Gowri Dorairajan1
(1)
Obstetrics and Gynecology, JIPMER, Puducherry, India
6.1 Rupture Following Open Resection of Myoma
Fibroid uterus is a known cause of infertility as well as recurrent preterm losses. Myomectomy in selected cases improves the pregnancy rates as well as outcomes. However, there is an increased risk of rupture in subsequent pregnancy at term or in labour, more so in cases where the cavity had been entered or where extensive myometrial tunnelling had been done. So these pregnancies are well-anticipated volcanoes. I can never forget this case I encountered about 18 years back. A third gravid woman was admitted to our hospital. She had previous two preterm deliveries; both the babies had died in the neonatal intensive care unit due to extreme prematurity. She was found to have a large fibroid for which she had undergone myomectomy, before conceiving the third time. The documentation was unequivocal. A large anterior wall intramural myoma had been removed. The uterine cavity had been opened. She was under close supervision from the beginning of this pregnancy. We admitted her at 28 weeks of pregnancy. We planned an elective caesarean section for her at 34 weeks of pregnancy (end of the same week of the fateful day). There were no antenatal complications. The foetus was growing well. All investigations were normal. Anaesthetists had been consulted, and blood availability had been ensured. Elective caesarean section was scheduled in 2 days time. On a fateful night, she complained of shoulder tip pain and epigastric pain. The blood pressure was normal. There was mild tachycardia. Before one could recognize and realize, the abdominal examination revealed foetal bradycardia. She was in the operation theatre within 10 min, but alas it had become a full-blown rupture. The foetus had been extruded into the abdominal cavity, and there was large rent in the upper segment. She lost not only the baby but also her uterus. She had an otherwise uneventful recovery. I still remember clearly the bed on which she had stayed all this while. It was indeed very agonizing. It makes me wonder why God is so cruel to a few. Why a few women come very close but never get to mother a child? It leaves me wondering about the mysterious, powerful universal force that operates and limits human endeavour.
Lenihan and colleagues [5] reported a case where shoulder tip pain was the only symptom alerting about a likely rupture in a patient who was under epidural analgesia during labour.
6.2 Rupture Following Previous Laparoscopic Myomectomy
Advances in science and technology with easy accessibility, affordability, and availability of artificial reproductive technology and minimally invasive surgery have proven to be a boon to a few helping them enjoy motherhood. However, at the same time, it has added to a whole new list of morbidity and mortality due to problems of abnormal placentation and higher age group-related medical problems. I would like to narrate the following case I recently encountered; another case as a testimony to the mystery of the powerful universal force. A 38-year-old woman had conceived with in vitro fertilization procedure. She had been infertile and undergone treatment for many years. She had been diagnosed with endometriosis and myoma uterus. Laparoscopic myomectomy of an anterior wall fibroid along with adhesiolysis was performed on her 2 years prior. She presented at 28 weeks of pregnancy with pain abdomen to our hospital. There was no bleeding from the vagina. She was not hypertensive. It was a singleton pregnancy. The resident duty team and the junior consultant had seen and managed the case. At admission the pulse was 110/min. Blood pressure was 120/70 mm of Hg. The patient was pale. Her BMI was 35. Morbid obesity obscured the abdominal findings. Contour was well made out, and foetal heart was difficult to localize clinically. Foetal heart activity was localized and confirmed to be normal on sonography. The uterus was not tense. We transfused two bottles of whole blood as she was severely anaemic. After 4 h suddenly the patient collapsed, with the low volume pulse of 120/min and blood pressure not recordable. She was severely pale. Abdominal examination revealed diffuse tenderness. Bedside ultrasound examination confirmed foetal demise and intrauterine death and free fluid in the peritoneal cavity. Even before the patient was wheeled in for laparotomy, she arrested and died. Such a drastic happening is an agony. On critically analysing the case, I realized there must have been concealed abruption to start with, which explains the pain and pallor but a live foetus at admission. The rising intrauterine tension must have resulted in rupture through the myometrium weakened due to laparoscopic myomectomy. The resulting rupture must have resulted in sudden brisk exsanguination in an already pale and compromised patient. It is very important to have a high index of suspicion of abruption in unexplained pain and pallor in the presence of a live foetus. A high index of suspicion is also needed for rupture in cases with laparoscopic myomectomy even though the documents may confirm that the cavity has not been opened. Whether this case started rupturing right at admission is contentious because the foetus was alive. Usually, rupture occurs near term or in labour in a woman who have had a myomectomy. Rupture can get initiated earlier even before she is in labour if the intrauterine tension is high. Multiple pregnancies, polyhydramnios, and concealed haemorrhage as possibly, in this case, can increase the intrauterine tension. The increased intrauterine pressure can result in rupture of the uterus at the site of weakened myomectomy scar.
6.3 Literature Review of Rupture After Myomectomy and Discussion
Many authors have reported a rupture in the third trimester after laparoscopic myomectomy [3, 9, 11]. Matsunaga et al. [6] reported a woman at 28 weeks of pregnancy with a defect of previous myomectomy scar. The defect was sutured and the pregnancy was continued. Elective caesarean section was carried out at 34 weeks.
Sutton and co-authors [10] reported a 44-year-old woman with previous fundal myomectomy who presented with acute pain abdomen. The diagnosis was established 12 h after admission when an emergency classical caesarean was done to deliver a live foetus. Dim and co-authors [2] reported yet another interesting case where a large fundal rupture of the uterus was diagnosed in a primigravida. She had undergone adenomyomectomy 11 months prior. The rupture was diagnosed 12 h after delivery.
Bernardi et al. [1] studied the outcome of laparoscopic myomectomies and reported a uterine rupture rate of 10 %. In the study by Tian and colleagues [12], the finding of scar defect was higher after laparoscopic myomectomy compared to transabdominal myomectomy where none of the cases had a defect. The authors have therefore recommended limited use of electrocautery during laparoscopic myomectomy. Pistofidis and colleagues [8] analysed the seven cases of uterine ruptures after laparoscopic myomectomies reported to the Board of Endoscopic Gynaecological Surgery over a 13-year period. They observed that haemostasis was achieved by bipolar diathermy alone in nearly 30 % of the cases. 86 % of cases were likely to have been exposed to over diathermy. Two-layered closure of the bed with sutures had been performed in only 14 % of cases. The interval between myomectomy and pregnancy was about 1.4 years. Uterine rupture was mostly seen after 34 weeks and during labour in about 14 % cases.
In a review of 19 cases of rupture of the uterus after laparoscopic myomectomy, Parker and colleagues [7] found that 17 cases had use of cautery during myomectomy. The authors recommended limited use of cautery and layered closure with suture during laparoscopic myomectomy. In the case reported by Kislei and colleagues [4], the woman experienced acute pain in the abdomen and went on to develop foetal distress as early as 23 weeks of pregnancy. She had undergone laparoscopic myomectomy a year earlier.
Thus, a high index of suspicion of ruptured uterus in subsequent pregnancies is needed in a woman who has undergone a myoma removal procedure. It is important to be vigilant for symptoms of pain including shoulder tip pain as a warning symptom. Prompt laparotomy when rupture is suspected would reduce the maternal morbidity and perinatal mortality.
References
1.
Bernardi TS, Radosa MP, Weisheit A, Diebolder H, Schneider U, Schleussner E, Runnebaum IB. Laparoscopic myomectomy: a 6-year follow-up single-center cohort analysis of fertility and obstetric outcome measures. Arch Gynecol Obstet. 2014;290(1):87–91. doi:10.1007/s00404-014-3155-2. Epub 2014 Feb 7.CrossRefPubMed
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Dim CC, Agu PU, Dim NR, Ikeme AC. Adenomyosis and uterine rupture during labour in a primigravida: an unusual obstetric emergency in Nigeria. Trop Doct. 2009;39(4):250–1. doi:10.1258/td.2009.080359.CrossRefPubMed
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Djaković I, Rudman SS, Kosec V. Uterine rupture following myomectomy in the third trimester. Acta Clin Croat. 2015;54(4):521–4.PubMed
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Kiseli M, Artas H, Armagan F, Dogan Z. Spontaneous rupture of the uterus in mid-trimester pregnancy due to increased uterine pressure with previous laparoscopic myomectomy. Int J Fertil Steril. 2013;7(3):239–42. Epub 2013 Sep 18.PubMedPubMedCentral
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Lenihan M, Krawczyk A, Canavan C. Shoulder-tip pain as an indicator of uterine rupture with a functioning epidural. Int J Obstet Anesth. 2012;21(2):200–1. doi:10.1016/j.ijoa.2012.01.004. Epub 2012 Mar 6.CrossRefPubMed
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Matsunaga J, Daly CB, Bochner CJ, Agnew CL. Repair of uterine dehiscence with the continuation of pregnancy. Obstet Gynecol. 2004;104(5 Pt 2):1211–2.CrossRefPubMed
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Parker WH, Einarsson J, Istre O, Dubuisson JB. Risk factors for uterine rupture after laparoscopic myomectomy. J Minim Invasive Gynecol. 2010;17(5):551–4. doi:10.1016/j.jmig.2010.04.015. Epub 2010 Jun 29.CrossRefPubMed
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Pistofidis G, Makrakis E, Balinakos P, Dimitriou E, Bardis N, Anaf V. Report of 7 uterine rupture cases after laparoscopic myomectomy: update of the literature. J Minim Invasive Gynecol. 2012;19(6):762–7. doi:10.1016/j.jmig.2012.07.003.CrossRefPubMed
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Song SY, Yoo HJ, Kang BH, Ko YB, Lee KH, Lee M. Two pregnancy cases of uterine scar dehiscence after laparoscopic myomectomy. Obstet Gynecol Sci. 2015;58(6):518–21. Published online 2015 Nov 16. doi: 10.5468/ogs.2015.58.6.518.
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Sutton C, Standen P, Acton J, Griffin C. Spontaneous uterine rupture in a preterm pregnancy following myomectomy. Case Rep Obstet Gynecol. 2016;2016:6195621. doi:10.1155/2016/6195621. Epub 2016 Jan 26.PubMedPubMedCentral
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Tauchi M, Hasegawa J, Oba T, Arakaki T, Takita H, Nakamura M, Sekizawa A. A case of uterine rupture diagnosed based on routine focused assessment with sonography for obstetrics. J Med Ultrason (2001). 2016;43(1):129–31. doi:10.1007/s10396-015-0662-0. Epub 2015 Sep 3.CrossRef
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Tian YC, Long TF, Dai YM. Pregnancy outcomes following different surgical approaches of myomectomy. Obstet Gynaecol Res. 2015;41(3):350–7. doi:10.1111/jog.12532. Epub 2014 Sep 26.CrossRef