Posterior Uterine Rupture during Pregnancy in a Patient with Previous Surgery for Severe Endometriosis: A Case Report

A 33-year-old woman with severe DIE underwent robot-assisted laparoscopy in 2023. Intraoperative findings revealed extensive lesions causing rectal and adnexal retraction towards the pouch of Douglas and sigmoid colon. The pelvis was densely adherent, with a left uterosacral nodule, a left hydrosalpinx and ipsilateral ureteral dilation. Surgical steps included a left retroperitoneal approach, salpingectomy, ureterolysis and monopolar adhesiolysis. Rectal lesion resection was attempted but abandoned due to obliterative adhesions. Eleven months post-laparoscopy, the patient conceived through frozen blastocyst transfer. At 29 weeks of gestation, she was admitted with threatened pre-term labour (painful contractions and a cervical length of 21 mm). Foetal status was reassuring, with category I heart rate tracing and normal umbilical Doppler. Management included antenatal corticosteroids (two 12 mg doses of betamethasone) and tocolysis with atosiban (an initial 6.75 mg bolus, followed by an infusion at 300 μg/min for 3 h and then maintenance at 100 μg/min for 48 h). At 32 + 2 weeks of gestation, the patient was readmitted for epigastric pain and uterine contractions. Initial foetal assessment showed a reassuring category I foetal heart rate tracing. Laboratory tests revealed elevated inflammatory markers (leucocytes – 19.6 G/L and C-reactive protein – 55 mg/mL). Due to threatened pre-term labour and suspected chorioamnionitis, atosiban and intravenous cefotaxime (1 g/8 h) were initiated. Given the atypical pain, a computed tomography (CT) scan was performed to exclude extra-obstetric emergencies, revealing a massive haemoperitoneum and perihepatic effusion. Following the CT findings of massive haemoperitoneum and associated foetal bradycardia, the decision for an emergency Category 1 (code red) caesarean section was taken. Intraoperatively, a rupture of the posterior uterine wall with massive haemoperitoneum was discovered [ Figure 1 ]. A 1540 g male infant was delivered through transverse segmental hysterotomy (Apgar 9/10/10). The uterine rupture was repaired using braided polyglactine 910 sutures (Vicryl 1, Ethicon, NJ, USA). Intraoperative photograph showing rupture of the posterior uterine wall The immediate post-partum period was physically uneventful, though the patient developed post-traumatic stress disorder following the Category 1 emergency caesarean section. This extreme surgical urgency, characterised by a ‘decision-to-delivery’ interval of under 10 min, caused persistent anxiety and intrusive memories, requiring specialised psychological support. One-month post-delivery, pelvic magnetic resonance imaging (MRI) evaluated residual endometriosis and uterine integrity. Imaging revealed a fibro-haemorrhagic endometriotic nodule on the left uterosacral ligament, causing rectal wall tethering without transparietal invasion [ Figure 2 ]. Fibrous thickening of the torus and right uterosacral ligament, ovarian endometriomas and bilateral haemorrhagic micro-implants were noted. Anteriorly, a pre-uterine haemorrhagic nodule was identified adjacent to the left rectus abdominis. Diffuse internal adenomyosis was also observed [ Figure 3 ]. T2-weighted magnetic resonance imaging sequence- axial view of the pelvis showing a fibro-haemorrhagic endometriotic nodule on the left uterosacral ligament (red circle) T2-weighted magnetic resonance imaging. Axial view of the pelvis showing adenomyotic lesions (red circle) Transrectal ultrasonography demonstrated a negative ‘sliding sign’ and an obliterated rectovaginal space. Rectal muscularis infiltration was identified over 19 mm, with adhesion to the torus [ Figure 4 ]. Following multi-disciplinary consultation and the patient’s desire for future pregnancy, hormonal suppression with dienogest (2 mg/day) was initiated for at least 3 months [ Figure 6 ]. Rectal endoscopic ultrasonography showing adhesion of the mid-rectum to the torus uterinus, with bowel involvement extending to the muscular layer over a length of 19 mm T2-weighted magnetic resonance imaging, coronal view, showing post-partum thickening of the posterior myometrium (13.5 mm) Patient’s timeline. MRI = Magnetic resonance imaging, IVF = In vitro fertilisation

Endometriosis affects approximately 10% of women of reproductive age.[ 1 ] In deep infiltrating endometriosis (DIE), complex surgery may improve fertility, but procedures involving the posterior uterine wall increase obstetric risks. Posterior uterine rupture is rare, typically occurring after surgery for stage 4 endometriosis and adenomyosis. Reported risk factors include excessive thermal energy, deep myometrial resection and a short surgery-to-conception interval.[ 2 ] We report a case of posterior uterine rupture in a 33-year-old primiparous patient after surgery for grade 4 endometriosis.

Posterior uterine rupture following deep endometriosis surgery remains a rare but severe complication. Our findings suggest that residual myometrial thickness is likely a key risk factor, alongside the use of thermal energy and the extent of retrocervical resection. Further prospective studies are now required to characterise these risks and establish standardised monitoring protocols to optimise obstetric safety in this population. MP was responsible for the literature search, data collection and drafting of the manuscript. SH, RDT and VLT participated in the critical revision of the manuscript for important intellectual content and provided final approval of the version to be published. The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed. There are no conflicts of interest. Data are available upon reasonable request from the corresponding author. Artificial intelligence was used for language editing and structural refinement of the manuscript.

Posterior uterine rupture is a rare but catastrophic complication, primarily following extensive retrocervical surgery for DIE. This structural weakness, often localised at the cervico-isthmic junction, can be visualised postoperatively through MRI as localised myometrial thinning.[ 3 ] In our case, the post-partum MRI confirmed adequate uterine wall recovery with a myometrial thickness of 13.5 mm [ Figure 5 ]. While no validated international threshold exists, studies suggest that a residual myometrium <2.5 mm on ultrasound during pregnancy is associated with an increased risk of rupture.[ 4 ] Clinical factors such as complex pelvic surgery involving the gastrointestinal tract or involving the cervico-isthmic junction should prompt extreme caution. Our patient conceived 11 months post-surgery, aligning with the recommended 6- to-12-month healing period.[ 5 ] However, the use of thermal energy during the initial laparoscopy remains a critical predisposing factor. The monopolar forceps used in our patient’s primary surgery are associated with significant lateral thermal spread and potential deep tissue necrosis.[ 6 ] In contrast, ultrasonic-based cautery systems, such as the Harmonic Ace, offer a theoretically safer alternative by providing targeted coagulation with minimal thermal dissipation, thereby better preserving the structural integrity of the posterior uterine wall.[ 7 ] The location of the rupture in our case – the posterior wall – is characteristic of surgeries involving the rectovaginal septum. An analysis of previously reported cases reveals recurring clinical patterns [ Table 1 ].[ 2 ] These procedures pose significant challenges, notably the difficulty in demarcating healthy myometrium from infiltrative pathological tissue, which often leads to unintentional focal thinning. While most literature cases utilised ultrasonic scalpels, our patient’s surgery involved monopolar energy. This suggests that the depth of dissection remains the primary risk factor, regardless of the instrumentation used. Comparative analysis of literature cases of posterior uterine rupture following surgery for deep infiltrating endometriosis Patients 1–7 are adapted from the series published by Ziadeh et al .[ 2 ] FHR=Foetal heart rate, USL=Uterosacral ligament, N/A=Not applicable, MRI=Magnetic resonance imaging Furthermore, when comparing neonatal outcomes [ Table 1 ], our patient’s infant achieved excellent Apgar scores (9/10/10), unlike some cases where prolonged bradycardia resulted in neurological sequelae. This underscores the necessity of an immediate Category 1 (code red) response. Consequently, a specialised preconception consultation is essential for patients with a history of DIE surgery to evaluate surgical reports, perform morphological assessment of the posterior segment and anticipate potential obstetric risks. While routine elective caesarean sections are not currently justified, individualised monitoring remains the cornerstone of safe maternal–foetal care.