Hemoperitoneum from Ruptured Leiomyoma

Author information

Mirchandani Anil*, Parulekar SV**, Dalvi Parita***

(* Assistant Professor, **Professor and Head of the department, *** First Year Resident, Department of Obstetrics and Gynecology, Seth GS Medical College and KEM Hospital, Mumbai, India.)

Abstract

Leiomyomas are the commonest benign tumors in women. They are known to have varied symptoms depending upon the location and size of the leiomyoma. Development of a hemoperitoneum from the surface of a subserous leiomyoma is the least common mode of presentation of a leiomyoma of the uterus. We report such a case with life threatening intraperitoneal hemorrhage occurring from rupture of veins on the surface of a subserous leiomyoma.

Introduction

Leiomyoma of uterus happens in 30% of all women. Most of the leiomyomas are asymptomatic. The commonest symptom of leiomyoma uterus is abnormal uterine bleeding in the form of menorrhagia. Complications that a woman with uterine leiomyoma may present with include acute cystic degeneration, torsion, and acute red degeneration of the leiomyoma. One of the rarest complications of leiomyoma uterus which happens in subserous leiomyoma is rupture of the surface vessels over subserous leiomyoma. We report a case of such a complication in a middle aged patient.

Case Report

A 39 year old woman, married for 15 years, with previous 3 normal deliveries, tubal ligation surgery done in the past, presented with complaints of left lower abdominal pain for 3 days. The pain was progressively increasing in intensity. There was history of giddiness and easy fatigability for 3 days. There was no history of any bowel or urinary bladder related symptoms. There was no history of missed periods or any other menstrual complaint. There was no history of any other major medical or surgical illness except incidental gall stones. Her clinical examination revealed tachycardia of 102 beats per minute, moderate pallor, blood pressure of 100/60 mm of Hg. General and systemic examination revealed no abnormality. There was tenderness in the right iliac fossa, hypogastrium and hypochondrium, Horse shoe shaped dullness was present on abdominal percussion, suggestive of free fluid in the abdomen.  The uterus was of normal size. There was 8 week sized firm cystic mass arising from uterine fundus. There was no cervical motion tenderness but there was left forniceal tenderness. Her hemoglobin was 5g/dL. Pregnancy test on urine was negative. Abdominopelvic ultrasonography (USG) showed a fundal leiomyoma measuring 6 x 8 cm, and free fluid in the abdomen and pelvis with internal echoes, suggestive of a hemoperitoneum, Gall Bladder was mildly distended. Liver and spleen were normal. Computerized tomography confirmed these findings. A colpopuncture yielded free flow of blood which did not clot. In view of absence of any features of an alternative source of hemoperitoneum and presence of a subserous leiomyoma, a provisional diagnosis of rupture of a surface vessel of a uterine subserous leiomyoma was made. An exploratory laparotomy was performed. There was a 7x7 cm subserous leiomyoma with bleeding surface veins. Both ovaries and fallopian tubes were normal. Hemoperitoneum of 500 ml was present along with clots weighing 100 g. A myomectomy was performed. Redundant serosa with the bleeding vessels was removed. The bed of the leiomyoma was closed with interrupted sutures of No. 1 polyglactin and covered with the serosal flap of the leiomyoma. Patient was transfused with 4 units of blood. The patient made an uneventful recovery. Histopathology report confirmed benign leiomyoma.

Figure 1. Uterine fundal leiomyoma (white arrow) with rupture of surface veins. The uterus (black arrow) is held with Shirodkar's uterus holding forceps.

Figure 2. The veins on the surface of the leiomyoma are seen to be bleeding.

Discussion

Life threatening hemoperitoneum is an extremely rare complication of a uterine leiomyoma. The most common cause of it is bleeding from the ruptured surface vessels on the subserous leiomyoma.^[1] The hemorrhage is likely to be more acute and more severe if the ruptured vessel is an artery than when it is a vein. The other causes may be avulsion or torsion of, or blunt trauma to the leiomyoma. The first such reported case was way back in 1861 by Von Rokitansky in the autopsy of a girl who had died of intraperitoneal hemorrhage from the subserous venous rupture over leiomyoma uterus.^[2] Venous congestion and increased vascularity in leiomyoma is known to cause sudden rupture of superficial veins over leiomyoma, especially during a pregnancy.^[2,3] It may also occur if the patient is on anticoagulant therapy for any unrelated indication.^[4] The hemorrhage is likely to be less severe when the cause is torsion of a subserous pedunculated leiomyoma, because the vessels are usually occluded. Our patient had no antecedent history of blunt trauma or anticoagulation, she was not pregnant and rupture of its surface veins was spontaneous in nature. Exploratory laparotomy becomes the diagnostic and life saving therapeutic modality of treatment in such cases. Similar treatment can be given with laparoscopic surgery.^[5] The aim of this case report is to make the readers aware of this differential diagnosis while dealing with a case of acute abdomen and shock in gynecologic case of subserous leiomyoma uterus.

References

1.      Buttery BW. Spontaneous hemoperitoneum complicating fibromyomata. Aust N Z J Obstet Gynaecol 1972; 12 : 210-3.

2.      Wong L, Ching TW, Kok TL, Koon TH. Spontaneous hemoperitoneum from a uterine leiomyoma in pregnancy. Acta Obstet Gynecol Scand 2005;84:1208–1209.

3.      Mattison DR, Yeh SY, Hemoperitoneum from rupture of uterine vein overlying a leiomyoma. Am J Obstet 1980; 136: 415:16.

4.      Matsuda M1, Watanabe Y, Tonosu N, Nabeya Y, Arima H, Matsuzaki H, et al. Hemoperitoneum secondary to exophytic leiomyoma: report of a case. Surg Today. 2000;30(5):448-50.

5.      Estrade-Huchon S1, Bouhanna P, Limot O, Fauconnier A, Bader G.Severe life-threatening hemoperitoneum from posttraumatic avulsion of a pedunculated uterine leiomyoma. J Minim Invasive Gynecol. 2010;17(5):651-2..

Citation

Mirchandani A, Parulekar SV, Dalvi P. Hemoperitoneum from Ruptured Leiomyoma. JPGO 2014 Volume 1 Number 10. Available from: http://www.jpgo.org/2014/10/hemoperitoneum-from-ruptured-leiomyoma.html