Unsafe abortion remains a major cause of preventable maternal morbidity and mortality, particularly in developing countries. Uterine rupture is a rare but life-threatening complication that may occur following unsafe abortion practices, especially during the second trimester of pregnancy. We report the case of a 27-year-old woman, gravida 3 para 2 living 2 (G3P2L2), with a history of approximately 16 weeks of amenorrhea who presented with severe abdominal pain and vaginal bleeding following termination of pregnancy at an unauthorized healthcare facility. On admission, she was severely pale, drowsy, and hemodynamically unstable. Bedside ultrasonography revealed massive hemoperitoneum with products of conception and fetal parts within the abdominal cavity, suggestive of uterine rupture. An emergency exploratory laparotomy was performed, which revealed approximately 1200 mL of hemoperitoneum and a large cornual uterine rupture with extrusion of products of conception into the peritoneal cavity. Due to the extent of the injury and the patient’s unstable condition, a hysterectomy was performed. The patient received multiple blood transfusions, recovered well postoperatively, and was discharged in stable condition. This case highlights the severe consequences of unsafe abortion and emphasizes the importance of timely diagnosis and prompt surgical intervention in reducing maternal mortality. Strengthening access to safe abortion services, improving reproductive health education, and addressing socioeconomic factors contributing to unsafe abortion are essential to prevent such life-threatening complications.
Unsafe abortion remains a major public health concern and a significant contributor to preventable maternal morbidity and mortality, particularly in developing countries. The World Health Organization (WHO) defines unsafe abortion as a procedure for terminating a pregnancy that is performed either by individuals lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both [1,2]. Globally, an estimated 73 million induced abortions occur annually, of which approximately 45% are considered unsafe, with the vast majority occurring in low- and middle-income countries [3]. Common complications of unsafe abortion include incomplete abortion, severe hemorrhage, uterine perforation, pelvic infection, sepsis, and, rarely, uterine rupture [4,5]. Uterine rupture is a life-threatening obstetric emergency that requires prompt diagnosis and immediate surgical intervention to prevent maternal mortality.
CASE PRESENTATION
A 27-year-old woman from a rural area near Udaipur, belonging to a low socioeconomic background, gravida 3 para 2 living 2 (G3P2L2), with both previous deliveries being full-term vaginal births, presented to the emergency department with complaints of severe abdominal pain and vaginal bleeding for the preceding six hours. She had a history of four months of amenorrhea, and her last menstrual period was on 02 April 2024. Her previous menstrual cycles had been regular.
The patient had undergone termination of pregnancy at an unauthorized healthcare facility on 31 July 2024. Following the procedure, she developed severe abdominal pain and vaginal bleeding and was subsequently referred to our tertiary care center for further management. On arrival, an emergency bedside ultrasonography was performed, which revealed massive hemoperitoneum along with products of conception within the abdominal cavity, highly suggestive of uterine rupture.
On examination, the patient appeared severely pale and drowsy. She was hemodynamically unstable, with a blood pressure of 60/30 mmHg, pulse rate of 142 beats per minute, and oxygen saturation of 94% on room air. Abdominal examination revealed marked distension, generalized tenderness, and guarding. Active vaginal bleeding was present. In view of the patient's critical condition and findings suggestive of uterine rupture with hemorrhagic shock, an urgent multidisciplinary assessment was undertaken, and she was immediately shifted for emergency exploratory laparotomy after obtaining high-risk informed consent.
Intraoperatively, approximately 1200 mL of hemoperitoneum along with large blood clots was encountered. A large uterine defect measuring approximately 5 × 3 cm was identified in the cornual region of the uterus, with irregular margins. Products of conception and fetal parts were found free within the peritoneal cavity. Owing to the extensive uterine damage and the patient's hemodynamic instability, an emergency hysterectomy with evacuation of hemoperitoneum was performed. Multiple units of blood and blood products were transfused intraoperatively. Following surgery, the patient was shifted to the intensive care unit for close monitoring and further management.
The postoperative period was uneventful, and the patient showed gradual clinical improvement. She was discharged in stable condition on the sixth postoperative day. Follow-up evaluations at 15 days and one month after discharge revealed satisfactory recovery without any postoperative complications.
Figure 1-4: Surgical specimen and intraoperative findings showing cornual uterine rupture with associated hemoperitoneum. Figure 1 depicts the ruptured uterus with blood clots and products of conception; Figures 2 and 3 demonstrate the uterine rupture intraoperatively; Figure 4 shows the products of conception retrieved from the abdominal cavity.
DISCUSSION
Unsafe abortion remains a significant cause of preventable maternal morbidity and mortality worldwide, particularly in developing countries. Uterine perforation and uterine rupture are among the most serious complications associated with unsafe abortion and may result in massive hemorrhage, sepsis, and death if not recognized and managed promptly [4,5]. The risk of maternal complications following abortion is influenced by several factors, including gestational age, the method used for pregnancy termination, the skill of the provider, and timely access to post-abortion care [5].
The majority of unsafe abortions occur in low- and middle-income countries where barriers to safe reproductive healthcare services continue to exist [3]. Several socioeconomic and cultural factors contribute to unsafe abortion practices. In many South Asian countries, deeply rooted patriarchal traditions and a preference for male offspring have been reported as important determinants influencing reproductive decisions [6–10]. In settings where sex-selective abortion is prohibited, some women may seek abortion services from untrained providers operating outside the formal healthcare system, thereby increasing the risk of severe complications [10]. Other factors associated with unsafe abortion include low educational status, poverty, social stigma, limited awareness regarding legal abortion services, and inadequate access to qualified healthcare providers [11,12].
Age has also been identified as an important determinant of unsafe abortion and abortion-related mortality. Yokoe et al. reported that younger women, particularly adolescents and women aged 24 years or younger, are at a higher risk of undergoing unsafe abortion and experiencing abortion-related mortality [13]. Furthermore, a WHO-supported study conducted in Colombia suggested that nearly one-fifth of induced abortions could potentially be prevented through improved access to contraceptive information and high-quality family planning services [14].
The present case highlights a rare but life-threatening complication of unsafe second-trimester abortion resulting in uterine rupture with massive hemoperitoneum and hemorrhagic shock. The patient presented with severe abdominal pain, vaginal bleeding, and profound hemodynamic instability. Prompt diagnosis using bedside ultrasonography and immediate surgical intervention were crucial in saving her life. Intraoperatively, a large cornual uterine rupture with extrusion of products of conception into the abdominal cavity was identified, necessitating emergency hysterectomy.
The choice of surgical management in uterine rupture depends on the extent of uterine injury, the patient's hemodynamic status, future fertility desires, and the presence of uncontrolled bleeding. Uterine repair may be considered in young women with limited uterine damage, controlled hemorrhage, and a desire for future fertility. However, in cases of extensive uterine rupture, hemodynamic instability, or when childbearing is complete, hysterectomy remains the definitive life-saving procedure [15].
Uterine rupture following unsafe second-trimester abortion is an uncommon but catastrophic complication. Similar cases have been reported in the literature, particularly in settings where abortion services are provided by untrained personnel. The present case is notable because the patient had no previous cesarean section or uterine surgery and developed a large cornual rupture with massive hemoperitoneum following an attempted pregnancy termination at an unauthorized facility. Prompt diagnosis and emergency surgical intervention were crucial for a favorable maternal outcome.
This case emphasizes the need for strengthening access to safe abortion services, promoting contraceptive awareness, and ensuring that pregnancy termination procedures are performed only by trained healthcare providers in appropriately equipped healthcare facilities.
CONCLUSION
Unsafe abortion continues to be an important and preventable cause of maternal morbidity and mortality, particularly in developing countries. Severe complications such as uterine rupture, hemorrhage, sepsis, uterine perforation, and genital tract injuries may occur when abortion services are sought from unqualified providers. Early recognition of complications and timely surgical intervention are essential for reducing maternal mortality. Addressing the underlying determinants of unsafe abortion, including low socioeconomic status, limited access to reproductive healthcare, inadequate awareness regarding legal abortion services, gender inequality, and social stigma, is crucial. Strengthening family planning services, improving contraceptive uptake, promoting female education, and enforcing existing laws against sex-selective practices can contribute significantly to reducing the burden of unsafe abortion and its associated complications.
DECLARATIONS
Consent: Written informed consent was obtained from the patient for publication of this case report and accompanying images.
Conflict of Interest: The authors declare no conflict of interest.
Funding: No funding was received for this study.
Author Contributions: All authors contributed to patient management, manuscript preparation, critical revision, and approval of the final manuscript.
REFERENCES
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