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A treacherous scar
Images in Obstetrics
www. AJOG.org
A treacherous scar Luciano Leidi, MD; Maurizio Brusati, MD; Maria G. Vespa, MD
CASE NOTES
A 33-year-old primigravida was seen at 20 weeks’ gestation for abdominal pain and vaginal bleeding. Four months before becoming pregnant, she underwent laparoscopic myomectomy with removal of a 10-cm subserous-intramural leiomyoma of the uterine fundus. At physical examination, the fetal heart beat could not be auscultated. The patient’s abdomen was tense; her cervix was closed; and there was evidence of scant vaginal bleeding. An abdominal ultrasound showed a single fetus without cardiac pulsation, surrounded by normal amniotic fluid. The biometry was in range for gestational age. An abrupted placenta was suspected, but abdominal sonography could not definitively assess the placental site. A subsequent transvaginal ultrasound supplied unexpected results: the patient’s uterus was clearly empty. The posterior wall near the fundus was ruptured, and through this defect, the placenta appeared almost completely abrupted (Figure 1).
A transvaginal ultrasound provided unexpected results. Leidi. A treacherous scar. AJOG 2007.
CONCLUSIONS Laparotomy disclosed a 1.5-L hemoperitoneum and a broad tear in the posterior uterine fundus. The fetus, a normal, 318 g, female with an intact amniotic sac, was completely extruded (Figure 2). We delivered the fetus and the placenta and then repaired the uterine defect using 2 layers of sutures. From the Department of Obstetrics and Gynecology, Chivasso Civic Hospital, Chivasso (Turin), Italy. Cite this article as: Leidi L, Brusati M, Vespa MG. A treacherous scar. Am J Obstet Gynecol 2007;197: 553.e1-553.e2. 0002-9378/$32.00 © 2007 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2007.08.051
Transfusions were administered, and the patient was discharged on the fifth postoperative day. Uterine rupture during pregnancy is an exceptional event among patients who have undergone myomectomy by laparotomy. In contrast, laparoscopic myomectomy is increasingly implicated when uterine rupture occurs in early pregnancy. One possible cause of the rising frequency of uterine rupture after laparoscopic myomectomy is the wide use of electrosurgery, which might result in poor vascularization and tissue necrosis. These factors could have a deleterious effect on scar strength. Furthermore, meticulous closure of the myometrial bed
following myomectomy is difficult by laparoscopy, and this could interfere with scar integrity.1 However, in some reported cases of laparoscopically-assisted myomectomy, the uterine incision was repaired in layers through a minilaparotomy, suggesting that the ultimate strength of the uterine scar may depend not only on how the incision is sutured but also on how it is made.2 Moreover, a short time interval between surgery and pregnancy could be a risk factor for incomplete healing, but there are no data to support this hypothesis. Indeed, a previously described case occurred 8 years after laparoscopic myomectomy.3 Sonographic detection of uterine rupture should be a feasible objective. Actu-
NOVEMBER 2007 American Journal of Obstetrics & Gynecology
553.e1
Images in Obstetrics FIGURE 2
Operative findings exposed an extraordinary situation
www.AJOG.org ing some features of the uterine rupture, such as the empty uterus, which otherwise would have gone unnoticed. Although uterine rupture in pregnancy after myomectomy—including laparoscopic myomectomy—is rare, women who have undergone the procedure should be closely watched throughout pregnancy. Uterine rupture should be part of the differential diagnosis if f they present with abdominal pain. REFERENCES
Leidi. A treacherous scar. AJOG 2007.
ally, the correct diagnosis can be missed when an abdominal examination is performed because direct signs of rupture (ie, the gap in the uterine wall and the bulge of the amniotic sac) and indirect
553.e2
signs (ie, hemoperitoneum and the empty uterus with the fetus outside) can be masked by advanced pregnancy. This case illustrates that transvaginal sonography appears more effective in identify-
American Journal of Obstetrics & Gynecology NOVEMBER 2007
1. Dubuisson JB, Fauconnier A, Deffarges JV, Norgaard C, Kreiker G, Chapron C. Pregnancy outcome and deliveries following laparoscopic myomectomy. Hum Reprod 2000;15:869-73. 2. Asakura H, Oda T, Tsunoda Y, Matsushima T, Kaseki H, Takeshita T. A case report: change in fetal heart rate pattern on spontaneous uterine rupture at 35 weeks’ gestation after laparoscopically assisted myomectomy. J Nippon Med Sch 2004;71:69-72. 3. Oktem O, Gökaslan H, Durmusoglu F. Spontaneous uterine rupture in pregnancy 8 years after laparoscopic myomectomy. J Am Assoc Gynecol Laparosc 2001;8:618-21.
www. AJOG.org
A treacherous scar Luciano Leidi, MD; Maurizio Brusati, MD; Maria G. Vespa, MD
CASE NOTES
A 33-year-old primigravida was seen at 20 weeks’ gestation for abdominal pain and vaginal bleeding. Four months before becoming pregnant, she underwent laparoscopic myomectomy with removal of a 10-cm subserous-intramural leiomyoma of the uterine fundus. At physical examination, the fetal heart beat could not be auscultated. The patient’s abdomen was tense; her cervix was closed; and there was evidence of scant vaginal bleeding. An abdominal ultrasound showed a single fetus without cardiac pulsation, surrounded by normal amniotic fluid. The biometry was in range for gestational age. An abrupted placenta was suspected, but abdominal sonography could not definitively assess the placental site. A subsequent transvaginal ultrasound supplied unexpected results: the patient’s uterus was clearly empty. The posterior wall near the fundus was ruptured, and through this defect, the placenta appeared almost completely abrupted (Figure 1).
A transvaginal ultrasound provided unexpected results. Leidi. A treacherous scar. AJOG 2007.
CONCLUSIONS Laparotomy disclosed a 1.5-L hemoperitoneum and a broad tear in the posterior uterine fundus. The fetus, a normal, 318 g, female with an intact amniotic sac, was completely extruded (Figure 2). We delivered the fetus and the placenta and then repaired the uterine defect using 2 layers of sutures. From the Department of Obstetrics and Gynecology, Chivasso Civic Hospital, Chivasso (Turin), Italy. Cite this article as: Leidi L, Brusati M, Vespa MG. A treacherous scar. Am J Obstet Gynecol 2007;197: 553.e1-553.e2. 0002-9378/$32.00 © 2007 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2007.08.051
Transfusions were administered, and the patient was discharged on the fifth postoperative day. Uterine rupture during pregnancy is an exceptional event among patients who have undergone myomectomy by laparotomy. In contrast, laparoscopic myomectomy is increasingly implicated when uterine rupture occurs in early pregnancy. One possible cause of the rising frequency of uterine rupture after laparoscopic myomectomy is the wide use of electrosurgery, which might result in poor vascularization and tissue necrosis. These factors could have a deleterious effect on scar strength. Furthermore, meticulous closure of the myometrial bed
following myomectomy is difficult by laparoscopy, and this could interfere with scar integrity.1 However, in some reported cases of laparoscopically-assisted myomectomy, the uterine incision was repaired in layers through a minilaparotomy, suggesting that the ultimate strength of the uterine scar may depend not only on how the incision is sutured but also on how it is made.2 Moreover, a short time interval between surgery and pregnancy could be a risk factor for incomplete healing, but there are no data to support this hypothesis. Indeed, a previously described case occurred 8 years after laparoscopic myomectomy.3 Sonographic detection of uterine rupture should be a feasible objective. Actu-
NOVEMBER 2007 American Journal of Obstetrics & Gynecology
553.e1
Images in Obstetrics FIGURE 2
Operative findings exposed an extraordinary situation
www.AJOG.org ing some features of the uterine rupture, such as the empty uterus, which otherwise would have gone unnoticed. Although uterine rupture in pregnancy after myomectomy—including laparoscopic myomectomy—is rare, women who have undergone the procedure should be closely watched throughout pregnancy. Uterine rupture should be part of the differential diagnosis if f they present with abdominal pain. REFERENCES
Leidi. A treacherous scar. AJOG 2007.
ally, the correct diagnosis can be missed when an abdominal examination is performed because direct signs of rupture (ie, the gap in the uterine wall and the bulge of the amniotic sac) and indirect
553.e2
signs (ie, hemoperitoneum and the empty uterus with the fetus outside) can be masked by advanced pregnancy. This case illustrates that transvaginal sonography appears more effective in identify-
American Journal of Obstetrics & Gynecology NOVEMBER 2007
1. Dubuisson JB, Fauconnier A, Deffarges JV, Norgaard C, Kreiker G, Chapron C. Pregnancy outcome and deliveries following laparoscopic myomectomy. Hum Reprod 2000;15:869-73. 2. Asakura H, Oda T, Tsunoda Y, Matsushima T, Kaseki H, Takeshita T. A case report: change in fetal heart rate pattern on spontaneous uterine rupture at 35 weeks’ gestation after laparoscopically assisted myomectomy. J Nippon Med Sch 2004;71:69-72. 3. Oktem O, Gökaslan H, Durmusoglu F. Spontaneous uterine rupture in pregnancy 8 years after laparoscopic myomectomy. J Am Assoc Gynecol Laparosc 2001;8:618-21.