Neglected uterine rupture… myth or reality? - A case report.

A 36-year-old patient, G5P5 (five pregnancies, five vaginal deliveries, all five children alive), delivered her last child four days before her admission. She presented on postpartum day 4 following a spontaneous vaginal delivery (without instrumental assistance) of a newborn weighing 3600 g, reporting progressively worsening pelvic pain with abdominal distension ( Fig. 1 ). Her symptoms escalated with diffuse pain limiting her activities, accompanied by fatigue, dizziness, and palpitations. Fig. 1 Abdominal distension. Fig. 1 Abdominal distension. Upon arrival at the emergency department, she had tachycardia at 130 bpm, blood pressure of 120/70 mmHg, generalized pallor of mucosal surfaces, and profuse sweating. Her abdomen was distended and soft to palpation, with shifting dullness. Speculum examination showed no intrauterine bleeding, while a vaginal examination coupled with abdominal palpation revealed an enlarged, mobile uterus extremely painful upon movement, with no palpable lateral uterine masses. Ultrasound indicated an enlarged, empty uterus shifted to the left with a discontinuity on the right lateral edge, as well as a hematoma on the same side and abundant peritoneal fluid reaching Morison's pouch ( Fig. 2 , Fig. 3 ). Fig. 2 Hemoperitoneum of great abundance arriving as far as Morisson. Fig. 2 Fig. 3 Uterine vacuity line (blue arrow) with hematoma at the level of the broad ligament (Red arrow) and Pelvic effusion (Green star). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.) Fig. 3 Hemoperitoneum of great abundance arriving as far as Morisson. Uterine vacuity line (blue arrow) with hematoma at the level of the broad ligament (Red arrow) and Pelvic effusion (Green star). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.) The patient was transferred to the recovery room for stabilization and subsequently taken to the operating room, where an emergency laparotomy was performed due to the suspected uterine rupture. Intraoperative findings included a large volume hemoperitoneum and a right lateral uterine rupture extending from the uterine body to the lower segment, severing the right uterine pedicle, filled with an infected hematoma leading to partial uterine necrosis ( Fig. 4 , Fig. 5 ). Fig. 4 Uterine rupture sealed by hematoma. Fig. 4 Fig. 5 Hysterectomy specimen showing rupture along the lateral uterine border. Fig. 5 Uterine rupture sealed by hematoma. Hysterectomy specimen showing rupture along the lateral uterine border. Given the inability to repair the lesions and the presence of necrotic areas, a total interadnexal hysterectomy with hemostasis was performed, followed by extensive washing of the abdominal cavity. The recovery process was favorable, and the patient was discharged from our facility six days later.

Youssef ESSEBBAGH, Othmane ELHARMOUCHI: performed surgery, paper writing and editing. Najia ZERAIDI, Aziz BAIDADA: literature review, Supervision. Youssef ESSEBBAGH, Khadija ERRMILI, Saloua Iddouba: Manuscript editing, picture editing.

A consent was obtained from the patient to publish this case report and accompanying images.

This case report is exempt from ethical approval in our institute, Ibn Sina University Hospital Center.

The authors declare that there is no funding or grant support.

Not applicable

Youssef ESSEBBAGH M.D., Gynaecology-Obstetrics and Endoscopy Department, Maternity Souissi, University Hospital Center IBN SINA, University Mohammed V, Rabat, Morocco Email: [email protected]

Neglected uterine rupture in an unscarred uterus is a rare but serious pregnancy complication. Its prognosis is poor due to the high mortality and morbidity rates, which exceed those of rupture in a scarred uterus. The clinical presentation can be misleading, leading to diagnostic delays. Management of this condition is a life-threatening emergency that requires the mobilization of a multidisciplinary team.

Spontaneous neglected uterine rupture in an unscarred uterus is an extremely rare condition, with an estimated incidence of around 1 in 10,000 pregnancies. This complication is more common in developing countries, reflecting differences in socioeconomic conditions, healthcare scarcity, and lower levels of medical monitoring [ 1 , 3 ]. In an unscarred uterus, rupture can occur due to trauma from direct or indirect impact or from obstetric maneuvers (such as intrauterine manipulations or fundal pressure). It can also happen spontaneously in the presence of certain risk factors, including uterine malformations, multiparity, obstetric maneuvers, instrumental extractions, mechanical dystocia, placental abnormalities, history of uterine curettage, and the use of oxytocics [ 3 ]. In some cases, rupture of a previously healthy pregnant uterus has no clear cause. Schrinsky identified ten cases of spontaneous rupture without any predisposing factors in his series of 40 cases. Iloki reported five cases of rupture with no defined cause out of 59 cases, while Parry and colleagues suggested that potential risk factors for unexplained uterine rupture might include uterine diverticula, arteriovenous malformations, and endometriosis. In their analysis of 26 cases, Liu et al. found irreversible cellular damage in the muscle fibers of the lower uterine segment in cases of rupture during labor in an unscarred uterus. They concluded that excessive and prolonged pressure from the fetal presentation on the lower segment in prolonged labor could lead to these pathological consequences. While this hypothesis is plausible, it is limited as it does not explain ruptures in unscarred uteri that occur early in labor [ 4 ]. The unique aspects of our clinical case include the delay between delivery and diagnosis of the uterine rupture, as well as the absence of facilitating or predictive factors for rupture. In our patient, multiparity was the only risk factor identified, making this event entirely unpredictable. Clinically, constant abdominal-pelvic pain is the primary symptom, along with hemodynamic instability ranging from mild tachycardia to true hemorrhagic shock. A suprapubic pelvic ultrasound is the first-line examination, which may reveal a variable amount of hemoperitoneum, anterior and posterior to the uterus, or filling Morison's pouch. It can also show an enlarged uterus with irregular contours and a discontinuity that may be filled with a hematoma in cases of neglected rupture, and sometimes a visible vacuity line. This examination is helpful in ruling out the main differential diagnosis in cases of significant hemoperitoneum, namely, a ruptured subcapsular liver hematoma in the context of severe preeclampsia [ 3 , 5 ]. Therapeutic management of uterine rupture remains an urgent medical and surgical intervention that begins with stabilization and is followed by an emergency laparotomy. Ideally, surgical management of rupture in a young woman desiring future pregnancies should be conservative and involve simply suturing the rupture. However, when conservative treatment is impossible due to extensive lesions, the patient's hemodynamic instability, or necrotic uterine tissue, hysterectomy becomes necessary. In cases of neglected rupture, conservative treatment is rarely an option. In our case, radical treatment was decided upon based on intraoperative findings [ 6 , 7 ].

Uterine rupture in an unscarred uterus is a rare and severe complication that can endanger both maternal and fetal life, as well as impact the future obstetric outcomes for the woman. The incidence of uterine rupture in the general population ranges from 1 in 1235 to 1 in 4366 deliveries, while for unscarred uteri, it is estimated between 1 in 16,840 and 1 in 19,765 deliveries in high-income countries. In published studies, fetal mortality is estimated between 12 % and 35 %, with a hysterectomy rate of 20 % to 30 %. Risk factors are poorly identified [ 1 ]. In this work, we present a case of neglected uterine rupture diagnosed four days postpartum. Through this case and in light of a literature review, we emphasize the characteristics of this complication, especially diagnostic methods, therapeutic management, and prognosis of this rare complication. Our work has been reported in line with the SCARE Guidelines 2023 criteria [ 2 ].

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