Hemoperitoneum Secondary to Deserosalized Uterine Leiomyoma

Abstract

Introduction:

A 31-year-old G0 with a known subserosal uterine leiomyoma presented to an academic medical center with acute onset of abdominal pain.

Case Description/Technique Description:

During diagnostic laparoscopy, hemoperitoneum of 1200 mL was evacuated and generalized oozing was noted from several areas of deserosalized leiomyoma tissue. An uncomplicated laparoscopic myomectomy was performed.

Discussion:

Acute hemorrhage secondary to a deserosalized uterine leiomyoma is a rare diagnosis but should be considered in any reproductive-aged person with a uterus and history of leiomyoma and presents with signs of acute intra-abdominal hemorrhage. If allowable by the patient’s clinical status, such cases may be managed in a minimally invasive fashion.

INTRODUCTION

Uterine leiomyomas are noncancerous smooth muscle neoplasms that occur in up to 70%–70% of persons with a uterus and a common indication for hysterectomy. Approximately 50% of persons with uterine leiomyomas have symptoms including prolonged and heavy menstrual bleeding or bulk-related symptoms such as pelvic pressure, constipation, or urinary frequency.¹ This morbidity associated with uterine leiomyomas is compounded by delayed diagnosis, with one third of patients waiting 5 years for diagnosis and some up to 8 years. Many patients report negative impacts to quality of life and employment.² Options for management of uterine leiomyomas include medical therapies; minimally invasive options such as uterine artery embolization or radiofrequency ablation; and surgical options including myomectomy and hysterectomy.¹

More rare complications of uterine leiomyomas include torsion, acute degeneration, or rupture. Gynecologic causes of hemoperitoneum include ectopic pregnancy and ruptured ovarian cysts as leading differential diagnoses; however, hemoperitoneum rarely can be due to acute bleeding from uterine leiomyoma. We report a case of acute abdomen due to hemoperitoneum from a deserosalized uterine leiomyoma which was managed in a minimally invasive fashion.

CASE DESCRIPTION

This study was deemed to be exempt from review by the governing Institutional Review Board and the patient gave written informed consent for publication. A 31-year-old G0 with a known 6 cm subserosal (FIGO 6) uterine leiomyoma and no other significant past medical or surgical history presented to the emergency department with acute onset of abdominal and pelvic pain.³ No inciting factor or vigorous physical activity was reported prior to presentation. She reported regular 28-day menstrual cycles, with last menstrual period starting 12 days prior to presentation. She was not taking any form of hormonal contraception. Her temperature was 36.5°C, heart rate was 79 beats per minute, respiratory rate was 16 per minute, and blood pressure was 126/83 mm Hg. Her physical examination was notable for significant tenderness to palpation in all four abdominal quadrants with guarding. Hemoglobin was 11.0 g/dL without recent comparison. A quantitative β hCG level was negative. A transabdominal and transvaginal pelvic ultrasound was obtained which showed the known subserosal leiomyoma, which appeared more medialized since the prior ultrasound comparison, and extensive blood products in the abdomen and pelvis (Figure 1A). Bilateral ovaries appeared normal without cysts. A contrast-enhanced CT scan abdomen and pelvis was then obtained which showed moderate hemoperitoneum with sentinel clot about the uterus (Figure 1B).

Figure 1.

Preoperative imaging. (A) Transvaginal sagittal pelvic ultrasound showed known 6 cm posterior subserosal leiomyoma (dashed blue circle), which appeared more medialized since the prior ultrasound comparison, and extensive complex free fluid in the abdomen and pelvis. (B) Contrast-enhanced coronal CT abdomen and pelvis showed moderate hemoperitoneum with sentinel clot around the uterus (dashed red outline).

Given the clinical findings, the leading differential diagnosis was leiomyoma rupture or torsion leading to hemoperitoneum and emergent intervention was recommended. During diagnostic laparoscopy, hemoperitoneum of 1200 mL was found and evacuated (Figure 2A). The known subserosal leiomyoma was visualized and was noted to be deserosalized, with a clear demarcation between the uterine serosa and the leiomyoma tissue (Figure 2B-C). Active generalized oozing was noted from several areas of the leiomyoma tissue. No adhesions were noted between the leiomyoma and the surrounding structures. A laparoscopic myomectomy was performed in the usual fashion with an estimated blood loss from the procedure of 100 mL (Figure 2D). Once the fibroid was removed from the uterus, it was placed into a surgical bag, and the umbilical incision was extended to 2 cm. In-bag morcellation of the fibroid was performed to remove the specimen utilizing the ExCITE (Extracorporeal C-Incision Tissue Extraction) technique.⁴ Postoperative course was uncomplicated. Hemoglobin on postoperative day 1 dropped from 11.0 g/dL to 8.4 g/dL consistent with equilibration following the hemoperitoneum noted during surgery; thereafter, it remained stable, and she did not require any blood products. She discharged home on postoperative day 1. Pathologic examination confirmed leiomyoma with variable degenerative changes noted. At her 6-week postoperative visit, the patient was found to have made a full recovery without complications. Postoperative imaging with sonohysterogram completed 4 months after surgery demonstrated a well-healed uterus with no residual fibroids and a normal-appearing cavity (Figure 3).

Figure 2.

Intraoperative findings. (A) Hemoperitoneum noted upon entry to the abdomen, a total of 1200 mL. (B) Once the hemoperitoneum was evacuated, several clots were noted surrounding the subserosal leiomyoma. (C) Active generalized oozing was noted from the deserosalized leiomyoma. White arrows mark the sharp demarcation between uterine serosa and leiomyoma tissue. (D) Final appearance of the uterus following laparoscopic myomectomy.

Figure 3.

Postoperative transvaginal sonohysterogram with 3D rendering (right) demonstrating a sagittal view of a well-healed uterus with no residual fibroids and a normal-appearing cavity.

DISCUSSION

In this case, hemoperitoneum was caused by a deserosalized uterine leiomyoma and was managed by minimally invasive laparoscopic myomectomy. Hemoperitoneum secondary to leiomyoma is rare, with fewer than 100 cases reported in the literature.⁵ Typically, hemoperitoneum due to a leiomyoma is venous in origin. This may be due to an increase in abdominal pressure which leads to rupture of congested superficial veins.^6–14 Previous reviews have identified trauma, defecation, sexual intercourse, pregnancy, or menstruation as possible etiologies of venous congestion.¹⁵ Less commonly, hemoperitoneum can result from arterial sources or from leiomyoma avulsion or rupture.^6,15–21 In our case, however, the hemoperitoneum occurred spontaneously, with no identifiable inciting event. The patient was in the follicular phase of her menstrual cycle; previous reports have not found a consistent association between leiomyoma avulsion or rupture and menstrual cycle phase.¹³ There have been a few reports of spontaneous hemoperitoneum; in these cases, hemorrhage was hypothesized to be due to leiomyoma degeneration or necrosis.^5,11,21,22 This is consistent with the pathology findings in our case in which variable degenerative changes were noted.

Unique to our case was the finding of deserosalized leiomyoma tissue. Rather than bleeding from a single venous or arterial vessel, generalized oozing was noted from the leiomyoma tissue, which had extruded itself from the uterine serosa. This presentation has been described in only two other cases. In the first, a patient presented with sudden onset abdominal pain and was found to have a 7 cm leiomyoma, over half of which projected beyond the surface of the uterus with a sharp demarcation between the serosa and the leiomyoma tissue.¹³ In the second, a patient presented with hypotension after running and was found to have rupture of the uterine serosa with complete enucleation of a large 15 cm diameter leiomyoma.²³ It was hypothesized that the force of the extrusion of the leiomyoma from the myometrium may have led to spontaneous hemorrhage from superficial vessels on the leiomyoma.¹³ In our case, a similarly sharp demarcation line was seen, delineating the leiomyoma tissue from the uterine serosa and it is possible that this tissue tension contributed to the spontaneous generalized bleeding that led to hemoperitoneum.

In these cases, preoperative diagnosis is uncommon due to the rarity of the diagnosis. Most commonly, preoperative diagnosis is unexplained hemoperitoneum. One prior case report has described accurate preoperative diagnosis of hemoperitoneum due to uterine leiomyoma via contrast-enhanced CT scan which showed extravasation from the dilated vessel on a uterine leiomyoma with associated hemoperitoneum.²⁴ In our case, a pelvic ultrasound was initially obtained as it was more readily available. This showed the known subserosal leiomyoma, which appeared more medialized since the prior ultrasound, with extensive complex free fluid in the abdomen and pelvis. The adnexa appeared normal bilaterally. These findings suggested that the uterine leiomyoma was the source of the hemoperitoneum and a differential diagnosis of leiomyoma rupture or torsion leading to hemoperitoneum. While other gynecologic sources of hemoperitoneum, such as ovarian cyst rupture, were considered, the amount of hemoperitoneum seen was larger than what would be expected from ovarian cyst rupture. A contrast-enhanced CT scan was then obtained to rule out other intra-abdominal pathology. This showed moderate hemoperitoneum with sentinel clot about the uterus, further supporting a gynecologic source of the hemoperitoneum. In our case, the patient was hemodynamically stable which allowed both a pelvic ultrasound and CT scan to be obtained to refine the suspected diagnosis. In other cases, patients who are hemodynamically unstable may require emergency intervention prior to any or only one type of imaging, which may limit the ability to make this rare diagnosis preoperatively. While pelvic ultrasounds are the most useful to characterize gynecologic pathology, with limited time, CT scans may also be useful not only for preoperative diagnosis but also to exclude other intra-abdominal pathology.

Finally, also unique in our case was our management with a minimally invasive laparoscopic myomectomy. A vast majority of these cases have been managed with exploratory laparotomy with open myomectomy or supracervical or total abdominal hysterectomy. There have been a few cases which started with diagnostic laparoscopy and ultimately converted to exploratory laparotomy and two cases which were initially managed with uterine artery embolization but ultimately resulted in abdominal hysterectomies.^5,25,26 In our case, the patient remained hemodynamically stable throughout evaluation which allowed a minimally invasive surgical approach. There are significant benefits to minimally invasive surgery when possible, including but not limited to shorter hospital stays and easier recovery for the patient. Furthermore, myomectomy is a fertility-sparing procedure, particularly important in young patients who desire future fertility, and was of utmost importance to our patient. When allowable by the patient’s clinical status, similar cases may be managed in a minimally invasive fashion.

CONCLUSION

In conclusion, acute hemorrhage secondary to uterine leiomyoma is a rare diagnosis that should be suspected in any reproductive-aged person with a uterus with a history of leiomyoma and findings of acute intra-abdominal hemorrhage. While pelvic ultrasound and CT scan can be helpful in evaluation, preoperative diagnosis is frequently difficult. Emergent surgical intervention is necessary for management of this rare diagnosis; if allowed by the patient’s clinical status, such cases may be managed in a minimally invasive fashion.