A case report of intramural pregnancy with uterine rupture: a warning signal from ineffective evacuation

Objective: Intramural pregnancy is a rare form of ectopic pregnancy. We report a case of undiagnosed intramural pregnancy that progressed from ineffective evacuation to uterine rupture. Patient: A challenging case of a 41-year-old woman who experienced uterine rupture at 15 weeks' gestation due to intramural pregnancy. Results: The patient was once misdiagnosed with an intrauterine pregnancy with an intrauterine device (IUD) and underwent ineffective evacuation. After 9 weeks, she was referred to our hospital with complaints of sudden-onset lower abdominal distension. An emergency ultrasound revealed a fetus without cardiac activity floating in the peritoneal cavity and a clear rupture site at the uterine fundus. Given the clinical suspicion of uterine rupture, an emergency laparotomy was performed. Intraoperatively, the peritoneal cavity contained approximately 1700 mL of hemoperitoneum. The amniotic sac and fetus were found to be free in the abdominal cavity. Notably, a 3.5 × 3.0 cm defect was found at the uterine fundus with active bleeding, which did not communicate with the uterine cavity. The bilateral fallopian tubes and ovaries appeared grossly normal. After the intraperitoneal blood was evacuated, the dead fetus along with the amniotic sac was removed. The uterus was repaired with a continuous absorbable suture. The estimated blood loss was 1800 mL. Finally, the patient recovered well and was discharged. Conclusion: We present a case of an undiagnosed intramural pregnancy that progressed from ineffective evacuation to uterine rupture. An emergency laparotomy was performed to remove the dead fetus and repair the uterine defect. Therefore, intramural pregnancy should be strongly considered in women with previous uterine trauma, who present with persistent pregnancies with IUDs and a history of ineffective evacuation.