Trauma-induced uterine rupture: a rare but fatal obstetric emergency case report

Abstract

Traumatic uterine rupture is a rare complication of blunt abdominal trauma, most common in the third trimester but uncommon during the first or second trimester of pregnancy. Early recognition of pregnancy in women of reproductive age presenting with trauma is crucial, as clinical priorities, diagnostic strategies, and management may differ significantly. We report a case of traumatic uterine rupture in a 20-year-old woman at 18 weeks’ gestation following a motorcycle accident. This case emphasizes the importance of considering obstetric injuries in early pregnancy following trauma and the value of early pregnancy detection in guiding prompt and appropriate management.

Background

Traumatic uterine rupture accounts for ˂1% of all uterine ruptures but carries substantial maternal and fetal mortality [1, 2]. It mostly occurs in the third trimester, ~80% of cases reported between 28 and 36 weeks’ gestation [3, 4].

Uterine ruptures in the first or second trimester are rare but may occur in the presence of risk factors such as labor-induction agents or a scarred uterus [5, 6]. The incidence is reported as 5.1 per 10 000 deliveries in scarred uteri and 0.7 per 10 000 in unscarred uteri [7].

Diagnosis is particularly challenging when pregnancy is unknown or cannot be confirmed immediately because of impaired consciousness or the absence of collateral history. Delayed recognition may postpone obstetric consultation and life-saving surgical intervention.

Case presentation

A 20-year-old woman was brought to hospital after a motorcycle accident in which she was thrown from the motorcycle and struck a tree. Upon arrival, primary survey demonstrated she was tachypnoea, persistent hypotension, tachycardia and a Glasgow Coma Scale score of E3V3M5. Her abdomen was tense, distended, and guarded. She underwent rapid sequence intubation, application of a pelvic binder and aggressive fluid resuscitation. As haemodynamic instability persisted, the massive transfusion protocol was activated and uncrossmatched O-negative blood was administered. Extended Focused Assesment with Sonography in Trauma (eFAST) demonstrated significant intraperitoneal free fluid with an apparently empty uterus (Fig. 1). She received tranexamic acid and blood products for presumed class IV haemorrhagic shock secondary to intra-abdominal injury.

Approximately 20 min later, her husband informed the treating team that she was gravida 2 para 0 + 1 with an 18-week intrauterine pregnancy confirmed on an earlier antenatal scan. Urine pregnancy test (UPT) was positive. Repeat bedside ultrasound demonstrated disruption of the uterine fundus with the fetus lying freely within the peritoneal cavity adjacent to the liver, confirming traumatic uterine rupture (Fig. 2). Pelvic radiography also demonstrated bilateral superior and inferior pubic rami fractures with pubic diastasis (Fig. 3).

The obstetric gynecology and anesthesia teams proceeded with emergency exploratory laparotomy. Operative findings included a laceration involving the right anterolateral uterine wall, bleeding from the left utero-ovarian ligament and ~1 L of haemoperitoneum with an estimated surgical blood loss of 2.5 L. Uterine repair was performed; however, the fetus was non-viable. Despite intensive care support, the patient died on the third day after trauma.

Discussion

This case highlights the importance of recognizing early pregnancy and obstetric complications in female trauma patients of reproductive age.

The imperative of early pregnancy testing in trauma

Advanced Trauma Life Support recommends all female trauma patients of reproductive age should undergo a UPT [8]. This practice extends beyond medicolegal considerations regarding radiological investigation suitability; it is essential for anticipating potentially life-threatening obstetric complications, such as uterine rupture. Studies indicate that ~8% of pregnant trauma patients discover their pregnancy during trauma evaluation, with 3% of women admitted to trauma units being pregnant, of which 11% are incidentally discovered [9]. Therefore, every female of reproductive age with significant injuries should be considered pregnant until proven otherwise by definitive pregnancy testing or ultrasound examination [8].

Diagnostic challenges illustrated by this case

This patient presented with hemodynamic instability and no available collateral history. Heuristic thinking focused on managing her critical condition—presumed Class IV hypovolemic shock secondary to intra-abdominal injury—without initial consideration of reproductive-related complexities. The initial eFAST revealed an empty-appearing uterus, leading to premature dismissal of pregnancy-related complications.

Uterine rupture in the second trimester: a rare but documented complication

Clinicians must recognize that traumatic uterine rupture can occur throughout pregnancy, although it remains uncommon during the first and second trimesters [11]. A 2023 case from Uganda described uterine rupture at 18 weeks following a bathroom fall, with both maternal and fetal survival [5]. Similarly, a 2020 case from the United States documented uterine rupture at 18 weeks following a motor vehicle accident, also resulting in dual survival [11].

The expanded role of eFAST in pregnant trauma patients

eFAST is routinely performed during the primary survey to identify intra-abdominal and thoracic injuries in trauma patients [8]. The sensitivity and specificity of bedside ultrasound for detecting intra-peritoneal free fluid remain comparable between pregnant and non-pregnant patients [8]. However, in pregnant trauma patients, eFAST assumes an additional critical diagnostic role beyond standard free fluid detection [10, 12].

In this population, careful sonographic examination may reveal uterine wall discontinuity and visualization of fetal parts outside the normal uterine contour—findings highly suggestive of uterine rupture [13, 14]. The presence of massive intraperitoneal free fluid combined with disruption of the uterine wall should immediately raise concern for possible uterine rupture [15].

Clinical implications and recommendations

Based on this case and supporting literature, we propose the following structured approach to pregnant or potentially pregnant trauma patients:

1. Obtain UPT immediately upon arrival for all reproductive-aged female trauma patients.

2. Trauma training modules should incorporate evaluation of reproductive structures into the eFAST examination. This extended assessment should include systematic visualization of the uterus, assessment of uterine wall integrity, and intentional localization of any identified fetal structures.

3. Maintain a high index of suspicion for pregnancy-related complications, including uterine rupture and placental abruption, until these diagnoses are definitively excluded.

4. Obstetric-related emergencies should be systematically ruled out as part of standard trauma protocols in reproductive-aged women, rather than relying on clinical suspicion triggered by positive pregnancy tests or obvious gravid appearance.

This case reinforces that pregnancy status must be determined early in trauma evaluation and that sonographic assessment in this population requires deliberate examination of reproductive structures beyond standard trauma survey views.

Conflicts of interest

None declared.

Funding

None declared.

Consent

Written informed consent for publication of this case report was obtained from the patient’s husband, acting as next of kin, as the patient is deceased. A copy of the signed consent form is retained by the corresponding author and is available for review by the Editor-in-Chief upon request.

References