Combined Rupture of Vaginal Vault and Unscarred Uterus and Neonatal Death Following Induction of Labor with Misoprostol

Introduction: Rupture of unscarred uterus (primary uterine rupture) is a rare peripartum complication often associated with catastrophic maternal and neonatal outcomes. Case presentation: A 27-year-old primigravid lady, previously healthy, at 40 weeks + 2 days presented to a midwife’s clinic for routine antenatal consultation. She was advised to have induction of labor. This was initiated with 2 tablets of Misoprostol (400 mcg) vaginally. Twelve hours later, and after remaining at full cervical dilation for 4 hours, she was referred to our maternity service for alleged failure to descend. On arrival, she was apprehensive, exhausted but hemodynamically stable. Pelvic exam disclosed a fully dilated cervix with the vertex at S + 1 and a caput reaching the introitus. No fetal heart rate could be elicited by the CTG monitor and this was verified by a bedside ultrasonography. Operative vaginal delivery was performed due to maternal exhaustion. This was complicated by transient shoulder dystocia. Manual revision of the birth canal and the uterine cavity disclosed a suspicion of left vaginal vault gapping together with a left fundal uterine rupture. Consequently, the patient was rushed to the operating room for an urgent exploratory laparotomy. The rupture sites were identified and repaired while a large broad ligament hematoma on the same side was explored and hemostasis secured with ipsilateral uterine artery ligation of the fundal and cervical branches. The postoperative course was smooth and the patient left the hospital on the 5th day postpartum. Conclusion: Cases of unscarred uterine rupture are limited. One of the most frequent risk factor is the injudicious use of Misoprostol for labor induction. Sudden arrest of progress of labor or failure to descend might mask uterine rupture. We recommend that all birth attendants be familiar with the guidelines issued by FIGO, ACOG and other societies for the safe use of these potent uterotonics.