Intact amniotic sac prolapsing through a lower uterine segment rupture: a striking intraoperative image

Uterine rupture, though a well-recognized obstetric catastrophe, rarely presents itself with the intraoperative finding of an intact, prolapsed amniotic sac through the uterine defect, an exceptionally uncommon finding reported only in isolated case reports. A 28-year-old woman (G3P2) with two prior lower-segment caesarean sections (LSCS) presented at 34 weeks of gestation with sudden-onset severe abdominal pain and absent fetal movements since eight hours. On examination, patient was pale, in haemorrhagic shock (pulse 112 beats per minute; blood pressure 88/60 mmHg), with a tender abdomen and absent fetal heart sounds. Ultrasonography revealed an empty uterine cavity, intrauterine fetal demise, a defect in the anterior lower uterine wall, and free intraperitoneal fluid. Following resuscitation, emergency laparotomy was performed under general anaesthesia. Intra-operatively, a 6-cm longitudinal rupture was identified along the prior caesarean scar of the lower uterine segment. The striking intraoperative finding-depicted in the figure-was the complete prolapse of an intact, bulging amniotic sac through this uterine defect into the peritoneal cavity. Approximately 800 mL of haemoperitoneum was evacuated. The membranes were incised, and a stillborn male fetus (weight 2.0 kg) was delivered. The uterine defect was repaired in two interrupted layers, and bilateral tubal ligation was performed simultaneously. The patient had an uneventful postoperative recovery and was discharged on postoperative day four.