Skip to main content

Spontaneous antenatal uterine rupture in a primiparous patient with placenta praevia: Does previous laparoscopic treatment of endometriosis increase the risk?



Unprovoked spontaneous uterine rupture in a primigravid unscarred uterus is a rare but serious obstetric complication. Our case highlights a prelabour uterine rupture in a primiparous patient with an anterior placenta praevia and transverse lie at 32 weeks.

Case presentation

The patient presented with severe continuous abdominal pain and an abnormal Cardiotocograph antenatally. An emergency Caesarean section done with suspicion of concealed abruption revealed a cornual uterine rupture with 2 L of hemoperitoneum.


The patient and her baby recovered well from surgery, thus, emphasizing the necessity of timely intervention. An association with previous laparoscopic treatment of severe endometriosis and adenomyosis is explored.


A ruptured uterus is a catastrophic complication that can lead to severe maternal and fetal morbidity if not diagnosed in time. Common causes of uterine rupture include prior caesarean (8.9 and 37.1 per 10,000 births) (Miller et al. 1997), prior myomectomy, uterine malformations, connective tissue disorders, and placental disorders such as placenta percreta. Rupture of the uterus in the antenatal period prior to labour is a rare event, especially in an unscarred uterus. Uterine rupture in an unscarred uterus is as rare as 0.6 per 10,000 deliveries (Spencer and Robarts 2008).

Our case highlights an unprovoked uterine rupture in a primigravida with an IVF (in vitro fertilization) pregnancy at 32 weeks having a transverse lie and anterior placenta praevia. She had adenomyosis and a past history of laparoscopic treatment of severe endometriosis. Since this patient was not in labour and had an unscarred uterus, this was a rare complication encountered.

Case presentation

A primigravida with an IVF pregnancy following laparoscopic treatment of grade 4 endometriosis, presented at 32 weeks of gestation with an insidious onset of left upper quadrant abdominal pain for one and a half days. An antenatal ultrasound showed an anterior placenta praevia covering the cervical os with the fetus in a transverse lie and normal fetal growth.

On admission, she complained of severe continuous abdominal pain with a single episode of minimal vaginal bleeding. On examination, she had stable vitals, and mild pallor but generalized abdominal tenderness of rapidly increasing severity. There were no uterine contractions and a speculum examination showed a closed cervical os with no vaginal bleeding, which showed that the patient was not in labour. A Cardiotocograph (CTG) was done concomitantly, which showed fetal tachycardia, poor beat-to-beat variability, and atypical variable decelerations, suggestive of non-reassuring fetal status.

In view of the abnormal CTG, an emergency Caesarean section was done immediately on the suspicion of a concealed abruption. At caesarean, on entering the abdominal cavity via a transverse incision, 2 L of blood was found in the peritoneal cavity. A transverse lower segment incision was made on the uterus through the placenta to deliver the baby in a transverse lie by the internal podalic version. The uterus was delivered out of the abdomen to reveal a large rupture on the left side of the fundus, close to the cornu. The rupture was repaired in 3 layers with continuous sutures of Polyglactin 1.

She was transferred to ICU as she quickly became hemodynamically unstable during surgery, requiring 4 units of packed red blood cells and fresh frozen plasma. The baby was transferred in good condition to the neonatal care unit and in due course made an uneventful recovery. Following stabilization, the patient had an uncomplicated postoperative period and was discharged in stable condition. She was advised against further pregnancies (Figs. 1 and 2).

Fig. 1
figure 1

Abnormal CTG with fetal tachycardia and unprovoked fetal decelerations

Fig. 2
figure 2

Intraoperative image showing cornual rupture


Early detection of uterine rupture and prompt laparotomy are essential in reducing maternal and perinatal morbidity. The classic clinical picture of acute abdomen, hypovolemia, vaginal bleeding, and foetal distress may not always be accompanying symptom. Therefore, regardless of parity, it's crucial to maintain a high index of suspicion for uterine rupture in women presenting with any of the above symptoms. Less common conditions that may present with a similar spectrum of symptoms include subcapsular liver hematoma with or without rupture, rupture of the broad ligament, splenic rupture, uterine torsion, and uterine vein rupture. These conditions need prompt surgical exploration as they cause quick hemodynamic instability; therefore, a high level of clinical suspicion is always needed when above-mentioned symptoms occur in a non-laboring patient.

Our patient, a primigravida at 32 weeks, presented with continuous abdominal pain and fetal distress—symptoms consistent with concealed placental abruption. However, on performing an emergency caesarean, a cornual rupture in the uterus was identified, a rare event in a primigravid unscarred uterus. Early recourse to surgery, led to an optimal maternal and fetal outcome. It has been noted that rupture of an unscarred uterus is a more catastrophic event than rupture through a previous scar, as the area of rupture is more vascular (Miller et al. 1997).

It is important that we discuss that our patient had a history of primary subfertility with grade 4 endometriosis and adenomyosis. She underwent an uncomplicated laparoscopic resection of an ovarian endometrioma and pelvic adhesiolysis for grade 4 endometriosis, a year prior to her IVF. Literature suggests surgical treatment of severe endometriosis, such as deeply infiltrating endometriosis [DIE], has shown a causal relationship with uterine rupture (Ziadeh 2020; Fettback et al. 2015; Leone Roberti Maggiore et al. 2017; Vystavěl et al. 2018). This relationship of DIE with uterine rupture may be explained by a lack of a consensus regarding the depth of excision of tissues and decreased vascularisation of the uterine tissue following extensive bipolar coagulation required in these surgeries.

Our patient also had another risk factor of adenomyosis. There are case reports in the literature of spontaneous uterine rupture of an unscarred uterus caused by adenomyosis in the early third trimester (Vimercati et al. 2022). Alteration in organization and resistance of uterine fibers in adenomyosis may have a contributing role in this pathology (Nikolaou et al. 2013).


Our case demonstrates the potential of a primigravid unscarred uterus to rupture, even if not in labour. It is extremely important to keep this differential diagnosis in mind when a non-labouring primigravida presents with pain abdomen and is diagnosed with abnormal CTG.

Also, we have reviewed the literature where a causal relationship between laparoscopic treatment of severe endometriosis and adenomyosis with uterine rupture has been explored.

Availability of data and materials

Not Applicable.



In vitro fertilisation


Deeply infiltrating endometriosis




Intensive care unit


Download references


Not Applicable.


No funding was obtained for this study.

Author information

Authors and Affiliations



Both authors have contributed equally to the manuscript. Both authors have read and approved the manuscript.

Corresponding author

Correspondence to Ritisha Basu.

Ethics declarations

Ethics approval and consent to participate

Not Applicable.

Consent for publication

Informed consent taken from the patient.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Datta, S., Basu, R. Spontaneous antenatal uterine rupture in a primiparous patient with placenta praevia: Does previous laparoscopic treatment of endometriosis increase the risk?. Bull Natl Res Cent 47, 27 (2023).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: