Second-Trimester Uterine Rupture in an Unscarred Uterus Following Self-Administered Misoprostol: A Case Report and Literature Review

Introduction

Self-managed medication abortion, defined as terminating a pregnancy outside formal medical settings using approved medications, is increasingly practiced worldwide.^1,2 In contexts where clinic access is limited by legal, geographic or personal barriers, women may obtain abortion pills like misoprostol directly. ³ Medication abortion with mifepristone and misoprostol (or misoprostol alone) is highly effective when used correctly.^4,5 However, misuse or overdose of misoprostol, particularly unsupervised “street” regimens, can lead to uterine hyperstimulation and catastrophic outcomes.^6,7

Uterine rupture is a rare but serious obstetric emergency. ⁸ It most often occurs during active labor in women with a prior uterine scar (eg, from cesarean delivery). ⁹ By contrast, rupture in an unscarred uterus is exceedingly uncommon. ¹⁰ A recent multi-country survey (INOSS) of atypical ruptures, defined as those in unscarred, preterm or prelabour uteri, found an incidence of only ~0.2 per 10,000 births (0.002%) in unscarred uteri. ¹¹ Though rare, rupture in an unscarred uterus is life-threatening when it occurs.^11,12

Second-trimester pregnancy termination (13-26 weeks) can be achieved medically or surgically. ⁸ Evidence-based protocols typically employ moderate misoprostol dosing (often 400 µg vaginally every 3-6 hours).^4,13 When properly supervised, misoprostol-alone, or mifepristone/misoprostol regimens have high success and safety rates.^4,5 Still, higher doses and repeated use carry escalating risks. ⁵ For example, a systematic review found that second-trimester medical abortion regimens involving misoprostol and mifepristone have an extremely low uterine rupture risk (~0.01%) in women without prior cesarean; the risk was substantially higher (~1.1%) in those with a scar. ¹⁴ This underscores that uterine rupture in a non-scarred second-trimester patient is exceedingly rare under normal protocols.^8,11,14

We describe a case of mid-second-trimester uterine rupture in a patient with an ostensibly unscarred uterus following unsupervised high-dose misoprostol for abortion. This report emphasizes an unusual clinical scenario, rupture in a mid-trimester, previously unscarred uterus, and serves as a caution about unsafe self-administered abortion practices.

Case Presentation

A 30-year-old gravida 3 para 2 woman presented to the emergency department with 2 days of progressive lower-abdominal “pushing-down” pain and scant vaginal spotting after an unsupervised attempt at termination using misoprostol. She reported three 600 µg doses administered vaginally at 6-hour intervals and three 400 µg doses given sublingually over 48 hours. She had amenorrhea consistent with about 22 weeks’ gestation by dates and bedside ultrasound, 2 prior uncomplicated spontaneous vaginal deliveries, and no history of uterine surgery. On arrival she appeared acutely unwell and in pain; vital signs showed tachycardia (HR 104 bpm) and borderline hypotension (BP 97/62 mmHg). Abdominal examination revealed a tender, soft abdomen with an estimated fundal height of ~22 weeks and no signs of generalized peritonism; pelvic examination demonstrated a closed cervix without active vaginal bleeding.

Point-of-care transabdominal ultrasound confirmed a single intrauterine pregnancy with positive fetal heart activity and estimated gestation of ~22 weeks, an intramyometrial isoechoic lesion at the fundus measuring approximately 3.2 × 2.6 cm, and moderate pelvic free fluid consistent with hemoperitoneum. Laboratory investigations showed leukocytosis (WBC 24.1 × 10⁹/L, 89.7% neutrophils), hemoglobin 11.1 g/dL, hematocrit 32.4%, platelets 174 × 10⁹/L, and blood group A positive. Given hemodynamic instability and sonographic free fluid, the working diagnosis was uterine rupture versus complicated second-trimester termination with intra-abdominal bleeding; the patient was cross-matched, counseled, and taken urgently to the operating theater for exploratory laparotomy under general anesthesia.

At laparotomy there was approximately 500 to 600 mL of hemoperitoneum. A 5 cm full-thickness transverse rupture was identified in the anterior lower uterine segment; the rupture edges were friable and partially necrotic (Figure 1). A nonviable male fetal tissue was floating within the peritoneal cavity and was removed; the cavity was debrided prior to repair (Figure 2). The necrotic edges were debrided and the uterine defect repaired in 3 layers with delayed-absorbable sutures. Hemostasis was achieved without extension into major pelvic vessels and hysterectomy was not required. Intraoperative management included transfusion of 2 units of packed red blood cells, administration of broad-spectrum intravenous antibiotics (ceftriaxone and metronidazole) and initiation of standard thromboprophylaxis.

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Figure 1.

Intraoperative views of a second-trimester uterine rupture. (A) A 5 cm full-thickness transverse rupture in the anterior lower uterine segment with exposed amniotic sac, extruded fetal tissue, and hemoperitoneum prior to debridement and repair. (B) Nonviable fetus with attached placental tissue, surrounded by clot and blood.

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Figure 2.

Post-fetal-tissue removal image showing debrided necrotic edges of the uterine defect prior to 3-layer repair.

The immediate postoperative course was uneventful. The patient stabilized without need for reoperation; postoperative hemoglobin was 8.5 g/dL. She received analgesia, completed the prescribed antibiotic course, and was discharged on postoperative day 5 after counseling; she accepted a progestin implant for contraception. At 6-week follow-up she reported resolution of pain, pelvic examination was normal, and transvaginal ultrasound demonstrated an intact uterine repair without fluid collection. Intraoperative photographs document the defect prior to repair and the uterine cavity after removal of fetal tissue and debridement. The patient was counseled about the increased risk of uterine rupture in future pregnancies and advised to seek early antenatal care, plan delivery at a tertiary facility with surgical capability, and have individualized discussion regarding timing and mode of delivery in subsequent pregnancies.

She is married, lives with her partner and 2 children, works locally as a market vendor, and completed primary education. She reported limited access to local reproductive-health services because of distance and cost, and stated the pregnancy was unplanned and unwanted; she cited financial constraints and difficulty accessing a clinic as the primary reasons for attempting an unsupervised termination.

Discussion

Self-administered abortion medications are an increasingly recognized phenomenon. ¹ Recent U.S. studies suggest that a notable minority of women have attempted self-managed abortion (SMA) with medications.^1,2 Factors driving SMA include legal restrictions, cost, travel barriers, or personal preference for privacy.^2,3 As Steinberg et al note, as institutional abortion access becomes more restricted, self-managed attempts tend to rise. ¹ Globally, it is estimated that half of all abortions remain unsafe, often involving suboptimal dosing or unregulated agents. ¹⁵ In our case, the patient obtained misoprostol independently and administered a supratherapeutic regimen (total 3000 μg over 48 hours), far above typical induction protocols. This unregulated use exemplifies how overdosing can precipitate severe complications, a point underscored by recent case series. For instance, Ezemenaka et al reported 2 second-trimester ruptures following “high doses” of misoprostol given outside medical supervision; both cases required hysterectomy and intensive care. ⁷ Such reports highlight that improper misoprostol dosing can directly cause uterine rupture even in uteri without prior surgery. ⁷ Selected published reports of uterine rupture temporally associated with misoprostol use are summarized in Table 1 to contextualize our case with regard to gestational age, prior scar status, operative management, and outcomes.

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Table 1.

Selected published reports of uterine rupture associated with misoprostol use.

No.	Citation (year)	Country	Gestational age	Prior uterine surgery/scar	Surgical management
1	Belay et al, 2025 (16)	Ethiopia	23 w + 2 d	Unscarred	Emergency laparotomy; debridement and uterine repair (3-layer closure)
2	Ezemenaka et al, 2025 (7)	Nigeria	Late pregnancy/second trimester (reported)	Reported as unscarred	Emergency laparotomy; hysterectomy(s) reported in the series
3	Tigga 2019 (6)	India (case/series)	Second trimester/atypical rupture	Unscarred (reported)	Laparotomy with operative management (repair described)
4	Flis et al, 2023 (8)	Poland	Second trimester/variable	Unscarred context discussed	Emergency laparotomy; operative management described
5	Halassy et al, 2019 (12)	USA	Gravid, uterus (near-term atypical case described)	Unscarred	Laparotomy and surgical repair described

Diagnosing uterine rupture in this context is challenging. ⁸ The clinical presentation can mimic other conditions, delaying recognition. “Silent” or atypical rupture may present with relatively subtle signs: pain without overt peritonism, a closed cervix, and minimal vaginal bleeding.^6,11 In Tigga’s series, extruded fetal parts within an intact sac can tamponade bleeding, masking classic signs. ⁶ Ultrasonography may also mislead; some reports noted an extruded fetus being misinterpreted as a placenta previa on imaging.^6,8 In our patient, point-of-care ultrasound was crucial: it showed free intraperitoneal fluid and an intramyometrial lesion, raising suspicion. Given any hemodynamic instability or intraperitoneal fluid on imaging, prompt laparotomy is indicated.^8,11 Early recognition allowed salvage of the uterus in this case.

This case expands the spectrum of misoprostol-related injury. Uterine rupture is most feared in scarred, term-laboring uteri, and is extremely rare mid-trimester in unscarred cases.^11,14 Here, prolonged hyperstimulation from high-dose misoprostol likely led to focal myometrial ischemia and necrosis at the lower segment, culminating in rupture. ⁷ The rupture margins were friable and necrotic, as observed intraoperatively (Figure 1). Although formal studies of mid-trimester misoprostol physiology are scant,^6,7 this case suggests that ischemic necrosis from hyperstimulation can occur rapidly outside labor.

Surgical management must be individualized. ¹³ Given the patient’s desire for future fertility and the localized nature of the rupture, the decision was to repair rather than perform a hysterectomy. Contemporary data support uterus-sparing repair when feasible.^8,13 In a Japanese nationwide series, women undergoing uterine repair had significantly lower rates of blood transfusion and shorter hospital stays than those undergoing hysterectomy. ¹³ Conversely, population analyses show that unscarred uterine ruptures more often end in hysterectomy: Al-Zirqi et al found a 2.6-fold higher odds of peripartum hysterectomy in unscarred versus scarred ruptures. ⁹ In large registries, about 20% to 25% of ruptures result in hysterectomy, and roughly 40% to 45% result in severe hemorrhage requiring intervention.^9,11 In our patient, the defect could be debrided and closed in 3 layers with absorbable suture, achieving hemostasis without hysterectomy. Intraoperative transfusion (2 units) and antibiotics were administered. Short-term outcomes were favorable: the patient stabilized, was discharged on postoperative day 5, and imaging at 6 weeks confirmed an intact repair. These findings underscore that timely laparotomy with conservative repair can preserve fertility and avoid the morbidity of hysterectomy.^9,13

This case also emphasizes broader public health lessons. First, it highlights the dangers of unsupervised high-dose regimens. Clinicians and pharmacists should reinforce guideline-based dosing ⁴ : for example, studies suggest 400 μg misoprostol (vaginally every 3-4 hours) is optimal for second-trimester induction, whereas cumulative doses well above 2000 μg pose significantly higher risk of adverse effects. ⁷ Community education and provider training are needed so that patients understand safe regimens and the importance of medical supervision during abortion. ¹ Second, the case underscores the need for accessible, high-quality abortion services. Restrictive laws and poor availability drive some women toward unmonitored methods.^1-3 Improving safe service access and counseling may reduce harmful self-management. ² Third, obstetric units should adopt early triage protocols: any woman with obstetric pain after attempted abortion warrants prompt imaging to rule out intra-abdominal bleeding. ⁸ Finally, post-abortion care is critical. Post-procedure follow-up allows detection of complications and provision of contraception.^11,17 In our case, the patient received a progestin implant prior to discharge. Uptake of post-abortion contraception is a key opportunity: in 1 systematic review in Africa ~59% of women accepted a contraceptive method after abortion. ¹⁸ Structured post-abortion counseling dramatically increases uptake ¹⁹ ; Dagnew and Asresie found women receiving family planning counseling had significantly higher odds of using contraception thereafter. ¹⁸ Enhancing post-abortion family planning services can reduce the risk of repeat unintended pregnancies and associated morbidity.^1,18,19

Conclusion

This unusual case of second-trimester uterine rupture in an unscarred uterus after self-administered misoprostol illustrates several lessons. First, it highlights that unsupervised high-dose abortion regimens can have catastrophic outcomes outside the usual labor setting. Clinicians must maintain vigilance for rupture even in non-laboring patients who present with abdominal pain after medical abortion. Second, the case demonstrates that timely recognition and laparotomy can allow conservative repair and fertility preservation; such repair is preferable whenever tissue viability permits, given the lower morbidity compared to hysterectomy. Third, it reinforces the importance of public health measures: expanding safe, supervised abortion access, ensuring clear dosing instructions, and providing post-abortion contraception and follow-up are essential to prevent similar adverse events. Ultimately, thorough patient education and robust health system protocols are needed to mitigate the risks of self-managed abortion and safeguard maternal health.