Hypovolaemic shock due to intra-abdominal haemorrhage from multiple uterine fibroids

Abstract

Intra-abdominal bleeding due to uterine fibroids is extremely rare, and preoperative diagnosis is difficult. Herein, we report a case of preoperatively diagnosed hypovolaemic shock due to intra-abdominal haemorrhage, in which fatal sequelae were prevented. A 46-year-old non-pregnant woman was brought to the hospital with a sudden-onset lower abdominal pain. On admission, she was in shock, and abdominal CT showed severe intra-abdominal haemorrhage. Since bleeding from uterine fibroids was suspected, an emergency simple total hysterectomy was performed, and her condition became stable after the operation. Intra-abdominal haemorrhage with hypovolaemic shock requires prompt surgical intervention. Although it occurs very rarely due to bleeding from uterine fibroids, imaging shows large fibroids; if the patient is not pregnant, bleeding from the fibroids should be considered.

Background

Fibroids are the most common benign uterine tumours.¹ Acute complications due to uterine leiomyoma, including torsion, degeneration, and intra-abdominal haemorrhage of subserosal or pedunculated uterine fibroids, rarely occur.² Intravaginal bleeding is the most common bleeding caused by uterine fibroids, and intra-abdominal bleeding is extremely rare. Although there have been some reports of intraperitoneal haemorrhage due to superficial vascular rupture of uterine fibroids, arterial haemorrhage is even rarer as a cause of haemorrhagic shock.³ Herein, we report the successful emergency treatment of a patient who suffered intra-abdominal haemorrhage and haemorrhagic shock due to arterial haemorrhage from multiple uterine fibroids.

Case presentation

A 46-year-old woman with a body mass index of 18 kg/m² who had no history of pregnancy developed sudden lower abdominal pain on the first day of menstruation without any particular cause and was brought to the emergency department because of vomiting and difficulty in walking. Her medical history was significant for endometriosis, a prior uterine myomectomy, and hypertension, and she was taking amlodipine at the time.

At the time of admission, her blood pressure and pulse rate were 70/50 mm Hg and 70 beats/min, respectively. She presented with peripheral wetness and cold due to shock. Her level of consciousness was E4V4M6 on the Glasgow Coma Scale. Blood tests showed acute bleeding: haemoglobin level of 101 g/L, fibrinogen of 133 mg/dL, lactate of 5.4 mmol/L and base excess of −7.6 mmol/L (table 1).

Table 1.

Blood test results on admission and the first day after surgery

Preoperative arterial blood gas (10 L of oxygen was administered)
pH	7.394
pCO2	27.4	mm Hg
pO2	360	mm Hg
Lactate	5	mmol/L
HCO3	18.5	mmol/L
Base excess	−7.6	mmol/L

Preoperative and postoperative complete blood cell count
	Preoperative	Postoperative
White cell count	17. 6	10 .4	×109cells/L
Haemoglobin	101	107	g/L
Platelet	2 180	980	×109cells/L

Preoperative and postoperative serum chemistry
Total bilirubin	0.3	1	mg/dL
Aspartate transaminase	13	18	IU/L
Alanine transaminase	8	10	IU/L
Lactate dehydrogenase	199		IU/L
γ-glutamyl transpeptidase	23		U/L
Albumin	3.1	3	g/dL
Blood urea nitrogen	16.8	13.4	mg/dL
Creatinine	1.4	0.59	mg/dL
Sodium	144	143	mmol/L
Chlorine	110	111	mmol/L
Potassium	4.1	3.4	mmol/L
C reactive protein	<0.1	2.2	mg/dL
Lactate	5.4		mmol/L

Preoperative and postoperative blood coagulation test
PT-INR	1.04	1.08
PT	83	77	%
APTT	24.2	29.0	s
Fibrinogen	133	252	m/dL
D-dimer	0.34		µg/dL

The postoperative blood test was performed on the first day after surgery. The patient had been transfused with 12 units of red blood cells and 10 units of frozen fresh blood.

APTT, activated partial thromboplastin time; pCO₂, partial pressure of carbon dioxide; pO₂, partial pressure of oxygen; PT-INR, prothrombin time-international normalised ratio.

Abdominal CT was performed because focused assessment with sonography for trauma showed marked ascites up to the surface of the liver and a mass occupying the pelvis. Abdominal CT showed a large amount of haemoperitoneum (figure 1), multiple uterine fibroids with a maximum diameter of 11 cm, and a faint contrast-enhanced area around the blood vessels at the bottom of the uterus in the arterial phase, suggesting bleeding at this site (figure 2).

Figure 1.

Abdominal CT. Extensive intra-abdominal haemorrhage extends to the liver surface and spleen.

Figure 2.

Abdominal CT. The outflow of the contrast medium at the arrow indicates the site of multiple uterine fibroids.

Treatment

Blood transfusion was started immediately, and emergency laparotomy was performed. During intraoperative examination, the abdominal cavity was filled with dark-red blood clots. The uterus was swollen to the size of 10×17 cm². A part of the fibroid at the bottom of the uterus was torn, and arterial bleeding was observed; hence, suture haemostasis was performed (figure 3). In addition, since venous bleeding was observed from the two blood vessels on the surface of the fibroid, cauterisation and haemostasis were performed with an electric knife (figure 4). A simple total hysterectomy was performed, and the total amount of bleeding was 2000 mL. Six units of red cell concentrate and four units of fresh frozen plasma were transfused preoperatively and intraoperatively. However, postoperative haemoglobin and fibrinogen levels were 72 g/L and 24 mg/dL, respectively; therefore, six additional units of red cell concentrate and six units of fresh frozen plasma were transfused, which finally stabilised the patient’s condition (table 1). The postoperative course was uneventful, and the patient was discharged 10 days postoperatively. Postoperative histopathological examination revealed that the removed uterus weighed 1.05 kg, and multiple leiomyomas approximately 14 cm in size were observed in the uterus; however, no degeneration or malignancy was noted. Endometriotic lesions were observed under the serosa of the uterine corpus.

Figure 3.

Intraoperative findings. Arterial bleeding is observed from the root of the uterine fibroid.

Figure 4.

Intraoperative findings. Venous bleeding is observed from the blood vessels on the surface of the uterine fibroid.

Outcome and follow-up

The postoperative course was uneventful, and no complications were observed. Therefore, she was discharged 7 days after the operation. One month thereafter, she was examined (follow-up) at the outpatient department.

Discussion

Uterine fibrosis is a benign tumour that develops in the smooth muscles of the myometrium and is observed in approximately 75% of women aged >30 years.¹ According to Lim et al,³ intraperitoneal haemorrhage due to uterine fibroids is rare, and it has only been reported in 125 cases since 1902.

It presents with hypovolaemic shock accompanied by abdominal pain, and the mortality rate is approximately 3.2%. Preoperative diagnosis is extremely difficult, and only 4 of 125 reported cases were preoperatively diagnosed. Abdominal pain is the most common symptom; sudden-onset lower abdominal pain has been reported in 83.2% of cases, and 69.6% of these cases were hypovolaemic.

Intraperitoneal bleeding due to uterine fibroids is primarily caused by the rupture of blood vessels on the surface of uterine fibroids (in 60.8% of cases, 76.3% had venous rupture, 11.3% had arterial rupture, and the rupture type was not identifiable in 11.3% of cases).³

Moreover, intraperitoneal bleeding is caused by the rupture of uterine fibroids and uterine fibroid detachment in 27.2% and 8% of the cases, respectively.³ Although venous rupture is more frequent than arterial rupture, some reports have indicated that arterial bleeding was more often observed in patients with a history of hypertension.⁴

Causes of superficial blood vessel rupture in uterine fibroids include blood vessel fragility and increased venous pressure associated with increased abdominal pressure. Sampson found that subserous fibroids significantly changed the vascular architecture of the uterus. He demonstrated that a significant portion of the uterine arterial supply is shunted to the tumour, with venous drainage through dilated veins crossing over the surface of the fibroid and entering large channels at the periphery of the supporting myometrium. These vascular malformations give rise to prominent and weak superficial blood vessels and are associated with fibroids that are ≥10 cm in diameter.⁵ Similarly, Horowitz suggest that superficial blood vessels may rupture in fibroids with a diameter >10 cm.⁶ Additionally, large fibroids can overstretch the surface arteries and cause arterial rupture.⁷ Furthermore, elevation in abdominal pressure and arterial pressure can rupture the arteries on the surface of the uterine fibroid.⁸ Elevated abdominal pressure supposedly causes congestion and rupture of superficial blood vessels in uterine fibroids. Deopuria previously reported increased abdominal pressure caused by intense physical activities, intense sexual intercourse, abdominal massage, defecation, sports and treatment under anaesthesia as triggers for intra-abdominal bleeding.⁴ Menstruation and pregnancy can equally cause venous congestion and rupture.⁵

In this case, menstruation and defecation were the presumed triggers, and hypertension was a comorbidity. Temporary congestion due to menstruation and defecation, increased blood flow, and increased blood pressure may have triggered the rupture of the arteries and veins on the surface of the uterine fibroid, causing intraperitoneal bleeding.

Regarding the selection of surgical methods for treating bleeding due to uterine fibroids, Deopuria recommends total hysterectomy in multiparous and postmenopausal women who do not wish to become pregnant and myomectomy in young women and those who wish to preserve fertility or in cases where bleeding can be stopped.⁴ To prevent recurrence, ligation and haemostasis of ruptured blood vessels that may cause rebleeding is not recommended. However, in one report, uterine fibroids were identified preoperatively as a source of bleeding, and haemodynamics were stabilised by transcatheter bilateral uterine artery embolisation before laparotomy.⁹ Fortunately, our patient’s condition was preoperatively diagnosed by imaging; therefore, the possibility of total hysterectomy was explained to the patient and her family preoperatively.

Intraperitoneal haemorrhage due to uterine fibroids is often difficult to diagnose preoperatively, but mortality is low. The low mortality rate in this condition may be because the bleeding in uterine fibroids consists mostly of venous blood, and because most patients with this condition are young and healthy women. Surgical procedures should be selected based on the patient’s general condition and long-term fertility concerns. The need for preoperative diagnosis of this disease is determined based on the surgical procedure that is selected. Fertile women may be provided uterine protection if they want to maintain fertility.

In this case, there were multiple uterine fibroids with a maximum diameter of 11 cm, and hypertension as a comorbidity and incentives due to menstruation and defecation were observed. Temporary congestion due to menstruation and defecation, increased blood flow, and increased blood pressure may have caused arteries and veins on the surface of the uterine fibroid to rupture, causing intraperitoneal bleeding.

We reviewed 28 previously reported case reports in English. Blood test data were available for 23 of the 28 cases, of which 15 had low haemoglobin levels (56–106 g/L) on blood test at the time of visit. In only one case, the lactate level was mentioned, which had increased to 2.5 mmol/L, and the haemoglobin level was 80 g/L. The vital signs indicated shock (blood pressure 78/52 mm Hg, pulse rate 80/min).^{6 8–34} In our case, the haemoglobin level at the time of admission was 101 g/L, which indicated anaemia, the lactate level was elevated to 5 mmol/L, and vital signs also pointed towards shock. The patient had clearly reached critical DO2 as indicated by her extraordinarily high blood lactate and base deficit, suggesting that the attempt to elevate oxygen carrying content by placing the patient on 100% oxygen probably had less impact than the effect of blood component replacement of lost red blood cells (ie, haemoglobin) through transfusion.

We hypothesised that despite the high lactate level in blood gas, the pH was normal owing to respiratory compensation. In addition, the apparent bradycardia (70 beats/min) in the face of severe hypotension (70/50 mm Hg) may reflect a combined effect of a blunted vagally mediated cardiac baroreflex and significant sympathetic withdrawal at the time of emergency transport, despite the presence of hypovolaemic shock.³⁵ Additionally, abdominal pain could have made it worse.

When a patient with uterine fibroids of >10 cm diameter presents with sudden abdominal pain and unexplained intraperitoneal bleeding, uterine fibroids should be considered a cause of bleeding, especially when the patient has risk factors such as increased intra-abdominal pressure.

Learning points.

• Uterine fibroids are rarely the cause of intra-abdominal haemorrhage and hypovolaemic shock.

• This patient with a history of hypertension presented with acute abdominal pain, and abdominal CT revealed haemoperitoneum and multiple uterine fibroids approximately 10 cm in size.

• Surgical findings revealed fibroids with both venous and arterial bleeding, and a total hysterectomy was performed.

• In cases of intra-abdominal haemorrhage in non-pregnant women, uterine fibroids >10 cm should be considered a possible source of bleeding.