Spontaneous Rupture in the Posterior Uterine Wall of an Unscarred Uterus

Spontaneous rupture of an unscarred uterus is an exceptionally rare but life-threatening obstetric complication. Its diagnosis may be particularly challenging when clinical manifestations are atypical and classical risk factors are absent. We report the case of a 27-year-old gravida 3, para 2 woman with two previous vaginal deliveries and no history of uterine surgery. She presented in spontaneous labor at 39 weeks of gestation. Labor was augmented with oxytocin and resulted in vaginal delivery of a live male neonate weighing 3000 g, with Apgar scores of 9 and 10 at one and five minutes, respectively. During episiotomy repair, abnormal vaginal bleeding was noted despite a well-contracted uterus. Manual exploration of the uterine cavity raised suspicion of a uterine defect, which prompted emergency laparotomy. Surgical exploration revealed a moderate hemoperitoneum and an approximately 8-cm rupture of the left posterior uterine wall of the unscarred uterus extending toward the pouch of Douglas. The uterine defect was initially repaired by primary suturing; however, severe postpartum hemorrhage secondary to refractory uterine atony necessitated a hemostatic hysterectomy. The patient received two units of packed red blood cells and had an uneventful postoperative recovery. This case highlights the importance of maintaining a high index of suspicion for uterine rupture even in unscarred uteri, particularly when unexplained postpartum hemorrhage occurs despite an apparently normal labor and delivery. Early recognition and prompt surgical management are essential to optimize maternal outcomes.