Late post-partum hemorrhage revealing a delayed uterine rupture in an unscarred uterus: a case report.

A 44-year-old female patient with no medical or surgical history, gravida 5, para 5. Five vaginal deliveries, five living children, with the third and fourth being macrosomic weighing 4100 g and 4300 g, respectively, without any history of gestational diabetes during pregnancy. All deliveries were spontaneous, non-instrumental, and uncomplicated, with uneventful postpartum courses. The last pregnancy was carried to term. Labor was harmonious and spontaneous without the use of oxytocin, lasting a total of five hours until full cervical dilation with a cephalic presentation and an engaged head. Due to a fetal heart rate abnormality at full dilation, a vacuum extraction was indicated, resulting in the delivery of a male newborn weighing 3700 g, with a simple vaginal tear. The patient was urgently referred to our maternity facility for the management of late postpartum hemorrhagic shock. During the first 24 h of monitoring, the patient was conscious, hemodynamically and respiratory stable. Suddenly, she experienced postpartum hemorrhage with a blood loss of 1 l accompanied by numerous blood clots and tachycardia measured at 120 bpm. Given this situation, the patient was stabilized. Meanwhile, a gynecological examination was performed, revealing the absence of uterine fundus palpation, suggesting uterine atony as the primary diagnosis. On speculum examination, active endouterine bleeding was observed. Uterine revision was indicated under analgesia, suspecting a left lateral uterine rupture. The patient was urgently transferred to us in hemorrhagic shock twenty minutes later. She had a Glasgow Coma Score of 13/15, a blood pressure of 60/40 mmHg, and tachycardia at 140 bpm. The patient exhibited pallor of the skin and mucous membranes, along with cold extremities and profuse sweating. Clinical examination revealed abdominal distension and profuse vaginal bleeding consisting of reddish, clotting blood, estimated at 500 ml. An urgent pelvic and abdominal ultrasound was performed, revealing fluid accumulation in the Douglas pouch ( Fig. 1 ) and in Morison's pouch ( Fig. 2 ). Fig. 1 Fluid accumulation in the Douglas pouch. Fig. 1 Fig. 2 Fluid accumulation in the Morison's pouch. Fig. 2 Fluid accumulation in the Douglas pouch. Fluid accumulation in the Morison's pouch. Given the hemodynamic shock in the postpartum context, with a strong clinical suspicion of uterine rupture following the uterine revision, as well as the findings from the clinical examination and ultrasound, performing any additional complementary examination would only delay urgent management. Therefore, an emergency exploratory laparotomy was indicated under general anesthesia. A complete biological workup was performed, along with a blood request. On exploration, a hemoperitoneum of 1 l was found, along with a left posterior lateral uterine rupture extending from the uterine body to the vagina, respecting the uterine artery at its level ( Fig. 3 , Fig. 4 ). Fig. 3 Uterine rupture (yellow star: round ligament, blue star: utero-ovarian ligament, green star: uterine rupture of the left posterolateral wall). Fig. 3 Fig. 4 The operative specimen of the hysterectomy showing a uterine rupture at the level of the lateral-posterior border (green star). Fig. 4 Uterine rupture (yellow star: round ligament, blue star: utero-ovarian ligament, green star: uterine rupture of the left posterolateral wall). The operative specimen of the hysterectomy showing a uterine rupture at the level of the lateral-posterior border (green star). Due to the inability to repair the lesions and persistent hemodynamic instability, a hemostatic interadnexal hysterectomy was performed, followed by extensive peritoneal lavage. Hemostasis was successfully achieved. The patient received a blood transfusion of 13 packed red blood cell units (5 intraoperatively), along with 14 units of fresh frozen plasma (FFP) and 6 g of fibrinogen. The initial biological workup on admission showed hemoglobin (Hb) at 8.1 g/dL, platelets at 51,000, prothrombin time (PT) at 25 %, activated partial thromboplastin time (aPTT) at 2.39, fibrinogen at 1.1 g/L, aspartate aminotransferase (ASAT) at 2203, and alanine aminotransferase (ALAT) at 1742. Additionally, blood urea was 0.57 mmol/L, and creatinine was 16.6 μmol/L. The patient was admitted to the intensive care unit (ICU) for 10 days for the management of disseminated intravascular coagulation (DIC). She was then transferred to our department for three days, during which she had an uncomplicated recovery. A follow-up biological workup at discharge showed Hb at 10 g/dL, platelets at 245,000, PT at 75 %, aPTT at 0.96, with normal renal function (urea at 0.46 mmol/L and creatinine at 7.1 μmol/L). ASAT was 35, and ALAT was 108. The rest of the laboratory results were within normal limits. The patient received psychological support for one month, which facilitated better recovery.

Oumaima Kassou, Nisrine Benaouicha, Amina Etber: performed surgery. Oumaima Kassou: paper writing and editing. Nisrine Benaouicha, Aziz Baidada: literature review, supervision. Oumaima Kassou: Manuscript editing, picture editing. Oumaima Kassou, Nisrine Benaouicha, Amina Etber: performed surgery. Oumaima Kassou: paper writing and editing. Nisrine Benaouicha, Aziz Baidada: literature review, supervision. Oumaima Kassou: Manuscript editing, picture editing.

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval is not applicable. The case reports are not containing any personal information. Ethics approval is not required for this case report.

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1. Name of the registry: Clinicaltrials.gov – for all human studies – free. Name of the registry: Clinicaltrials.gov – for all human studies – free.

Oumaima Kassou.

Uterine rupture in an unscarred uterus is a rare but serious event. The clinical presentation is not always striking, which can delay diagnosis. Close clinical monitoring during the postpartum period is essential. Any unusual symptoms should prompt consideration of this diagnosis to ensure early and appropriate management. We propose a clinical implication that emphasizes the importance of vigilance in managing patients with risk factors for uterine rupture, as presented in this study. In our department, uterine revision has become systematic for patients with a risk factor for uterine rupture, and a scientific study is being conducted in this regard, along with close postpartum monitoring.

According to the World Health Organization, the average incidence of uterine rupture is 5.3 per 10,000 deliveries [ 5 ]. Uterine rupture is a severe obstetric complication and a life-threatening emergency, significantly contributing to maternal and perinatal morbidity and mortality [ 6 , 7 ]. Our case demonstrates that this rare condition can lead to maternal morbidity requiring a hemostatic hysterectomy, with consequent DIC, and may even result in maternal death if management is delayed. Uterine rupture is relatively rare overall, it occurs more frequently in low-income countries, highlighting disparities in socioeconomic conditions, limited healthcare access, and insufficient medical monitoring [ 8 , 9 ]. The risk factors identified in the literature are numerous but not specific. In an unscarred uterus, the most recognized risk factors include multiparity, mechanical dystocia, prolonged labor, the use of prostaglandins, misoprostol, and oxytocin, as well as obstetric maneuvers (including version and instrumental extractions) and uterine malformations [ 10 ]. Sho et al. identified other predictive factors for uterine rupture, such as arteriovenous malformations, uterine diverticula, and endometriosis [ 11 ]. In our case, the identified risk factors were multiparity and instrumental delivery. The diagnosis of uterine rupture in an unscarred uterus is often delayed due to its nonspecific symptoms, leading to more severe maternal and fetal complications. These ruptures are predominantly identified during uterine examination following postpartum hemorrhage, as demonstrated in our case [ [10] , [11] , [12] , [13] , [14] ]. They should be suspected in instances of bleeding at the end of labor or immediately postpartum, particularly when accompanied by persistent abdominal pain despite epidural analgesia or unexplained maternal hypotension [ [10] , [11] , [12] , [13] , [14] , [15] , [16] ]. In our case, the delay in diagnosis was due to the fact that the case was silent, with no immediate postpartum hemorrhage (within the first two hours) or hemodynamic instability that would have indicated an urgent uterine revision. Placental examination at delivery was complete. Additionally, there were no signs of peritoneal irritation (no pain, no vomiting). All these factors contributed to the delayed diagnosis. The uterine examination performed due to late postpartum hemorrhage allowed the diagnosis of uterine rupture. In cases of neglected ruptures, conservative treatment is rarely possible. The choice of surgical treatment, whether a simple suture of the rupture as a conservative approach or a hysterectomy as a radical treatment, primarily depends on the extent of the lesions. In young women desiring pregnancy, conservative treatment is ideal if the rupture is uncomplicated and not extensive. However, if the lesions are extensive or the patient's hemodynamic instability, a hysterectomy becomes necessary [ [9] , [10] , [11] , [12] , [13] , [14] , [15] , [16] , [17] , [18] ]. As in our patient's case, the lesions were extensive and difficult to repair without achieving effective hemostasis, and given the DIC and hemodynamic instability, a hemostatic hysterectomy was indicated.

Not commissioned, externally peer-reviewed.

Uterine rupture is a highly critical obstetric emergency associated with a heightened risk of both maternal and perinatal morbidity and mortality [ 1 ]. Spontaneous uterine rupture is a life-threatening complication that must be considered in all obstetric patients presenting with shock. Physicians attending vaginal deliveries must remain vigilant for signs and symptoms indicative of uterine rupture. The primary etiological factors contributing to the rupture of an intact uterus include grand multiparity, cephalopelvic disproportion, fetal malpresentation, challenging instrumental deliveries, obstetric interventions, and improper use of oxytocin [ 2 ]. Understanding the risk factors and responding promptly can be crucial in saving the lives of both mother and child in these emergency situations. More than 90 % of uterine rupture cases occur in women with a history of cesarean delivery, while the incidence of rupture in an unscarred uterus ranges from 1 in 7643 to 1 in 16,849 [ 3 ]. We present a case of a delayed uterine rupture in an unscarred uterus in a multiparous woman with instrumental delivery, revealed by hemorrhagic shock within 24 h postpartum leading to a hemostatic hysterectomy, confirming the risk of maternal morbidity and mortality. This case highlights the need to consider uterine rupture even in an unscarred uterus and to thoroughly analyze the details concerning the patient's obstetric history and the course of the ongoing labor. Our work has been reported in line with the SCARE Guidelines 2025 criteria [ 4 ].

The authors declare that they have no competing interests relevant to the content of this article. N/A.