Massive hemoperitoneum resulting from spontaneous rupture of uterine leiomyoma

Pelvic Pain in Reproductive Age: US Findings

Pelvic pain in reproductive age often represents a diagnostic challenge due to the variety of potential causes characterized by overlapping clinical symptoms, including gynecological and other disorders (e.g., entero-colic or urological). It is also necessary to determine if there is a possibility of pregnancy to rule out any related complications, such as ectopic pregnancy. Although ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI) are strongly integrated, the choice of which is the ideal diagnostic tool should be guided both by clinical suspicion (gynecological vs. non-gynecological cause) and by the risk ratio–benefit (ionizing radiation and instrumental costs), too. The didactic objective proposed by this review consists in the diagnosis of the cause and differential of pelvic pain in reproductive age by describing and critically analyzing the US diagnostic clues of the most frequent adnexal, uterine, and vascular causes.

A rare case of acute abdomen: spontaneous rupture of degenerated fibroid

A 29-year-old nulliparous woman presented with an acute abdomen. She had a large uterus with multiple fibroids and was on the waiting list for elective surgery. An urgent CT scan demonstrated an extensive intraperitoneal fluid collection suspicious for fibroid rupture. She required an emergency laparotomy which identified a rupture of the largest degenerative fibroid. There was 2 Litres of pus in the peritoneal cavity. This case was a rare presentation of spontaneous fibroid rupture due to degeneration and necrosis, and acute abdomen from peritoneal irritation. Imaging was vital in making the diagnosis, and urgent surgical intervention was essential to reduce morbidity and mortality.

Use of point-of-care ultrasound to diagnose spontaneous rupture of fibroid in pregnancy

Background: Complications of fibroids in pregnancy are well known, including postpartum hemorrhage, labor dystocia, and cesarean delivery. Outside of pregnancy and labor, the rare occurrence of spontaneous fibroid rupture has been documented. Case: The current case report involves a woman who presented with acute abdominal pain in the third trimester of pregnancy and was found to have spontaneous rupture of a fibroid before the onset of labor. Her initial presentation, diagnosis through use of point-of-care ultrasound, acute surgical management, and postoperative course are described. Conclusion: When assessing acute abdominal pain in a pregnant patient, fibroid rupture should be considered despite the absence of prior uterine surgery. Bedside point-of-care ultrasonography is a useful tool for assessment of abdominal pain in the third trimester of pregnancy.

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.

Intra-leiomyoma hemorrhage in postmenopausal woman presented with acute abdominal pain

Intra-leiomyoma hemorrhage in postmenopausal woman is a very rare complication. This case report represents a case report of spontaneous hemorrhage inside the uterine leiomyoma in postmenopausal woman who presented with acute abdomen. A 55-year-old woman, multipara, postmenopausal for 7 years, known case of multiple fibroid uteruses, was presented to the emergency department of Ahmadi Hospital, Kuwait Oil Company, with acute abdominal pain and vomiting, without any reported trauma and/or associated vaginal bleeding. The studied woman was generally stable regarding her vital signs, her hemoglobin dropped from 12 to 10.2 g/dl. Abdominal examination revealed; palpable pelvi-abdominal mass firms in consistency with tenderness and guarding which provisionally support the diagnosis of degenerated fibroids or intra-leiomyoma hemorrhage. The diagnosis was confirmed by basic pelvi-abdominal ultrasound, followed by correction of the patient's general condition and total abdominal hysterectomy with bilateral salpingo-oophrectomy (TAHBSO). Bisected largest cystic fibroid showed brownish serous fluid inside with organized clotted hematoma which confirmed the diagnosis of intra-leiomyoma hemorrhage. Postoperatively, the studied woman received an unit of packed red blood cells for correction of the postoperative anemia and discharged from the hospital in good general condition for postoperative follow-up in the outpatients’ department on iron tablets. This case report represents a rare complication of intra-leiomyoma hemorrhage in postmenopausal, diagnosed by the basic clinical and ultrasound findings. The case was managed by TAHBSO after correction of the general condition because of the increased risk of the sarcomatous changes of the uterine fibroid in postmenopausal women.

Point-of-care Ultrasonography of a Rare Cause of Hemoperitoneum

A young woman presented to the emergency department with lethargy, hemodynamic instability, and diffuse abdominal tenderness. On point-of-care ultrasound (PoCUS), she was found to have intraperitoneal free fluid and a large pelvic mass, which were discovered intraoperatively to be hemoperitoneum due to ruptured vessels of a uterine leiomyoma. Although rare, a life-threatening, ruptured leiomyoma may be treated surgically if recognized in an expedient fashion. A PoCUS can aid the emergency clinician in prompt diagnosis.

Spontaneous subserosal venous rupture overlying a uterine leiomyoma in a young woman

Uterine leiomyomas are very common tumors found in women. Rupture of veins on the surface of uterine leiomyoma is an unusual source of hemoperitoneum. It is an extremely uncommon gynaecological cause of hemoperitoneum. It is a life threatening emergency. We report a case of massive intraperitoneal hemorrhage due to rupture of vessels on the surface of subserous leiomyoma. A differential diagnosis of rupture of leiomyoma’ssurface vessel should be considered, while dealing with a case of hemoperitoneum with pelvic mass.

Hypovolemic Shock and Hemoperitoneum from Spontaneous Avulsion of a Large Pedunculated Uterine Leiomyoma

Hemoperitoneum with hypovolemic shock from avulsion of a pedunculated leiomyoma is a rare but highly fatal condition that can occur spontaneously or as a result of trauma. We report a case of hemoperitoneum and hypovolemic shock secondary to a bleeding leiomyoma detected via computed tomography (CT) scan in a 39 year old premenopausal, gravida 0 female that presented with abdominal pain and became hemodynamically unstable in the emergency department. A preoperative bimanual exam revealed a mass consistent with a 20 week gestational uterus. Following fluid resuscitation, the patient underwent emergent myomectomy and ligation of the right uterine artery and was discharged home in good condition.

Uterine leiomyoma mimicking a gastrointestinal stromal tumor with chronic spontaneous hemorrhage: A case report

Uterine leiomyomas are the most common tumors to affect women. Cases of uterine leiomyoma mimicking a gastrointestinal stromal tumor with chronic spontaneous hemorrhage are extremely rare, and similar cases to that of the present study are yet to be reported. In the current study, a 48-year-old female presented with symptoms of lower abdominal pain after menses that had persisted for 4 months. The patient was initially diagnosed with uterine leiomyoma. However, according to the results of the gross and auxiliary examinations, a diagnosis of a gastrointestinal stromal tumor could not be excluded. Therefore, the patient underwent a rectal sigmoid bowel resection, subtotal hysterectomy and bilateral salpingectomy. Subsequent to surgery, the immunohistochemical examinations confirmed the initial diagnosis of uterine leiomyoma. The surgery had therefore involved an unnecessary organ resection.

Post-operative hemorrhage after myomectomy: safety and efficacy of transcatheter uterine artery embolization

Objective

To evaluate the safety and clinical efficacy of transcatheter uterine artery embolization (UAE) for post-myomectomy hemorrhage.

Materials and Methods

We identified eight female patients (age ranged from 29 to 51 years and with a median age of 37) in two regional hospitals who suffered from post-myomectomy hemorrhage requiring UAE during the time period from 2004 to 2012. A retrospective review of the patients' clinical data, uterine artery angiographic findings, embolization details, and clinical outcomes was conducted.

Results

The pelvic angiography findings were as follows: hypervascular staining without bleeding focus (n = 5); active contrast extravasation from the uterine artery (n = 2); and pseudoaneurysm in the uterus (n = 1). Gelatin sponge particle was used in bilateral uterine arteries of all eight patients, acting as an empirical or therapeutic embolization agent for the various angiographic findings. N-butyl-2-cyanoacrylate was administered to the target bleeding uterine arteries in the two patients with active contrast extravasation. Technical and clinical success were achieved in all patients (100%) with bleeding cessation and no further related surgical intervention or embolization procedure was required for hemorrhage control. Uterine artery dissection occurred in one patient as a minor complication. Normal menstrual cycles were restored in all patients.

Conclusion

Uterine artery embolization is a safe, minimally invasive, and effective management option for controlling post-myomectomy hemorrhage without the need for hysterectomy.

Uterine leiomyoma with spontaneous intraleiomyoma hemorrhage, perforation, and hemoperitoneum in postmenopausal woman: Computed tomography diagnosis

Spontaneous intraleiomyoma hemorrhage, perforation, and hemoperitoneum are very rare complications of uterine leiomyoma. We report a case of postmenopausal woman who presented with acute abdomen found to have intraleiomyoma hemorrhage, perforation, and hemoperitoneum. Our case also illustrates the computed tomography findings of such complications of uterine leiomyoma.

Severe life-threatening hemoperitoneum from posttraumatic avulsion of a pedunculated uterine leiomyoma

Uterine leiomyomas are common tumors in women, and most of their complications are well known. Rupture of a uterine leiomyoma is an unusual source of severe hemoperitoneum. The cause seems to be spontaneous rupture of a leiomyoma vessel or is secondary to abdominal trauma. Herein, we describe the case of a 46-year-old woman who had a history of uterine myomas and came to the emergency department with acute abdominal pain after she fell while jogging. The patient's hemodynamic parameters were stable. An ultrasound examination and computed tomography scan showed multiple uterine myomas and free fluid in the peritoneum without signs of splenic rupture. Laparoscopy was performed, which revealed active bleeding from the base of a pedunculated myoma. The patient required transfusion of 2 units of packed red blood cells, and a subtotal hysterectomy via laparotomy was performed, with an uneventful postoperative course. Because surgical management is needed in an emergency, physicians should be aware of this rare but severe complication in patients with known uterine myomas.