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Images in Women's Health

September 2003

Tyler Muffly, BA; Jay Goldberg, MD; Barry Goldberg, MD

Case

A 39-year-old gravida 2 para 0010 at 16 weeks of gestation presented to the office complaining of severe left lower abdominal pain, which was acute in onset. She had undergone a laparoscopic myomectomy 2 years previously to remove a 9-cm anterior and a 5-cm posterior leiomyoma. An ultrasound 1 week prior to presentation visualized three anterior leiomyomata measuring 3.1 x 2.3 x 2.2 cm, 2.6 x 2.2 x 2.2 cm, and 1.8 x 1.4 x 2.0 cm (Figure 1). On examination, the pain was localized to the anterior uterus. Rebound tenderness and guarding were noted, but the bowel sounds were active and normal. She was afebrile without any other abnormal clinical findings. Her white blood cell count and the differential were normal.

Ultrasound with color Doppler showed an area anteriorly in the uterine fundus appearing to be a fluid-filled cavity in the uterine wall, possibly representing a uterine rupture and central cystic changes in one of the leiomyomata (Figure 2). Given the sonographic change in appearance from the previous week, her prior surgical myomectomy, and her clinical presentation, the authors thought uterine rupture to be the most likely diagnosis.

With her symptoms worsening, she was immediately taken to the operating room for a diagnostic laparoscopy. On initial visualization, there appeared to be an area of uterine rupture with membranes protruding through the myometrium (Figure 3). This finding was verified by several physicians. After converting to laparotomy, what had appeared to be the area of rupture was actually a large subserosal fluid collection, which spontaneously ruptured. The myometrium was intact. The authors then determined that the fluid collection was most likely transudate caused by inflammation from underlying leiomyoma degeneration and necrosis. The authors noted no other abnormal findings.

Three days later, after initially improving clinically, her lower abdominal pain worsened. A computed tomography scan of the abdomen and pelvis had no findings to explain her symptoms. The next day, she was noted to have premature rupture of membranes, with prolapse of the umbilical cord. A dilation and evacuation was performed uneventfully. Following the dilation and evacuation, her condition quickly improved. She was discharged home 2 days later.

Discussion

Standard management of leiomyoma degeneration in pregnancy is primarily supportive, including analgesics, ice to the abdomen, and bed rest. As it is normally a self-limiting process, further intervention is usually unnecessary. The diagnosis of leiomyoma degeneration is often one of exclusion, with the differential diagnosis including chorioamnionitis, ovarian torsion, appendicitis, preterm labor, abruption, and uterine rupture.

The combination of a prior laparoscopic myomectomy, localized pain acute in onset at the site of a uterine scar, the sonographic findings, and an acute abdomen, made uterine rupture initially a likely diagnosis in this patient. Although rare, uterine rupture during the second trimester has been reported following laparoscopic myomectomy.¹ As seen in Figure 3, laparoscopic visualization of the subserosal fluid collection overlying the area of fibroid degeneration fooled several physicians, appearing to be an area of complete uterine dehiscence with protruding membranes.

Physiologically, the inflammation from the necrosing leiomyoma most likely led to the accumulation of the overlying subserosal fluid collection. As no fluid collection was sonographically seen 1 week before, the authors concluded that it was directly caused by the underlying leiomyoma degeneration and associated inflammation. The authors cannot determine what contribution toward the premature rupture of membranes can be separately attributed to the fibroid degradation and the surgical intervention.

Uterine Leiomyomata

Uterine leiomyomata is the most common tumor of the female reproductive tract; it affects approximately 20% of women aged more than 35 years.² Leiomyomas during pregnancy have been shown to be associated with a number of complications: degeneration, premature rupture of membranes, preterm delivery, malpresentation, dystocia, placental abruption, and postpartum hemorrhage. Red or hemorrhagic degeneration, the most common complication associated with leiomyomata during pregnancy, most commonly occurs around the 20th week.³ Degeneration of leiomyomas during pregnancy is usually a self-limiting process, with reported complications including infection, preterm labor, and disseminated intravascular coagulopathy.⁴

References

1. Dubuisson JB, Fauconnier A, Deffarges JV, et al. Pregnancy outcome and deliveries following laparoscopic myomectomy. Hum Reprod. 2000; 15(4):869-873.
2. Floridon C, Lund N, Thomsen S. Alternative treatment for symptomatic fibroids. Curr Opin Obstet Gynecol. 2001;13(5):491-495.
3. Carlan SJ, O’Brien WF, Holbrook J, et al. Cystic degeneration of a leiomyoma masquerading as a postoperative abscess. Am J Perinatol. 1992;9(3): 175-178.
4. Makar AP, Meulyzer PR, Vergote IB, et al. A case report of unusual complication of myomatous uterus in pregnancy: spontaneous perforation of myoma after red degeneration. Euro J Obstet Gynecol Reprod Biol. 1989; 31(3):289-293.

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