Concurrent uterine rupture and refractory uterine atony leading to catastrophic postpartum hemorrhage: a case report

Introduction: Postpartum hemorrhage (PPH) remains a leading cause of maternal morbidity and mortality worldwide, particularly in low- and middle-income countries. Uterine atony is the most common etiology, while uterine rupture is less frequent but catastrophic. The coexistence of both conditions is rare and poses significant management challenges. Case presentation: We report the case of a multiparous woman who developed massive PPH due to a combination of uterine rupture and refractory uterine atony. Despite maximal uterotonic therapy, uterine massage, and fluid resuscitation, bleeding persisted. Abdominal ultrasonography revealed intraperitoneal free fluid, consistent with intra-abdominal hemorrhage. The patient underwent an emergency total abdominal hysterectomy with bilateral salpingectomy. During resuscitation, uncrossmatched O Rh(+) blood was administered, followed by a massive transfusion protocol including whole blood, packed red cells, fresh frozen plasma, and platelets. Discussion: This case underscores the importance of early recognition and rapid escalation in PPH management. Hysterectomy, although considered a last resort, was life-saving in this scenario. The use of uncrossmatched blood and structured massive transfusion protocol ensured timely correction of dilutional coagulopathy, hypocalcemia, and metabolic acidosis. Postoperative care required multidisciplinary collaboration, including obstetrics, anesthesiology, intensive care, and transfusion medicine, to achieve hemodynamic stabilization and recovery. Conclusion: The rare coexistence of uterine rupture and refractory uterine atony highlights the need for prompt diagnosis, decisive surgical intervention, and balanced transfusion strategies. Multidisciplinary collaboration remains essential to optimize maternal outcomes in life-threatening obstetric hemorrhage.