial risk factor where prior APH, retained placenta, MVA for incomplete abortion, herbal medication use, and twin pregnancy could have synergistically contributed to the spontaneous rupture of the uterus. The twin pregnancy may have predisposed the patient to spontaneous uterine rupture, particularly in the context of cumulative risk factors. These include a history of APH, retained placenta, MVA for incomplete abortion in previous pregnancies, and reported use of herbal medications during the current gestation. Twin pregnancy induces uterine overdistention [ 19 ], which subsequently leads to myometrial ischemia and microscopic tears [ 12 ]. While minor APH alone may not directly cause uterine rupture, it may have predisposed the uterus to subtle myometrial changes such as localized fibrosis and ischemic injury [ 20 , 21 ]. This, in turn, leads to uterine weakening and rupture in later pregnancy if amplified with other risk factors. Her history of APH, MVA, and retained placenta (which was easily removed at the health center) may suggest that placenta accreta spectrum (PAS) could have contributed to the rupture of the uterus [ 22 , 23 ]. Although rigorous studies proving the direct link between a history of MVA and uterine rupture are limited, unintentional uterine perforation during MVA procedures may damage the uterine wall [ 24 , 25 ] and, as a result, may raise future rupture risks. The intake of a nonspecific herbal remedy may have worsened the uterine rupture. This should be interpreted with caution, as the authors of this case report have not identified the type of herbal medicine the patient consumed. Some existing research in sub-Saharan Africa suggests that herbal remedies taken during pregnancy for abdominal pain can have uterotonic effects, which might lead to or worsen uterine rupture [ 26 , 27 ]. The patient indicated that she experienced some relief after using the herbal preparation, but her condition deteriorated later. Partially, this may suggest that the herbal medicine contains a blend of spasmolytic and vasoactive substances that offer short relief but gradually aggravate abdominal pain. The fact that the patient took the herbal preparation after the onset of abdominal pain may imply that the herbal medicine aggravated the already hypoxic and overdistended uterus rather than being the primary cause of the rupture. When pregnant women have abdominal pain and bleeding, spontaneous hemoperitoneum [ 28 ] and heavy bleeding from PAS [ 29 ] should be considered in the differential diagnosis. Additionally, a rupture of the uterine wall may indicate certain types of ectopic pregnancy, such as abdominal, retroperitoneal, interstitial, or cornual forms [ 30 – 32 ]. However, we ruled out ectopic pregnancy in our case on the basis of the results of the ultrasound and what we found during surgery. The initial normal ultrasound diagnosis at the rural health center may indicate diagnostic limitations in peripheral settings, leading to a delay in diagnosis and referral to the highest level of health facilities. Skill gaps in ultrasound interpretation and a lack of high-resolution equipment can lead to missed early signs of myometrial thinning or small dehiscences. This case shows that a thorough ultrasound scan and prompt treatment are needed [ 33 ] to handle uterine rupture and prevent similar cases from happening. We performed an emergency hysterectomy with bilateral salpingectomy. We decided this owing to the extensive fundal rupture and hemodynamic instability of the patient. This decision aligns with the recommendations of surgical guidelines [ 34 , 35 ]. The surgical guidelines recommend hysterectomy over uterine repair when there is extensive rupture, devitalized uterine tissue, and hemodynamic instability of the patient.

An exploratory laparotomy was done right away on arrival at the hospital, as it was an emergency. The laparotomy showed extensive hemoperitoneum (2 L of blood) and transverse rupture of the fundus (10 cm) with necrotic margins. The two fetuses (one completely and the other partially) were floating freely in the peritoneal cavity. Each of the fetuses weighed approximately 250 g. The placenta was found to be partially detached. The uterus appeared normal in contour and wall thickness, with no evidence of adhesions or scarring (Fig.  2 ). Fig. 2 Intraoperative finding of transverse fundal rupture ( A ), with necrotic margin ( B ) and retrieved twin fetuses alongside uterine specimen ( C ) Intraoperative finding of transverse fundal rupture ( A ), with necrotic margin ( B ) and retrieved twin fetuses alongside uterine specimen ( C )

Additional file 1: The CARE guidelines with page numbers where each item of the guideline is found in the manuscript. Additional file 1: The CARE guidelines with page numbers where each item of the guideline is found in the manuscript.