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