Second-trimester uterine rupture in a scarred uterus presenting as an acute abdomen: a diagnostic challenge

Uterine rupture is an uncommon but potentially catastrophic obstetric emergency, most often seen during labour in women with a scarred uterus. Rupture occurring in the second trimester, before the onset of labour, is far less common and can be mistaken for a surgical acute abdomen. We describe a 29-year-old woman, gravida 4 para 1, with a history of one previous cesarean section and two earlier uterine evacuations, who presented at 23 weeks of gestation with severe, diffuse abdominal pain and an episode of syncope. Ultrasonography on admission, together with medical and surgical assessment, did not establish a cause, and she subsequently deteriorated, with hypotension, tachycardia, and a sharp fall in haemoglobin. Repeat ultrasonography and an ultrasound-guided abdominal tap demonstrated haemoperitoneum, and emergency laparotomy revealed rupture along the previous cesarean scar together with a defect in the right broad ligament. The uterus was repaired and preserved successfully. This case highlights the need to consider uterine rupture in a woman with a scarred uterus presenting with acute abdomen, even before the third trimester and in the absence of labour.