Gowri Dorairajan1
(1)
Obstetrics and Gynecology, JIPMER, Puducherry, India
Perforations after surgical abortions or curettage are complications that most of the gynaecologists would have come across and managed. Fortunately, the perforations following illegal abortions with injuries to internal organs and frank peritonitis are on the decrease with the advent of medical methods of abortion.
As a special mention, I would like to bring out two rare presentations of rupture uterus.
I got a call from the emergency operation theatre by the registrar of surgery. They had opened up the abdomen of a 50-year-old postmenopausal lady admitted with a diagnosis of peritonitis. One litre of pus had been drained. They found a rent in the anterior wall of the uterus. All other organs were normal. The patient was under general anaesthesia in the supine position. There was no way to gather any more information. There was a 2 cm ragged rent in the anterior wall (Fig. 8.1). There was no obvious growth protruding from the rent. I decided to proceed with hysterectomy. When I was clamping to reach the cardinal ligaments, I realized that it is an advanced cancer cervix with induration of the cardinal ligament. Fortunately vesicovaginal plane was free. I could accomplish total hysterectomy and kept my fingers crossed that there should be no reactionary haemorrhage or infection. The cervix had an indurated growth. Fortunately, she had an uneventful recovery. The histopathology confirmed squamous cell carcinoma of the cervix. She received postoperative radiotherapy after complete wound healing. The learning point for all those in the emergency room is to have the cervix evaluated by a clinical examination in every woman with a surgical problem.
Fig. 8.1
The hysterectomy specimen of the woman with peritonitis showing perforated uterus due to pyometra that occurred due to underlying cancer of the uterine cervix
A similar case was reported by Shapey et al. [5]. An 84-year-old woman was diagnosed with peritonitis. She was suspected to have diverticulitis of the colon. But at laparotomy, there was perforation of the anterior wall of the uterus which was due to a large leiomyoma of the posterior wall that had undergone hyaline change.
In yet another case of a 46-year-old woman diagnosed with peritonitis, laparotomy revealed a necrosed perforated anterior wall which was confirmed to be due to endometrial carcinoma by histopathology [2].
Weng and colleagues [9] reported a 71-year-old woman with abdominal sepsis. Laparotomy revealed a rupture of the anterior wall of the uterus that was confirmed to be due to infarction of the myometrium. It was probably due to comorbid medical conditions that had caused atherosclerosis of uterine arterioles and ischaemia.
The following case I encountered was a very rare manifestation. A 42-year-old woman presented with severe pain in the lower abdomen. She was a known case of a fibroid uterus. She was asymptomatic. She had been following up. The fibroid was about 8 cm for the last 2 years. It was arising from the anterior wall. During the presentation with acute pain, there was tachycardia. Her blood pressure was normal. She was not anaemic. Abdomen revealed tender lower abdomen with guarding. There was an ill-defined mass in the hypogastrium. We initially thought there is degeneration of the myoma. She was admitted and managed with parenteral analgesics. However, her symptoms and signs did not settle. So the decision for surgery was taken. On opening the abdomen, there was minimal reactionary fluid in the abdomen with flimsy omentum adhesions to the uterus. The leiomyoma had perforated from the anterior wall of the uterus (Fig. 8.2). A total abdominal hysterectomy was carried out. There was no evidence of any malignancy.
Fig. 8.2
(a) Intraoperative photograph showing the perforating leiomyoma. (b) The hysterectomy specimen showing the perforated leiomyoma
Peng et al. [3] reported a nulliparous 39-year-old woman with acute internal bleeding and uterine masses. Laparotomy confirmed a rupture at the posterior cervical-uterine junction. The uterus was extremely enlarged with several leiomyoma and adenomyosis of the posterior wall. There was no history of prior surgeries or curettage. Ramskill and co-authors [4] reported a uterine rupture secondary to a fibroid in a 33-year-old woman in labour. She had no previous surgeries or abortion.
Spontaneous rupture of a degenerated fibroid was reported by Tan and Naidu [8] in a 31-year-old woman after 9 weeks of delivery. She had presented with severe pain abdomen. Imaging confirmed a posterior wall fibroid with a lot of free fluid. Exploratory laparotomy confirmed the rupture and bleeding from it. Myomectomy and suturing were successfully performed.
Bastu et al. [1] reported a 48-year-old nulliparous woman with acute pain abdomen. At laparotomy, she had 2 litres of haemoperitoneum and a large fibroid (smooth muscle tumour of unknown malignant potential) which had undergone cystic degeneration and had ruptured. Takai and colleagues reported a similar case [7].
Shashoua and colleagues have reported rupture of the uterus due to ischaemia three months after uterine artery embolization. The women required a hysterectomy [6].
Thus, rupture uterus could happen outside the setting of pregnancy or labour. It invariably presents with features of acute abdomen though there may not be associated hypovolemia due to haemorrhage.
References
1.
Bastu E, Akhan SE, Ozsurmeli M, Galandarov R, Sozen H, Gungor-Ugurlucan F, Iyibozkurt AC. Acute hemorrhage related to spontaneous rupture of a uterine fibroid: a rare case report. Eur J Gynaecol Oncol. 2013;34(3):271–2.PubMed
2.
Kurashina R, Shimada H, Matsushima T, Doi D, Asakura H, Takeshita T. Spontaneous uterine perforation due to clostridial gas gangrene associated with endometrial carcinoma. Nippon Med Sch. 2010;77(3):166–9.CrossRef
3.
Peng CR, Chen CP, Wang KG, Wang LK, Chen YY, Chen CY. Spontaneous rupture and massive hemoperitoneum from uterine leiomyomas and adenomyosis in a nongravid and unscarred uterus. Taiwan J Obstet Gynecol. 2015;54(2):198–200. doi:10.1016/j.tjog.2014.03.004.CrossRefPubMed
4.
Ramskill N, Hameed A, Beebeejaun Y. Spontaneous rupture of uterine leiomyoma during labour. BMJ Case Rep. 2014;2014:pii: bcr2014204364. doi:10.1136/bcr-2014-204364.CrossRef
5.
Shapey IM, Nasser T, Dickens P, Haldar M, Solkar MH. Spontaneously perforated pyometra: an unusual cause of acute abdomen and pneumoperitoneum. Ann R Coll Surg Engl. 2012;94(8):e246–8. doi:10.1308/003588412X13373405387410.CrossRefPubMedPubMedCentral
6.
Shashoua AR, Stringer NH, Pearlman JB, Behmaram B, Stringer EA. Ischemic uterine rupture and hysterectomy 3 months after uterine artery embolization. J Am Assoc Gynecol Laparosc. 2002;9(2):217–20.CrossRefPubMed
7.
Takai H, Tani H, Matsushita H. Rupture of a degenerated uterine fibroid as a cause of acute abdomen: a case report. J Reprod Med. 2013;58(1–2):72–4.PubMed
8.
Tan YL, Naidu A. Rare postpartum ruptured degenerated fibroid: a case report. J Obstet Gynaecol Res. 2014;40(5):1423–5. doi:10.1111/jog.12334. Epub 2014 Apr 2.CrossRefPubMed
9.
Weng LC, Menon T, Hool G. Spontaneous rupture of the non-gravid uterus. BMJ Case Rep. 2013;2013:pii: bcr2013008895. doi:10.1136/bcr-2013-008895.