Abstract

A 38 year-old parous lady with an unscarred uterus was admitted for induction of medical miscarriage following intrauterine death of a fetus with Edwards syndrome. She was asymptomatic post administration of mifepristone 48 hours prior to admission. As an inpatient she was given 5 doses of misoprostol (400 micrograms) vaginally. Lack of progress necessitated 4 further doses after 24 hours break. The patient had a persistent pyrexia of above 38 degrees following 4^th dose of misoprostol which was attributed to prostaglandin administration. Investigations revealed a CRP of 226 and a white cell count of 19.1. She was haemodynamically stable and used a remifentanyl PCA for analgesia. In view of lack of response to Misoprostol she was rescanned revealing a bulky uterus with the fetus lying intraperitoneally with an intact amniotic sac. CT scan revealed a 6.3 cm defect in the anterior uterine wall with an intact sac projecting beyond normal uterine contour. There was no free fluid. In view of this patient had a laparotomy revealing a 6 by 5 cm defect in the anterior uterine wall lined by necrotic tissue. In view of significant amount of necrosis a decision was made to proceed with subtotal hysterectomy. We wish to highlight this rare case wherein uterine rupture occurred due to infection and uterine wall necrosis possibly secondary to amniocentesis and fetal demise. All the classical features of uterine rupture like haemodynamic instability and intraperitoneal bleeding were absent. Only a high index of suspicion leading on to further imaging helped establish the diagnosis.