Uterine rupture can lead to a catastrophic complication to both mother and fetus. It primary contribution factor is a previous caesarean section, and it is challenging to diagnose especially in early gestational age.  33 years old, currently in her fourth pregnancy at 15 weeks of gestation with a history of one previous scar three years ago presented to our emergency department with generalized abdominal pain and dysuria. The initial impression was an acute abdomen to rule out surgical cause in early pregnancy as there was no evidence of ovarian cyst and free fluid. Surgical input obtained as acute appendicitis was one of the closest differentials. As she was fast deteriorating, a laparotomy was decided by the surgeon and noted massive hemoperitoneum with evidence of rupture uterus. The obstetrician called in and proceeds with subtotal hysterectomy as conservative measure failed due to uncontrolled bleeding. Abdominal packing was done, and relaparotomy was performed later for packed removal noted no active bleeding at the surgical site. Post-operative recovery was uneventful despite required 14 pints of pack cells transfusion and three cycles of DIVC regime. Pathological analyses of the specimen confirmed as placenta accrete. Though uterine rupture is rare in early gestation, it may consider in a patient with a scarred uterus; even there was no free fluid as initially, it is nonspecific, which makes diagnosis difficult. Delay in definitive management may cause significant maternal morbidity. The inconsistent findings will delay us to prompting definitive treatment of uterine rupture to make it a challenging scenario.

Keywords: Acute abdomen, uterine rupture, hemoperitoneum, placenta accreta