Uterine Rupture in a Multiparous Woman with Previous Spontaneous Vaginal Deliveries: A Rare Case Report

Abstract

Background:
Uterine rupture is an uncommon but life-threatening obstetric emergency. Classical risk factors include previous cesarean delivery, uterine surgery, labor induction or obstructed labor. It is particularly uncommon in women with an unscarred uterus. However, spontaneous rupture may still occur in multiparous women without identifiable predisposing factors. Advanced maternal age and cumulative myometrial thinning from repeated pregnancies have been suggested as potential contributors. Because clinical manifestations may be subtle, diagnosis can be challenging leading to delayed intervention and significant maternal and fetal morbidity.

Case Report:

We report the case of a 40-year-old gravida 3, para 2 woman at 33 + 1 weeks’ gestation who initially presented with mild abdominal pain and reassuring maternal and fetal evaluations. She had two prior uncomplicated spontaneous vaginal deliveries but no history of cesarean section, uterine instrumentation, or use of uterotonics. Twelve hours after discharge, she returned with severe abdominal pain, hemodynamic instability, and fetal demise. Emergency laparotomy revealed a 7-cm longitudinal fundal rupture of an unscarred uterus with complete extrusion of the fetus and placenta into the peritoneal cavity, accompanied by massive hemoperitoneum. The uterus was repaired, and the patient required extensive transfusion support. Postoperatively, she developed acute respiratory distress syndrome, aspiration pneumonia, and acute kidney injury, necessitating intensive care management. She eventually recovered and was later extubated on postoperative day 7 and was discharged on day 14.

Conclusion:
Spontaneous uterine rupture can occur in multiparous women without any previous uterine surgery and may present with nonspecific symptoms leading to delayed diagnosis. Treating obstetricians should maintain a high index of suspicion for possibility of uterine rupture in any pregnant patient presenting with acute abdominal pain. Timely diagnosis and early intervention is essential to prevent maternal as well as fetal morbidity and mortality.