Perforations after surgical abortions or curettage are complications that most of the gynaecologists would have come across and managed. Fortunately, the perforations following illegal abortions with injuries to internal organs and frank peritonitis are on the decrease with the advent of medical methods of abortion.

As a special mention, I would like to bring out two rare presentations of rupture uterus.

I got a call from the emergency operation theatre by the registrar of surgery. They had opened up the abdomen of a 50-year-old postmenopausal lady admitted with a diagnosis of peritonitis. One litre of pus had been drained. They found a rent in the anterior wall of the uterus. All other organs were normal. The patient was under general anaesthesia in the supine position. There was no way to gather any more information. There was a 2 cm ragged rent in the anterior wall (Fig. 8.1). There was no obvious growth protruding from the rent. I decided to proceed with hysterectomy. When I was clamping to reach the cardinal ligaments, I realized that it is an advanced cancer cervix with induration of the cardinal ligament. Fortunately vesicovaginal plane was free. I could accomplish total hysterectomy and kept my fingers crossed that there should be no reactionary haemorrhage or infection. The cervix had an indurated growth. Fortunately, she had an uneventful recovery. The histopathology confirmed squamous cell carcinoma of the cervix. She received postoperative radiotherapy after complete wound healing. The learning point for all those in the emergency room is to have the cervix evaluated by a clinical examination in every woman with a surgical problem.

A similar case was reported by Shapey et al. [5]. An 84-year-old woman was diagnosed with peritonitis. She was suspected to have diverticulitis of the colon. But at laparotomy, there was perforation of the anterior wall of the uterus which was due to a large leiomyoma of the posterior wall that had undergone hyaline change.

In yet another case of a 46-year-old woman diagnosed with peritonitis, laparotomy revealed a necrosed perforated anterior wall which was confirmed to be due to endometrial carcinoma by histopathology [2].

Weng and colleagues [9] reported a 71-year-old woman with abdominal sepsis. Laparotomy revealed a rupture of the anterior wall of the uterus that was confirmed to be due to infarction of the myometrium. It was probably due to comorbid medical conditions that had caused atherosclerosis of uterine arterioles and ischaemia.

The following case I encountered was a very rare manifestation. A 42-year-old woman presented with severe pain in the lower abdomen. She was a known case of a fibroid uterus. She was asymptomatic. She had been following up. The fibroid was about 8 cm for the last 2 years. It was arising from the anterior wall. During the presentation with acute pain, there was tachycardia. Her blood pressure was normal. She was not anaemic. Abdomen revealed tender lower abdomen with guarding. There was an ill-defined mass in the hypogastrium. We initially thought there is degeneration of the myoma. She was admitted and managed with parenteral analgesics. However, her symptoms and signs did not settle. So the decision for surgery was taken. On opening the abdomen, there was minimal reactionary fluid in the abdomen with flimsy omentum adhesions to the uterus. The leiomyoma had perforated from the anterior wall of the uterus (Fig. 8.2). A total abdominal hysterectomy was carried out. There was no evidence of any malignancy.