Atypical Presentation of Uterine Rupture in a Post-myomectomy Scar at 35+5 Weeks Gestation: A Case Report

Uterine rupture in the third trimester is a rare but life-threatening obstetric emergency, particularly in women with a history of uterine surgery such as myomectomy. This report describes an atypical presentation in a 43-year-old primigravida with a prior fundal myomectomy. At 35+5 weeks of gestation, she presented to the emergency department with nonspecific abdominal discomfort, diarrhea, and persistent vomiting for over 8 hours. Notably, she had missed her 32-week antenatal visit and did not respond to calls made 2 days prior regarding elective cesarean scheduling, later citing fear of the hospital environment. Her antenatal care had otherwise been regular. The pregnancy was planned, and she conceived four months after a fundal myomectomy performed on 29 May 2024. She had been counseled regarding the associated risks but was keen to conceive early due to her age. Consequently, her pregnancy was classified as high risk owing to a fresh uterine scar. On initial evaluation, the patient was hypotensive (BP 90/60 mmHg) and tachycardic (HR 100 bpm), and she reported perceiving normal fetal movements at that time. Fetal monitoring was initiated, and one hour into observation, cardiotocography revealed fetal bradycardia, with heart rates fluctuating between 60 and 130 bpm. An emergency lower-segment cesarean section under general anesthesia was performed. Intraoperatively, a massive hemoperitoneum and extensive intraperitoneal clots were discovered along with a full-thickness rupture at the fundal uterine scar. A breech fetus was delivered, the uterus was repaired in two layers, and one unit of packed red blood cells was transfused. The patient was monitored in the high-dependency unit and recovered well. This case emphasizes the importance of maintaining a high index of suspicion for uterine rupture, even in the absence of classic signs such as severe abdominal pain or vaginal bleeding. Early fetal monitoring, timely diagnosis, and prompt surgical intervention are essential to improving maternal and fetal outcomes in women with prior uterine surgery.