Early-third-trimester uterine rupture in an unscarred primigravida with a didelphic uterus: a case report

Uterus didelphys, one of the rarest types of Müllerian anomaly, is characterized by the presence of two separate uterine horns and/or two distinct cervices due to the failure of Müllerian duct fusion. It is associated with poor obstetric outcomes, including spontaneous abortion, preterm labor, fetal malpresentation, and, rarely, uterine rupture.

A 19-year-old primigravida from Sela Dingay woreda (resident of Sela Dingay town) in the North Shewa Zone of the Amhara Region was urgently referred to Debre Berhan University Hakim Gizaw Teaching Hospital from the woreda health center with a diagnosis of early third-trimester pregnancy (29 weeks, confirmed by a reliable last normal menstrual period) complicated by placental abruption. Clinical and instrumental evaluations revealed severe anemia (hemoglobin 5.5 g/dL), free fluid in the peritoneal cavity, absent fetal heartbeat, and a fundal placenta. Vaginal examination revealed a single cervix dilated to 1 cm. Given the suspicion of uterine rupture, preparations for an emergency laparotomy were initiated. After transfusing 2 units of fresh whole blood and obtaining informed consent, surgery was performed. Intraoperative findings included a rupture of the posterior aspect of the right hemi-uterus in a didelphic uterus. A newly deceased female fetus weighing 1.2 kg was extracted from the peritoneal cavity, and a subtotal hysterectomy of the ruptured hemi-uterus was carried out. Following postoperative stabilization in the intensive care unit, the patient was transferred to the maternity ward and discharged on the fifth postoperative day. She received counseling on future pregnancies, was administered Implanon NXT for long-acting contraception, and prescribed ferrous sulfate for 1 month. This case underscores the critical importance of comprehensive prenatal screening and vigilant management of pregnancies complicated by uterine anomalies to minimize risks and optimize maternal-fetal outcomes.

Uterine didelphys is rarely associated with early-third-trimester pre-labor uterine rupture, but when it occurs, it results significant feto-maternal comorbidity. Therefore, it is advisable to screen every primigravida mother for uterine anomalies in addition to performing fetal anatomical scans in the early trimester. This is crucial because the complications associated with this anomaly can be unexpected and may lead to maternal and fetal morbidity and mortality due to delayed treatment.