Silent Separation: Uterine Dehiscence After Second-Trimester Termination in Monochorionic Diamniotic Twins

Uterine rupture is a rare but life-threatening complication, most commonly associated with labor in women with a prior caesarean scar. Its occurrence in the second trimester, particularly in primigravid women with an unscarred uterus, is exceptionally uncommon. Here, we present a 29-year-old primigravida with a monochorionic-diamniotic (MCDA) twin pregnancy complicated by absent end-diastolic flow in one twin and subsequent intrauterine fetal demise at 21+5 weeks. Induction of labor with misoprostol resulted in delivery at 21+6 weeks. The early postpartum course was complicated by pyrexia, retained tissue, and recurrent heavy bleeding requiring ultrasound-guided surgical evacuation (SEVAC), uterine balloon tamponade, and major obstetric hemorrhage. Thirty-two days post-delivery, the patient collapsed with secondary postpartum hemorrhage. MRI later demonstrated a complete absence of the anterior uterine wall, consistent with rupture/dehiscence. Laparotomy confirmed a large anterior wall defect, which was successfully repaired, preserving fertility. This case gives us insight that second-trimester uterine rupture, though rare, is a potentially devastating condition. Clinicians should remain vigilant regardless of parity or uterine history. "Silent rupture" emphasizes the role of imaging in ambiguous cases. Conservative measures for postpartum hemorrhage must be used judiciously, and prompt surgical management optimizes outcomes and preserves fertility. Larger studies are needed to refine risk stratification and monitoring strategies.