Spontaneous Hemoperitoneum from Rupture of Massive Leiomyoma

Hypovolaemic shock due to intra-abdominal haemorrhage from multiple uterine fibroids

Intra-abdominal bleeding due to uterine fibroids is extremely rare, and preoperative diagnosis is difficult. Herein, we report a case of preoperatively diagnosed hypovolaemic shock due to intra-abdominal haemorrhage, in which fatal sequelae were prevented. A 46-year-old non-pregnant woman was brought to the hospital with a sudden-onset lower abdominal pain. On admission, she was in shock, and abdominal CT showed severe intra-abdominal haemorrhage. Since bleeding from uterine fibroids was suspected, an emergency simple total hysterectomy was performed, and her condition became stable after the operation. Intra-abdominal haemorrhage with hypovolaemic shock requires prompt surgical intervention. Although it occurs very rarely due to bleeding from uterine fibroids, imaging shows large fibroids; if the patient is not pregnant, bleeding from the fibroids should be considered.

Spontaneous Rupture of Leiomyoma Diagnosed Preoperatively with Noncontrast Computed Tomography

Background

Spontaneous rupture of benign uterine fibroids is extremely rare and has been associated with fibroid degeneration. It can cause acute intraperitoneal bleeding requiring immediate surgical intervention.

Case

A previously healthy 50-year-old, Caucasian, nullipara presented with syncope, hemodynamic instability, and an acute abdomen. Noncontrast computed tomography images showed a positive sentinel clot sign in the pelvis as well as a large uterine fibroid with internal hyperdense clot suggesting acute rupture. Urgent laparotomy and hysterectomy confirmed a ruptured, actively bleeding, uterine fibroid with final pathological diagnosis of a benign leiomyoma.

Conclusion

Prompt diagnosis and emergency surgical intervention were necessary to control acute hemorrhage from a ruptured uterine fibroid. Noncontrast computed tomography is an important adjunct to contrast-enhanced computed tomography and was vital for diagnosis in this case.

Life-threatening hemoperitoneum secondary to rupture of a uterine leiomyoma: A case report and review of the literature

INTRODUCTION

While uterine leiomyomas are the most common pelvic tumors in females, resultant hemoperitoneum is an extremely rare and acute complication which requires emergent intervention and resuscitation. To date, less than one-hundred cases have been reported in the literature.

PRESENTATION OF CASE

We report a case of massive hemoperitoneum due to spontaneous rupture of a 20 cm pedunculated leiomyoma in a 74-year-old female who presented as a trauma alert. Rapidly declining hemodynamic status with an ultrasound consistent with extensive hemoperitoneum led to activation of the massive transfusion protocol and an emergent laparotomy. In the operating theater the laparotomy revealed 4 L of blood. She underwent a myomectomy and subsequently, an angiogram and embolization of a bleeding uterine artery. In all, she required transfusion of 26 units of blood. Post operatively she was discharged home on hospital day 13.

DISCUSSION

Near fatal hemoperitoneum secondary to a uterine leiomyoma may be due to traumatic or spontaneous rupture of an overlying vein or artery. Leiomyomas greater than 10 cm in size have an increased risk of rupturing. A significant amount of blood can accumulate in the peritoneum resulting in hypovolemic shock.

CONCLUSION

Acute complications of uterine leiomyomas requiring surgical intervention are exceptionally rare. Candidates for the massive transfusion protocol must be appropriately and timely identified. Additionally, because surgery is a potential treatment for hemorrhage control in leiomyoma-related hemoperitoneum, surgeons should be aware of such complications.