Trauma is the leading cause of nonobstetric related maternal death [1]. Uterine rupture secondary to trauma affects 0.6% of obstetric traumas with a fetal mortality rate that approaches 100% [2]. Rapid imaging and emergency laparotomy are often necessary for diagnosis and treatment. Here we present a case of uterine rupture and fetal demise secondary to a gunshot wound (GSW).

A 14-year-old G0P0 patient at 18 weeks gestation presented to the emergency department with gunshot injuries of unknown caliber and range to the right chest, back, arm, ribs 4–6, and left pelvis. At the hospital, the patient exhibited unstable vital signs [pulse: 89 BPM, blood pressure (BP) 150/107 mmHg, SpO₂: 68%] and was therefore sedated and intubated. She had a chest tube placed with 1 L of bloody output and subsequently received 2 units of fresh frozen plasma and 2 units of packed red blood cells. A bedside pelvic ultrasound confirmed an intrauterine fetal demise with fetal long bones that appeared to protrude through the uterine wall (Figure 1 and Figure 2). The amniotic sac was noted to be intact. Additionally, a hypoechoic area adjacent to this rupture and hypotension suggested a collection of blood within the abdomen. These findings were confirmed on computed tomography (CT) scan (Figure 3 and Figure 4). There were no foreign bodies within the abdomen or pelvis seen on the CT to suggest retained bullets. Given these findings, an emergency exploratory laparotomy was performed jointly with both obstetric and trauma surgery teams present

Upon entry via a midline vertical incision, a 5 cm uterine rupture from the uterine fundus to the left cornua was noted. The amniotic sac was intact and protruding through the defect (Figure 1). Roughly 500 mL of hemoperitoneum was removed with no active bleeding noted. Surgeons found two penetrating wounds overlying the left psoas muscle with intact iliac vessels and ureters. There was no solid organ, intestinal, mesenteric, or diaphragmatic injury observed, hemodynamics remained stable, and psoas bleeding was controlled with direct pressure. An en caul delivery of the fetus and placenta was performed (Figure 5). Banjo curettage was used to remove any remaining pregnancy tissue. The uterus was then closed in three layers, an initial layer of 0-Vicryl followed by an imbricating layer of 0-Vicryl and finally a baseball stitch of 3-0 Vicryl. Following the closure of the uterus, a left salpingectomy was performed as it was transected at the level of the cornua. She had no immediate postoperative complications, was transferred to the pediatric intensive care unit (PICU) in stable condition, and was discharged home in stable condition on postoperative day 10.

Gunshot wounds during pregnancy are not uncommon in the United States—roughly 7% of pregnancies will be complicated by a traumatic injury, 4% of which come from GSWs [1]. Gunshot wounds to the abdomen of a pregnant individual are especially dangerous, causing 70% of fetuses to sustain an injury and up to 65% of pregnancies leading to fetal demise [3]. This case highlights an unusual presentation of fetal demise from a GSW, as uterine rupture occurred with preservation of an uninjured amniotic sac and fetus. The trauma and uterine rupture led to demise of the fetus.

This is a rare case of uterine trauma from a GSW resulting in the protrusion of fetal long bones from the uterus within the amniotic sac and fetal demise. In this case, it is likely that the ballistic led to the uterine rupture without injuring the amniotic sac or fetus.