Unusual Presentations of Uterine Rupture: A Case Series

Uterine rupture is an uncommon, but serious intrapartum complication. It is most often seen in patients with a prior low-transverse cesarean delivery undergoing a trial of labor (TOLAC). In our experience, not all ruptures present in patients with clear risk factors or with the classic signs and symptoms described in medical education. Because the incidence of these unusual presentations is rare, there is limited literature available. This case series seeks to highlight four cases of uterine rupture with distinct clinical presentations in order to facilitate prompt recognition and management if encountered in the future. Case 1 describes a classic presentation of uterine rupture in a G4P1112 at 31w1d with a history of previous vertical hysterotomy and short interval pregnancy. The patient was delivered promptly via repeat cesarean section and spontaneous uterine rupture was confirmed. The myometrial defect was repaired primarily. The second case describes a G6P2032 at 38w0d who presented to our triage for nausea/vomiting and back pain who was found to have pyelonephritis. She was diagnosed with severe fetal growth restriction and recommended to proceed with induction of labor. The patient’s induction was uncomplicated until the fetus demonstrated acute signs of acidemia on fetal heart rate monitoring and concurrently the maternal status changed. The patient was delivered promptly via primary cesarean section given concern for fetal status and an intraoperative diagnosis of uterine rupture was confirmed. The neonate was admitted to NICU for therapeutic hypothermia and the patient underwent total abdominal hysterectomy. Case 3 is a primigravida without prior uterine surgery undergoing induction of labor for a fetal demise at 37w4d whose presentation is classic for uterine rupture. The patient demonstrated signs of hemodynamic instability and loss of fetal station, with bedside ultrasound suggestive of extrauterine location of fetus and placenta. She was taken to the OR for laparotomy where the diagnosis of uterine rupture was confirmed. The final case is a G5P3013 who underwent medical termination of pregnancy at 19w for preterm, previable rupture of membranes. She had retained placenta for which she was taken to the OR initially with a plan for possible uterine curettage and was then diagnosed with uterine rupture during the procedure. At that point, the case was converted to laparotomy and a uterine rupture was confirmed. Final surgical pathology also identified placenta accreta spectrum grade 1. Beyond the prompt recognition and surgical management received, these cases highlight the importance of a high index of clinical concern and laparotomy when suspicious. Obstetricians are tasked with developing high-fidelity, multidisciplinary teams and creating a culture of safety for junior and interdisciplinary colleagues. The excellent interdisciplinary management of these patients allowed prompt recognition and efficient management.