167
Int. J. Gynecol. Obstet., 1990,31: 167-170 International Federation of Gynecology and Obstetrics
Early spontaneous uterus D. Golan,
A. Aharoni,
rupture of the post myomectomy
R. Gonen,
gravid
Y. BOW and M. Sharf
Department of Obstetrics and Gynecology and “Pathology, Haifa Medical Center (Rothschild), Faculty of Medicine, Technion - Israel Institute of Technology, Haifa (Israel) (Received July 6th, 1988) (Revised and accepted January 3Oth, 1989)
Abstract
Rupture of a pregnant uterus is a serious threat to the mother’s life and her fetus. Most of these cases have predisposing factors of which a post myomectomy scar is rare. Rupture of a post myomectomy gravid uterus usually occurs in the third trimester of pregnancy or during labor. We present a case of a very early spontaneous rupture which occurred at the 20th week of gestation in a post myomectomy uterus. To the best of our knowledge no previous report of a ruptured myomectomy scarred uterus has been described at such an early stage. Keywords:
Uterine rupture; myomectomy.
Introduction
Rupture of the pregnant uterus is a serious complication which has been well reviewed in the literature. Most of the cases occur during late pregnancy and labor. The incidence in early pregnancy is very rare and only a few cases have been reported. Most of the reported cases of uterine rupture had a previous cesarean section scar [4]. The incidence after myomectomy is extremely rare. The following report pre0020-7292/90/$03.50 0 1990 International Federation of Gynecology and Obstetrics Pmhlirhrd
2nd Printed
in 1rdanc-l
sents a case of spontaneous uterine rupture at 20th week gestation from a previous myomectomy, and placenta accreta. Case report
A 32-year-old woman, married for 11 years was admitted to the hospital at the 20th week of her pregnancy. Her previous obstetric history included one normal delivery with no placental complications. Eight years prior to her admission she had a myomectomy without opening of the uterine cavity. Her chief complaint on present admission abdominal was cramps, which increased during the previous week. She was examined the day before admission at the emergency unit and there was no “apparent” reason for hospitalization. Examination on admission showed lower abdominal tenderness, paleness and other symptoms of shock. The pelvic examination showed no vaginal bleeding, the cervix was closed and the uterine size was according to the gestational age. The fetal heart was heard. The clinical picture necessitated immediate laparotomy. At laparotomy the abdominal cavity contained approximately 1500 ml of blood and a dead fetus outside the amniotic sac. The uterus was ruptured across the anterior Case Report
168
Golan et al.
fundal wall (Fig. 1) which was bleeding profusely. The myometrium at this site was thin and was penetrated by an invasive placenta which almost reached the perimetrium. As there was no possibility for conservative treatment a hysterectomy was performed. It should be noted that this patient’s first pregnancy was a normal placental implantation and not a placenta accreta.
Microscopic The histological sections exhibited gestational hypertrophy and hyperplasia of the myometrium and endometrium including a well formed decidua. On the other hand, in the scar region the wall was thinned and a decidua basalis was absent (Fig. 2). Higher magnification showed the villi and Nitabuch’s fibrinoid to be firmly adherent to rather densely textured, collagenous fibrous tissue (Fig. 3).
Pathological findings Discussion Gross The uterus and the attached placenta weighted 520 g. The fetus weighed 300 g. The anterior surface near the fundus of the uterus showed a tear which measured 10 cm. Protruding from this tear was the placenta which could not be removed manually since it was tightly adherent to the fundal region (Fig. 1).
Gross view showing the dead Fig. 1. left arrow points to the cervical site.
Int J Gynecol
Obstet 31
Rupture of the uterus still remains a serious threat to the life of the mother and survival of the fetus. The incidence of uterine rupture is approximately one in 1500 deliveries [ 1,9]. Most of these cases had predisposing factors such as previous uterine scar, instrumented abortions or invasive placenta.
fetus and a large tear in uterine
fundus
with a protruding
placenta
(right
arrow).
The
Early rupture of uterus
site. Note extremelv Fig. 2. Low power view of uterine wall and placental attachment _.._P___& I_*. ______\ Hematoxylin 1 S_KMK NIL ML *_...-_ ~wrr corny,. and eos ,in (X 30) (Mag. 1 X 30).
rupture after According to Garnet, myomectomy is very rare and does not exceed one in 40-60 cases of ruptured uterus [3,7]. All of these cases occur in the third trimester of pregnancy or in labor. In our case a spontaneous rupture occurred at 20 weeks gestation. No previous report of a ruptured myomectomy-scarred uterus has been described in such an early stage of pregnancy. Review of the literature shows early spontaneous rupture of gravid uterus to be extremely rare from all other causes, as well [2,5,6]. The pathological finding was placenta accreta which penetrated the uterine wall at
thin remnant
of uterine
169
wall (serosai
the site of the previous myomectomy. The co-existence of placenta accreta in the myomectomy scar clearly increased the risk of uterine rupture [8]. In ‘our case, although the patient complained of lower abdominal pain for several days prior to her admission and in spite of the history and clinical picture which were highly suggestive of uterine rupture, no such possibility was thought of because of the early stage of pregnancy. This case report clearly shows that continual awareness of the possibility of uterine rupture in all stages of pregnancy, especially with existing predisposing factors, Case Reoort
170
Golan et al.
Fig. 3. Placental villi abutting upon scarred uterine wall. Villi are surrounded by fibrinoid deposits. Decidual cells are absent. The residual uterine wall consists of fibrous tissue. Hematoxylin and eosin ( x 200). (Mag. 1 x 200).
is essential. The mortality rate in rupture of the uterus is directly related to the delay between diagnosis and surgical treatment. Early and continuous awareness will enable prompt diagnosis and treatment.
6 7
8
References 9 1
2 3 4 5
Benson RC: Current obstetric and gynecologic diagnosis and treatment. Lange Med Pub1 Maruzen Asian, 4th edn, p 735, 1982. Camlibel FT: Spontaneous rupture of uterus caused by placenta percreta. NY State J Med Aug: 1373, 1981. Garnet JD: Uterine rupture during pregnancy. Obstet Gynecol 23: 898, 1964. Golan A, Sandbank M, Rubin A: Rupture of the pregnant uterus. Obstet Gynecol 56: 549, 1980. Iddenden DA, Nuttall ID: Early spontaneous rupture of the gravid uterus. Am J Obstet Gynecol IS: 971, 1983.
Int J Gynecol Obstet 31
Lazarus EJ: Early rupture of the gravid uterus. Am J Obstet Gynecol 132: 224, 1978. Palerme GR, Friedman EA: Rupture of the gravid uterus in the third trimester. Am J Obstet Gynecol 94: 571, 1966. Schram M, Askari M: Spontaneous rupture of uterus caused by placenta accreta at 17 weeks’ gestation. Report of a case. Obstet Gynecol 25: 624, 1965. Schrinsky DC, Benson RC: Kupture of the pregnant uterus: A review. Obstet Gynecol Surv 33: 217, 1978.
Address for reprints: D. Golan Department of Obstetrics and Gynecology Hail8 Medical Center (Rothschild) P.O. Box 4940 Hnifa 31048 Israel
Int. J. Gynecol. Obstet., 1990,31: 167-170 International Federation of Gynecology and Obstetrics
Early spontaneous uterus D. Golan,
A. Aharoni,
rupture of the post myomectomy
R. Gonen,
gravid
Y. BOW and M. Sharf
Department of Obstetrics and Gynecology and “Pathology, Haifa Medical Center (Rothschild), Faculty of Medicine, Technion - Israel Institute of Technology, Haifa (Israel) (Received July 6th, 1988) (Revised and accepted January 3Oth, 1989)
Abstract
Rupture of a pregnant uterus is a serious threat to the mother’s life and her fetus. Most of these cases have predisposing factors of which a post myomectomy scar is rare. Rupture of a post myomectomy gravid uterus usually occurs in the third trimester of pregnancy or during labor. We present a case of a very early spontaneous rupture which occurred at the 20th week of gestation in a post myomectomy uterus. To the best of our knowledge no previous report of a ruptured myomectomy scarred uterus has been described at such an early stage. Keywords:
Uterine rupture; myomectomy.
Introduction
Rupture of the pregnant uterus is a serious complication which has been well reviewed in the literature. Most of the cases occur during late pregnancy and labor. The incidence in early pregnancy is very rare and only a few cases have been reported. Most of the reported cases of uterine rupture had a previous cesarean section scar [4]. The incidence after myomectomy is extremely rare. The following report pre0020-7292/90/$03.50 0 1990 International Federation of Gynecology and Obstetrics Pmhlirhrd
2nd Printed
in 1rdanc-l
sents a case of spontaneous uterine rupture at 20th week gestation from a previous myomectomy, and placenta accreta. Case report
A 32-year-old woman, married for 11 years was admitted to the hospital at the 20th week of her pregnancy. Her previous obstetric history included one normal delivery with no placental complications. Eight years prior to her admission she had a myomectomy without opening of the uterine cavity. Her chief complaint on present admission abdominal was cramps, which increased during the previous week. She was examined the day before admission at the emergency unit and there was no “apparent” reason for hospitalization. Examination on admission showed lower abdominal tenderness, paleness and other symptoms of shock. The pelvic examination showed no vaginal bleeding, the cervix was closed and the uterine size was according to the gestational age. The fetal heart was heard. The clinical picture necessitated immediate laparotomy. At laparotomy the abdominal cavity contained approximately 1500 ml of blood and a dead fetus outside the amniotic sac. The uterus was ruptured across the anterior Case Report
168
Golan et al.
fundal wall (Fig. 1) which was bleeding profusely. The myometrium at this site was thin and was penetrated by an invasive placenta which almost reached the perimetrium. As there was no possibility for conservative treatment a hysterectomy was performed. It should be noted that this patient’s first pregnancy was a normal placental implantation and not a placenta accreta.
Microscopic The histological sections exhibited gestational hypertrophy and hyperplasia of the myometrium and endometrium including a well formed decidua. On the other hand, in the scar region the wall was thinned and a decidua basalis was absent (Fig. 2). Higher magnification showed the villi and Nitabuch’s fibrinoid to be firmly adherent to rather densely textured, collagenous fibrous tissue (Fig. 3).
Pathological findings Discussion Gross The uterus and the attached placenta weighted 520 g. The fetus weighed 300 g. The anterior surface near the fundus of the uterus showed a tear which measured 10 cm. Protruding from this tear was the placenta which could not be removed manually since it was tightly adherent to the fundal region (Fig. 1).
Gross view showing the dead Fig. 1. left arrow points to the cervical site.
Int J Gynecol
Obstet 31
Rupture of the uterus still remains a serious threat to the life of the mother and survival of the fetus. The incidence of uterine rupture is approximately one in 1500 deliveries [ 1,9]. Most of these cases had predisposing factors such as previous uterine scar, instrumented abortions or invasive placenta.
fetus and a large tear in uterine
fundus
with a protruding
placenta
(right
arrow).
The
Early rupture of uterus
site. Note extremelv Fig. 2. Low power view of uterine wall and placental attachment _.._P___& I_*. ______\ Hematoxylin 1 S_KMK NIL ML *_...-_ ~wrr corny,. and eos ,in (X 30) (Mag. 1 X 30).
rupture after According to Garnet, myomectomy is very rare and does not exceed one in 40-60 cases of ruptured uterus [3,7]. All of these cases occur in the third trimester of pregnancy or in labor. In our case a spontaneous rupture occurred at 20 weeks gestation. No previous report of a ruptured myomectomy-scarred uterus has been described in such an early stage of pregnancy. Review of the literature shows early spontaneous rupture of gravid uterus to be extremely rare from all other causes, as well [2,5,6]. The pathological finding was placenta accreta which penetrated the uterine wall at
thin remnant
of uterine
169
wall (serosai
the site of the previous myomectomy. The co-existence of placenta accreta in the myomectomy scar clearly increased the risk of uterine rupture [8]. In ‘our case, although the patient complained of lower abdominal pain for several days prior to her admission and in spite of the history and clinical picture which were highly suggestive of uterine rupture, no such possibility was thought of because of the early stage of pregnancy. This case report clearly shows that continual awareness of the possibility of uterine rupture in all stages of pregnancy, especially with existing predisposing factors, Case Reoort
170
Golan et al.
Fig. 3. Placental villi abutting upon scarred uterine wall. Villi are surrounded by fibrinoid deposits. Decidual cells are absent. The residual uterine wall consists of fibrous tissue. Hematoxylin and eosin ( x 200). (Mag. 1 x 200).
is essential. The mortality rate in rupture of the uterus is directly related to the delay between diagnosis and surgical treatment. Early and continuous awareness will enable prompt diagnosis and treatment.
6 7
8
References 9 1
2 3 4 5
Benson RC: Current obstetric and gynecologic diagnosis and treatment. Lange Med Pub1 Maruzen Asian, 4th edn, p 735, 1982. Camlibel FT: Spontaneous rupture of uterus caused by placenta percreta. NY State J Med Aug: 1373, 1981. Garnet JD: Uterine rupture during pregnancy. Obstet Gynecol 23: 898, 1964. Golan A, Sandbank M, Rubin A: Rupture of the pregnant uterus. Obstet Gynecol 56: 549, 1980. Iddenden DA, Nuttall ID: Early spontaneous rupture of the gravid uterus. Am J Obstet Gynecol IS: 971, 1983.
Int J Gynecol Obstet 31
Lazarus EJ: Early rupture of the gravid uterus. Am J Obstet Gynecol 132: 224, 1978. Palerme GR, Friedman EA: Rupture of the gravid uterus in the third trimester. Am J Obstet Gynecol 94: 571, 1966. Schram M, Askari M: Spontaneous rupture of uterus caused by placenta accreta at 17 weeks’ gestation. Report of a case. Obstet Gynecol 25: 624, 1965. Schrinsky DC, Benson RC: Kupture of the pregnant uterus: A review. Obstet Gynecol Surv 33: 217, 1978.
Address for reprints: D. Golan Department of Obstetrics and Gynecology Hail8 Medical Center (Rothschild) P.O. Box 4940 Hnifa 31048 Israel
