APGAR: Appearance, Pulse, Grimace, Activity and Respiration; HCT: Hematocrit; HBSAg: Hepatitis B Surface Antigen; HIV: Human Immunodeficiency Virus; VDRL: Venereal Disease Laboratory

Uterine rupture is tearing of the uterine wall partially or completely during pregnancy or delivery. It can be complete or incomplete rupture [1]. Rupture of the uterus can follow oxytocin stimulation, uterine scar, obstructed labor, and rarely blunt abdominal trauma [2]. Trauma in pregnancy remains one of the major contributors to maternal and fetal morbidity and mortality. It can be complicated by maternal injury causing intra-abdominal bleeding, uterine rupture, shock and death, direct fetal and/or placental injury [2,3].

A 35-year-old Gravida-V Para-IV (all alive) patient presented to Asella Teaching and Referral Hospital after sustaining an ox horn injury to her abdomen four hours previously whilst feeding her cows. She was unclear on the date of her Last Normal Menstrual Period (LNMP) but reported being amenorrheic for the last nine months. The patient reported falling to the ground immediately following the injury and noticed bleeding from the site. She later noticed dark-green fluid coming through the injury site. She had abdominal pain but no pushing down pain and no vaginal bleeding. The patient noticed a decline in fetal kicks. Antenatal Care (ANC) was provided at her local health center and she was given a tetanus toxoid vaccine.

On examination, she appeared unwell with BP=100/70 mmHg, PR=90 beats per minute, RR=26 breaths per minute, and T=35.8 degree Celsius. Her abdomen was distended, there was a 4 × 3 cm penetrating wound to the right lower quadrant through which blood mixed with meconium was passing. Fetal feet were palpable through the site of injury. The abdomen was tender all over and there were no uterine contractions. Uterine fundal height was sized at 36 weeks and the fetus was in a longitudinal lie with cephalic presentation. Fetal heartbeat was recorded at 146 beats per minute. On pelvic examination, the cervix was closed and there was no blood on the examining finger.

She was admitted to the hospital with the impression of thirdtrimester pregnancy+penetrating abdominal and uterine trauma secondary to ox horn injury.

Her laboratory investigation showed Blood group=O+, hematocrit=33.9%, HBSAg=Negative, and non-reactive VDRL and HIV test. Abdominal and Obstetric ultrasound showed Singleton alive intrauterine pregnancy with an aggregate gestational age of 36 weeks, longitudinal lie, cephalic presentation, fundal and posterior placenta, no evidence of abruption, no gross fetal congenital anomaly, and there was free peritoneal fluid in the right paracolic gutter area.

The patient was admitted to the labor ward and put on intravenous fluids, given a 1^st dose of 1 g Ceftriaxone and 500 mg metronidazole intravenously, and prepared for laparotomy after consent was taken. Under general anesthesia, the abdomen was cleaned, draped and entered through the midline incision. The Findings were alive fetus whose extremities partly protruded through about 6 cm fundal transverse anterior fresh uterine rupture with no major vessel involvement and there was about 500 ml Meconium mixed blood in the peritoneal cavity.

The uterine defect was extended to ‘T’ Shape type to effect delivery of female neonate weighing 2800 gms with an APGAR score of 6 and 9 in the 1^st and 5^th minutes respectively. Intact posterior and fundally implanted placenta was extracted by cord traction after oxytocin 10 IU was given intramuscularly. Then uterine mopped and defect closed in two layers. Bilateral tubal ligation was done using Modified Pomeroy’s technique. A general surgeon was involved in exploring the peritoneal cavity for possible other injury and no other injury were found. Then peritoneal lavage was done before abdomen was closed in layers. Edge of the horn injury site on fascia and skin was trimmed and closed separately.

The patient was in smooth post-operative condition for seven days in our Hospital and discharged with post-operative HCT of 33.8%. She was appointed to follow up care.

At follow up visit after 2 weeks, the mother and her neonate were found to be in good health.

Trauma affects 6% to 7% of pregnancies in the United States and is the leading cause of non-obstetric maternal death [4-6]. Motorcycle accident and physical assault are the leading causes of trauma during pregnancy in developed and developing nations respectively [7,8].

Penetrating injury causing uterine rupture is one of the rarest events in obstetrics worldwide and these few cases were mostly from gunshot injuries and, to a lesser degree, stab wounds [1,2]. There was no reported case of uterine rupture from ox horn injury. This is the 1^st case, yet reported, with penetrating abdominal and uterine injury from ox horn injury.

Obstetric trauma carries numerous complications including maternal injury leading to hemorrhagic shock and death, direct or indirect fetal injury causing intrauterine fetal demise, abruptio placentae, and uterine rupture. Hence, a timely and efficient evaluation is critical to ensure the well-being of the mother and fetus [1-3,5].

Traumatic uterine rupture is usually associated with poor fetal outcome [1,2]. Intrauterine fetal death has been reported in up to 60% of cases of penetrating abdominal trauma [2]. Interestingly, in this particular case, we managed to a delivery alive neonate with a good condition which might be due to the fact that there was no direct injury to the placenta, cord, and fetus.

On the other hand, the maternal outcome in these cases is generally more favorable with mortality during pregnancy being less than that witnessed in no pregnant victims [5]. Because of timely intervention, the absence of injury to other vital organs and uterine arteries, the maternal outcome was also good in our case.

In conclusion, penetrating trauma to the gravid uterus is a lifethreatening condition for both the mother and developing a fetus. The outcome may vary with whether the placenta is injured and/or other organs are also involved.

Penetrating trauma to the gravid uterus is life-threatening condition for both the mother and developing fetus but early intervention can prevent complications.

Written informed consent was obtained from the patient to publish this case report and any accompanying images. A copy of the written consent is available for review by the editor-in-chief of this journal.

There are no competing interests.

No funding sources.

Both TT and BE was involved in each step of manuscript preparation and checkup.

The authors thank Asella teaching and referral Hospital for allowing them to publish this case report.