Document Type : Case Report
Authors
1 Department of Obstetrics and Gynecology, Faculty of Medicine, University of Ufuk, Ankara, Turkey ;Department of Obstetrics and Gynecology, Elazıg Training and Research Hospital, Elazıg, Turkey
2 Department of Radiology, Elazıg Training and Research Hospital, Elazıg, Turkey
3 Department of Obstetrics and Gynecology, Elazıg Training and Research Hospital, Elazıg, Turkey
Abstract
Keywords
Uterine rupture, defined as disruption or tear
of the myometrium and serosa of uterus, is a life
threatening condition for both the mother and
the fetus. Previous caesarean scar or myomectomy, trauma, grand-multiparity, uterine anomaly
or injudicious use of oxytocin or prostaglandin
are some of the predisposing factors responsible
for rupture of the uterus during labor. Rupture
of the uterus may also be seen in the second trimester, occurring after induction for pregnancy
termination in scarred uterus most of the time.
The incidence of uterine rupture at second trimester pregnancy termination by misoprostol is
reported at 0.4% with one prior low transverse
cesarean delivery (
Spontaneous rupture of the uterus in the second trimester is very rare. Placenta percreta as
well as scar pregnancy have been thought as
predisposing factors of spontaneous midtrimester uterine rupture. But without any medication
for induction and placenta percreta, spontaneous rupture in midtrimester is a noteworthy
condition. Here we report a prolonged uterine
rupture in midtrimester
A 33-year-old pregnant woman was admitted to the emergency department of our clinic
with acute diffuse abdominal pain. Her history revealed infertility for 4-5 years and laparoscopic myomectomy performed for a single
3 cm subserous myoma located in the fundus,
one year ago in another institution. At laparoscopic myomectomy, hemostasis had been supplied by electrocoagulation and no suturing was
performed. Six months after the operation, she
successfully underwent IVF. On admission she
was at 23 weeks gestation according to her last
menstrual period and the ultrasonography revealed 23 weeks gestation with fetal heart beat
and posterior located placenta. No contractions
were detected on the tocogram. Her blood tests
including hemoglobin, white blood cell count,
liver enzymes and urine analysis were normal.
The cervix was closed and 35 mm in length
based on ultrasonography. Because of a possible diagnosis of preterm labor, intravenous
hydration was performed and the abdominal
pain regressed gradually. The patient was discharged 4 days later. Few hours after discharge,
she was readmitted with abdominal pain. In this
instance, an unusual image as amniotic band
on fundus uteri was detected by ultrasonography (
Ultrasonographic image of the patient at second admission, interpreted as amniotic band.
Myomectomy can be performed in unexplained
infertility cases with only myoma uteri in the female partner. The localization of the fibroids is
important for fertility. Submucous myomas are the
most problematic ones causing implantation problems and repeated miscarriages. However, there
are conflicts about relationship between intramural, subserous fibroids and infertility. Pregnancy
rates after myomectomy were reported approximately 50% in infertile patients (
Preoperative medical treatment with gonadotropin-releasing hormone (GnRH) agonists have
been known to reduce the size of the myoma, thus
reducing the blood loss in the operation (
One of the important complications after laparoscopic myomectomy is uterine rupture during
pregnancy. The incidence of uterine rupture in following pregnancies after laparoscopic myomectomy is reported at 1% by Dubuisson et al. (
As far as the authors know, very few cases of
spontaneous uterine rupture after laparoscopic
myomectomy in second trimester have been reported after 2002 (
Use of electrocoagulation during myomectomy in our case emphasizes the long-term consequences of electrical energy. Hasbargen et al.
(
This is the first case of early second trimester
spontaneous uterine rupture who was clinically
silent for four days until placental abruption occurred. As the patient presented with nonspecific symptoms, the differential diagnosis was
harder. The only risk factor was previous laparoscopic myomectomy, but the time of rupture
is noteworthy. The ultrasound evaluation during
the second hospitalization of the patient lead to
misdiagnosis thought to be amniotic band. In
pregnant patients presenting with nonspecific
abdominal pain, the obstetrician should keep in
mind the probability of silent rupture if there
is a history of laparoscopic myomectomy. MRI
may be helpful in accurate diagnosis for such
cases as reported by Hasbargen et al. (
Preoperative evaluation of infertile patients with myomas should be extensive (evaluation). Electrocoagulation may be dangerous even in superficially located small myomas; methods other than surgery for myomectomy such as MR-guided focused ultrasound are new alternatives for these patients. Infertile women should be carefully assessed and a discusssion about the advantages and possible complications of the treatment should be made.