Intrapartum posterior cul-de-sac rupture, a clinical enigma: a case report

Posterior cul-de-sac rupture is a rare intrapartum complication with non-specific symptoms that impede timely diagnosis. Reported risk factors include genital tract anomalies, prior pelvic infection, cesarean scar, and pharmacologic induction (e.g., misoprostol).

A 29-year-old primigravida presented at our Obstetrics and Gynecology department with fetal growth restriction at 38 weeks of gestation. Ultrasound revealed fetal growth restriction (an estimated fetal weight of 2196 g, <10th percentile), a single umbilical artery, and normal Doppler findings. Her cervical os was closed, so labor was induced with mifepristone followed by misoprostol. This was followed by spontaneous rupture of membranes. An emergency cesarean section was performed due to fetal distress, revealing a 5-cm tear extending from the pouch of Douglas to the cervicovaginal junction, repaired in layers. Postoperative antibiotics were administered, and she recovered well, with follow-up scheduled after 6 weeks.

Intrapartum rupture of the posterior cul-de-sac during induced labor is rare. Various circumstances have been associated with posterior vaginal wall ruptures, including vaginal atresia and previous pelvic infections. Despite the absence of identifiable risk factors, induction with misoprostol may have contributed to the rupture. A hallmark symptom is severe abdominal pain, which warrants attention even without known risk factors. Therefore, vigilance is crucial for diagnosing concealed vaginal wall ruptures during labor, particularly in the context of unexplained severe pain.

It is crucial to suspect the possibility of a hidden vaginal wall rupture during labor, particularly when there is unexplained acute pain. Future studies should compare outcomes across parity groups and evaluate induction-related risk.