Myomectomy is increasingly used as an elective procedure in selected patients to preserve or enhance fertility. The laparoscopic route reduces length of hospital stay and avoids adhesion formation. Complication rates in the short term are low, provided the surgeon is suitably trained. Cases of uterine rupture following laparoscopic myomectomy to remove subserous and even pedunculated myomas have been reported long before term, which raises concern regarding the integrity of a uterine scar following laparoscopic myomectomy.1 The case below highlights the importance of suspecting this rare complication in patients presenting with abdominal pain.
Mrs DA, 31 years old, gravida 3, para 0+2, was admitted to delivery suite of Latifa Hospital, via the emergency room, complaining of sudden-onset generalized abdominal pain. She was at 24 weeks' gestation, with a dichorionic diamniotic twin pregnancy conceived using in vitro fertilization (IVF) and there was no history of vaginal loss.
Her first pregnancy, a tubal ectopic pregnancy, was terminated at 6 weeks' gestation in another hospital by laparoscopic right salpingectomy, during which an incidental subserous myoma of 1.2 cm was found and excised. No details of myoma site, or method of removal, were mentioned in the operative report. The patient's second pregnancy resulted in miscarriage at 8 weeks' gestation and an evacuation of uterus was carried out. Seven months later, the patient underwent diagnostic laparoscopy to investigate the reason for her inability to conceive and it was found that her left fallopian tube was patent and there were no other abnormal findings. The patient had regular menstrual cycles, no prior medical illness or drug allergy and therefore underwent IVF.
On admission, the patient's vital signs were normal, but abdominal examination revealed her uterus to be enlarged, corresponding to a fetus of 28 weeks' gestation, and she was experiencing palpable contractions. A vaginal examination revealed a short soft cervix with os closed. Ultrasonography showed viable twin fetuses, of which the first was cephalic but the second was in the breech position. Cardiotocography (CTG) revealed regular uterine contractions and a diagnosis of threatened preterm labour was made; therefore, tocolytics were given alongside an intravenous infusion with Tractocile (Ferring, West Drayton, UK) and two doses of betamethasone steroid were given.
The patient's blood group was O Rh positive, her haemoglobin concentration was 11 g%, her white blood cell count was 18 000/mm3, her C–reactive protein level was 14.6 mg/l and her coagulation profile was normal. Tests that were used to look for hepatitis markers, human immunodeficiency virus and venereal disease were all negative. A mid-stream urine sample and a high vaginal swab both confirmed that no pathogens were present and detailed obstetric ultrasonography showed viable dichorionic diamniotic twins. The first twin was estimated to weigh 953 g and the second twin 1820 g. The liquor was found to be adequate around both twins and two placentae were seen, one anteriorly and one posteriorly.
After completion of the 48-hour cycle of Tractocile, the patient began to experience contractions again; therefore, oral nifedipine was given as second-line tocolytic in view of extreme fetal prematurity. She remained pain free for 24 hours before the contractions began again. The patient was suffering from dyspnoea, cough and palpitations but on vaginal examination, the os was still closed. Vital signs remained stable and a blood culture showed no growth, with tests for Mycoplasma giving a negative result. Chest radiography revealed bilateral haziness in the lower lung zones and Doppler study of lower limbs showed no signs of deep vein thrombosis. Medical consultation resulted in diagnosis of atypical pneumonia. Antibiotics were given intravenously and the patient's condition improved over the next 10 hours of observation in the high-dependency unit of Latifa Hospital.
During her stay, the patient continued to experience irregular abdominal pain. CTG was reassuring as regards the condition of both twins; however, on palpation, there was tenderness mainly on left side of uterus. It was decided that the babies should be delivered if signs of chorioamnionitis developed.
A week after her admission, the patient was experiencing stronger abdominal pain in association with shivering and dizziness; however, her vital signs were normal. Strong uterine contractions were palpable and there was tenderness in left upper quadrant of the uterus. CTG showed regular uterine contractions but the cervical os was still not sufficiently dilated for vaginal delivery. One hour following this examination, it was decided that an emergency lower segment caesarean section should be performed as intraperitoneal haemorrhage was suspected.
The lower uterine segment was incised and first baby was in the correct position for delivery, with the vertex at the front of the mother's pelvis. The baby was female and weighed 850 g with Apgar scores of 8 at 1 minute and 8 at 5 minutes. The second baby was delivered from the breech position, was also female, weighed 865 g and had Apgar scores of 6 at 1 minute and 8 at 5 minutes. Both babies were attended by a neonatologist and transferred to the special care baby unit (SBCU).
During investigation, a defect of 6 × 6 cm was noted at the left uterine cornua and posterior wall that resulted in placental tissue and the amniotic sac of the second twin protruding through the defect (Figure 1). No active bleeding was noted at that site (Figure 2) and both placentae, with complete membranes, were delivered and blood clots removed. The defective area was repaired in two layers and checked for integrity through the cavity (Figure 3). The lower segment incision was closed in two layers and haemostasis ensured. The patient suffered 1.5 litres of blood loss and her haemoglobin concentration was 8.6 g%. She was monitored in the intensive care unit postoperatively and received a blood transfusion. She was stable postnatally and discharged after 3 days with a haemoglobin concentration of 12.5 g%.
The first twin died after 20 days in SBCU; however, the second twin was doing well at the time of reporting.
The mother was reviewed at 6 weeks in the postnatal clinic and she was asymptomatic and the caesarean wound was well healed.
Laparoscopic myomectomy allows removal of small numbers of subserous and intramural myomas of less than 9 cm. Uterine rupture during pregnancy following laparoscopic myomectomy is a rare occurrence. The rate of uterine rupture after abdominal myomectomy is 5.3%, and after a previous caesarean ranges from 0.3% to 3.8%. In a large study reporting on pregnancies after laparoscopic myomectomy,1 the rate of uterine rupture was 1% and, to date, only 19 cases of uterine rupture have been reported in the literature, which raises concern regarding the integrity of the scar created by laparoscopic myomectomy. Factors commonly resulting in a weak scar include difficulty in suturing the defect, the use of electrocautery, single-layer closure, presence of haematoma, use of radiofrequencies for fusion of the tissues and the wound healing characteristics of the individual patient.
The first case of obstetric uterine rupture subsequent to removal of a superficial myoma via laparoscopic myomectomy was reported in 1997 in a primigravid woman at 33 weeks' gestation who presented with acute abdomen.2
In 2002, Hasbargen et al.3 reported a case of uterine rupture in a nulliparous woman at 29 weeks' gestation who had been diagnosed preoperatively via magnetic resonance imaging (MRI) and underwent laparoscopic subserosal myomectomy that used unipolar electrocautery to seal the wound. However, inflammation and necrosis are often associated with electrocautery and can lead to delayed healing of the wound and a weak scar.
Asakura et al.4 reported a case in 2004 of a multigravid woman at a gestation of 34 weeks and 1 day who was admitted because of threatened preterm labour with frequent uterine contractions and a normal fetal heart pattern. On examination, the internal os was closed; therefore, the tocolytic drug ritodrine was given and the patient was observed in hospital. At 35 weeks and 4 days of gestation, the patient had severe uterine tenderness. The fetal heart rate was initially reassuring but variable decelerations occurred after 7 hours and there was no reduction in the uterine tenderness, even after analgesia. Caesarean section revealed haemoperitoneum of 50 ml and a defect of 5 cm in the anterior fundus of the uterus. There was no fresh bleeding at site of rupture; therefore, the uterine dehiscence had occurred at admission (at 34 weeks and 1 day of gestation) and an overt rupture had occurred by the time of uterine tenderness (at 35 weeks and 4 days of gestation). In the case discussed previously, uterine dehiscence had occurred at 24 weeks and 4 days of gestation and overt rupture occurred a week later.
Uterine rupture has also been reported to occur without signs of fetal distress. Banas et al.5 reported such a case of spontaneous uterine rupture at 35 weeks' gestation, which was 3 years after the patient had undergone laparoscopic myomectomy, without signs of fetal distress.5
Principles to follow during laparoscopic myomectomy include:
Use microsurgical techniques with fine, atraumatic sutures.
Be sure to dissect along cleavage planes.
Use electrocoagulation sparingly while controlling bleeding to avoid excess thermal damage and haematoma formation, especially during subserous myomectomy.
Accurately approximate the hysterotomy incision by taking into account the full thickness of the edges of the uterus and ensure that the sutures are evenly spaced, irrespective of the number of suture layers.6
The mode of fetal delivery after laparoscopic myomectomy is elective caesarean section if the uterine wall was deeply penetrated during myomectomy, or vaginal delivery if subserous or pedunculated myomas were removed.
Laparoscopic myomectomy is an effective technique and is associated with a low rate of patient morbidity. As the aim of the intervention is to preserve the uterus for future pregnancy, it is important to maintain the integrity of uterine wall. Because of the increasing number of cases of uterine rupture after laparoscopic myomectomy, stringent selection of patients suitable for the surgical procedure7 and awareness that this complication may occur long before term is essential. Uterine rupture can occur after removal of superficial myomas and even in the presence of a reassuring fetal heart pattern; therefore, careful review of surgical records is warranted. In our case, uterine rupture occurred early, at 24 weeks' gestation, as the uterus was already overdistended by twins. MRI was not used as a diagnostic modality in this case, but may be the only method for preoperative diagnosis of uterine rupture,3 especially in women with posterior uterine scars.