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Spontaneous hemoperitoneum from a uterine leiomyoma in pregnancy

2005; Informa; Volume: 84; Issue: 12 Linguagem: Inglês

10.1080/j.0001-6349.2002.0070a.x

1600-0412

Lisa Wong, Tan Wei Ching, Tan Lay Kok, Tan Hak Koon,

Eosinophilic Disorders and Syndromes

Uterine leiomyomas are common tumors found in many women in the reproductive age group (1,2). Spontaneous hemoperitoneum is an extremely rare complication. The bleeding is usuallyvenous in origin and can be severe and life threatening enough to cause anemia and hypotension(3).The diagnosis is often not evident until at the time of laparotomy (4). We report a case of spontaneous hemoperitoneum resulting from a uterine leiomyoma in a woman presenting in early pregnancy. A 27-year-old Chinese primiparous woman booked for antenatal care at 8 weeks of gestation during which an ultrasound scan demonstrated a viable intrauterine gestation and a large anterior uterine fibroid measuring 12 cm in diameter. She was asymptomatic at the time of diagnosis. She presented to the Accident & Emergency Department 3 days later with sudden onset of acute epigastric pain associated with vomiting and diarrhea. On examination, her parameters were stable. Her blood pressure was 116/71 mmHg and pulse rate 82 per minute. Examination of the abdomen revealed tenderness in the epigastric region associated with rebound and guarding. A 20-week size pelvi-abdominal mass was palpable but it was not tender. Cervical excitation was negative and there was no adnexal tenderness. Abdominal sonogram confirmed an intrauterine gestational sac with a viable fetus corresponding to 8 weeks gestation and a 12-cm fundal fibroid. There was alarge amount of free peritoneal fluid in the upper abdomen suggestive of blood clots. The clinical diagnosis was that of a perforated viscus and the patient was admitted to the high-dependency surgical ward with a view for a laparotomy. Upon admission, her symptoms improved and the laparotomy was deferred. Investigations done included a full blood count, which showed a hemoglobin level of 9.6 g/l and hematocrit of 27.4%. A repeat blood test 12 h later showed a fall in the hemoglobin level to 7.9 g/l. She was transfused with three pints of packed cells but her hemoglobin level did not improve. She also developed A low grade fever and tachycardia the next day. In view of the persistent signs of blood loss from an unknown source, a decision was made for an exploratory laparotomy. Intra-operatively, the surgeons found 1 l of hemoperitoneum. The bleeding source was found to be from a venous sinus coursing over the surface of a 12-cm subserosal fibroid. The liver, spleen and intestines were examined and found to be normal. Hemostastic sutures were put around the vessels to arrest the bleeding. A myomectomy was not performed. Her postoperative recovery was uneventful. Subsequent sonograms confirmed a viable pregnancy. She was discharged well on the 7th postoperative day. Two weeks after the surgery, the patient returned for an early follow-up appointment in the gynecologic clinic. She had recovered wellfrom the procedure and ultrasound revealedaprogressing pregnancy. She was kept on close antenatal follow-up and subsequently had a forceps-assisted vaginal delivery for prolonged second stage oflabor. She eventually underwent a laparotomy myomectomy 6 months later and an 8-cm subserosal fundal fibroid was removed. The diagnosis of an ectopic pregnancy has to be excluded in every woman presenting in earlypregnancy with acute abdominal pain and a suspected hemoperitoneum. In our patient, an ultrasoundhad confirmed an intrauterine gestational sac. Other differential diagnoses such as aheterotrophic pregnancy must be considered though spontaneous heterotrophic pregnancy is extremely rare with anincidence of 1 in 30 000 (5). In pregnancy, hemodynamic changes occur to cause increased vascularity of the uterus. Uterine fibroids rarely complicate pregnancy or labor although studies have documented complications such as red degeneration, fetal malpresentation, labor dystocia if located over the lower segment of the uterus and postpartum hemorrhage (6). Uterine leiomyoma causing spontaneous hemoperitoneum is a very rare condition with less than 100 cases to date (3). The first case was reported by Karl von Rokitansky (7) in 1861 who wrote 'Large or multiple fibroids exert a pressure on … the uterus itself… and hence an enlargement of the blood vessel which may be further stretched and occasionally be torn. In this manner, it has been noted and a tear of a subserosal vein in a fibroid led to hemorrhage into the peritoneal cavity'. Deopuria et al. (8) identified a number of precipitating factors that can cause rupture of the superficial veins traversing the surface of the fibroid. These include venous congestion during pregnancy or menstruation, uterine manipulation, straining at stool or lifting heavy weights and violent coitus (8–11). It has also been reported that posterior wall fibroids are at higher risk, as trauma from direct contact with the sacral promontary can result in rupture and hemoperitoneum (4). The bleeding is usually venous in origin and can be severe enough to cause anemia, hypotension and shock (3). In pregnancy, Saidi et al. (11) described the dual effect of increased vascularity and venous congestion together with mechanical extrusion of the fibroid can aggravate the condition and the force of tension created on the surface of the fibroid can lead to a tear of thesuperficial veins. In most cases, as with our case, the bleeding occurred from torn enlarged veins coursing over the surface of subserosal fibroids. The correct diagnosis is seldom made until at the time of the laparotomy (9,11). Ultrasound and cat scans can reveal the presence of freefluid in the peritoneal cavity suggestiveofhemoperitoneum. The common preoperative diagnosis is often that of intra-abdominal bleeding of unknown source as was in our case. Other differential diagnoses include ruptured ectopic pregnancy, torsion of an ovarian cyst and other non-gynecological causes such as a perforated peptic ulcer or viscus. In his review of 53 cases, Buttery et al. (4)reported that the correct diagnosis was made preoperatively in only 4 of the 53 cases. He also reported thatdeath resulted in 3 out of the 53 cases reviewed. In all three cases, the hemoperitoneum was associated with pregnancy and no surgical treatment was attempted. Surgery is often deferred in pregnancy so as to avoidany unnecessary effects of anesthesia on thefetus. However, surgical treatment is often necessary in order to establish the cause of the bleeding and more importantly, to secure hemostasis. Delay in surgery can result in uncontrolled bleeding and death. Concerns about the possibility of re-bleeding as the pregnancy progresses must be borne inmind although there are no reports in the literature documenting this. Nonetheless, the woman needs to have continued surveillance for this possibility for the rest of the pregnancy and should be counselled for a myomectomy after delivery. Spontaneous hemoperitoneum from a uterine leiomyoma in pregnancy is extremely rare. This life-threatening condition should be kept in mind in women with fibroids presenting with an acute abdomen in early pregnancy and signs of blood loss.