Introduction:
Uterine rupture is a serious obstetric complication that occurs mainly in the third trimester of pregnancy or during labour, especially in previously scarred uterus. Advanced maternal age, grand multiparous, placenta increta, macrosomia, shoulder dystocia, and medical termination of pregnancy are some contributing factors to uterine rupture. The overall incidence of uterine rupture in unscarred uterus is 0.5-2 per 10 000 deliveries, The risk of scar rupture after one caesarean section is oneĀ in 200 women with spontaneous births.(1)
Uterine rupture in the first or second trimester of pregnancy is extremely rare, and may vary in presentation and course of events, which make the clinical diagnosis challenging. These may be masked by the physiological and anatomical changes during pregnancy. The lack of high index of suspicion diverts attention to search for other non-gynaecological problems.(2) Unlike rupture in the lower uterine segment in the third trimester or during delivery, the common site of rupture in the first trimester is the fundal region. (3,4)
Case Report:
A 28 year-old woman, gravida 4, para2+1 who was16 weeks pregnant presented with a sudden onset of epigastric pain that radiated to her back following a fall. Her first pregnancy was a caesarean delivery for term breech presentation followed by two successful vaginal deliveries. She had one first trimester miscarriages which had been surgically managed.
On presentation, her vital sgins was stable and was admitted under observation and pain management. However she started to deteriorate clinically, became tachycardia 120/min and hypotensive 90/50. She also reported shoulder tip pain and shortness of breath.
On examination, patient looked pale; her abdomen was distended and peritonitic. A bedside ultrasound showed single viable intrauterine pregnancy and large amount of free fluid in the abdomen. Consultant informed and surgical team involved. Decision taken to proceed to theatre and patient consented for midline exploratory laparotomy +/- proceed. Her hemoglobin on VBG was 4 gm%.
Intraoperatively haemoperitoneum of 2 liters of fresh blood and clots noted. The stomach, liver, spleen, kidneys, and major vessels were normal. There was a rupture of the uterine fundus