Abstract
Uterine fibroids (leiomyomas) are benign smooth muscle tumors of the uterus. Fibroids can develop anywhere within the muscular wall. Leiomyomas may be associated with infertility. Laparoscopic myomectomy is often used to remove symptomatic intramural or subserosal fibroids. Advantages of the procedure include short recovery time and minimal perioperative morbidity. At the same time, the multilayer suture technique is more complicated during laparoscopy. A rare but serious complication of laparoscopic myomectomies is uterine rupture. A brief review of the literature and a clinical example of a 33-year-old woman with history of infertility, laparoscopic myomectomies and uterine rupture followed by peripartum hemorrhage is presented. The treatment of leiomyomas is a challenge not only because of possible recurrence but also due to long-term consequences following successful myomectomy. Management of patients with uterine scars should include careful planning of the route of delivery, as the risk of rupture may be increased.
Uterine rupture is a rare but serious complication of pregnancy. This medical condition is defined as the tearing of all uterine layers and may be life-threatening for both the mother and the fetus. Most cases of uterine rupture occur in patients who have undergone surgical procedures in the past, but it can also occur in women with unscarred uteruses.
Uterine scars may have various origins; the two most common situations include Cesarean deliveries and surgical treatment of fibroids. Uterine fibroids (leiomyomas) are benign smooth muscle tumors of the uterus, which may develop anywhere within the muscular wall.
The estimated occurrence of unscarred pregnant uterine rupture ranges from 1 in 20,000 to 1 in 5,700 pregnancies (1-4). The risk of rupture increases to 0.3-1% among women with previous Cesarean section (5-7). The situation is similar in cases of women who have undergone different types of surgeries, including myomectomy. Some studies indicate that the incidence of uterine rupture following myomectomy may be between 1% and 3.7% of pregnancies (8, 9).
Overall, an increasing trend of uterine rupture has been observed in recent decades. According to a Norwegian study comparing prevalence of uterine rupture over a period of 40 years, the incidence was six-times higher in 2008 than in 1978 (10). Therefore, it may be necessary to pay more attention to this obstetric complication.
Influence of Leiomyoma on Fertility
Leiomyomas are estimated to be associated with 1 to 2% of infertility cases (11). Management of women with fibroids and infertility without a diagnosed reason should focus on both increasing the chances of pregnancy and avoiding unnecessary myomectomy. The fundamental factor related to fertility is fibroid location, not size (12). Notably, leiomyomas are the most common pelvic tumors among women, and the vast majority develop before menopause. The exact percentage may even reach 70-80% of women, depending on ethnicity (13). Leiomyomas are usually classified according to location as intramural, submucosal, subserosal, cervical or hybrid (in cases where both the serosa and endometrium are impacted) (14). The method of treatment should be carefully and individually selected, as different types of fibroids may require different approaches. In addition, some methods, including systemic treatment, may negatively affect fertility.
Subserosal fibroids do not seem to affect fertility. However, treatment of subserosal fibroids may be necessary because of other typical symptoms. The impact of intramural leiomyomas on fertility has not been precisely identified (12). It is possible that intramural tumors located near the fallopian tube ostium or the uterine cervix disrupt fertilization (15, 16). Submucosal fibroids have the highest impact on the uterine cavity environment and may therefore interfere with conception and pregnancy outcome (17).
Fibroids may affect fertility in numerous ways, such as by interfering with implantation or rapidly distending the uterus in early pregnancy. Medical treatment depends on the location, size, and number of leiomyomas.
Methods of Leiomyoma Treatment and Their Impact on Fertility
Pharmacological treatment of fibroids may lead to ovulation suppression and decreased estrogen production, may have a negative effect on receptor activity, and can potentially interfere with implantation. Therefore, this is not a therapy of choice for patients with fertility issues, which makes surgical methods preferable (18).
Many studies report that laparoscopic treatment is superior to laparotomic myomectomy (19, 20). This is mostly due to shorter hospitalization and quicker recovery time, minimal perioperative morbidity, less postoperative pain and less blood loss. The main criteria for choosing the best type of myomectomy are the experience of the surgical team and the appropriate selection of patients. The laparoscopic technique requires excellent skills, as it is more difficult to make adequate sutures using this method. In some cases of subserosal fibroids, especially those of small sizes, multilayer sutures may not be required.
Several complications are more likely to develop after laparoscopic myomectomy. Uterine rupture affects a small proportion of patients, but its outcome may be very severe, even fatal (9). It is crucial to remember that some complications may be avoided by using the proper technique when performing a laparotomy. Abdominal fibroid removal via anterior uterine incision minimizes the formation of postoperative adhesions (18).
Case Report
This case describes pregnancy outcome in a 33-year-old patient with 4-year history of infertility, including laparoscopic treatment of leiomyomas. Myomectomy was performed twice, at 4 years and 12 months prior to admission. Surgical fibroid treatment did not lead to spontaneous conception. Consequently, the patient underwent assisted reproduction therapy by in vitro fertilization. This procedure resulted in dichorionic diamniotic twin pregnancy.
The patient was admitted to hospital in the 31st week of gestation because of threatened preterm delivery. A pessary insertion procedure was performed 3 weeks prior to admission. Therefore, pharmacological treatment with tocolytics and steroids was implemented. The patient demonstrated intolerance to beta-mimetics by developing dyspnea and this required withdrawal of the tocolytic agent.
Uterine rupture at a postmyomectomic site during the 32nd week of gestation.
On account of labor onset and abnormal cardiotocographic records of one fetus, a Cesarean section was performed in the 32nd week of gestation. During the operation, a rupture in a post-laparoscopic scar of the front wall of the uterus was revealed (Figure 1). No newly developed leiomyomas were observed. The wound was sutured immediately after the delivery. Unfortunately, peripartum hemorrhage could not be completely prevented. Perioperative blood loss was approximately 1,500 ml, and the patient required a blood transfusion. Altogether, 3 units of packed red blood cells, 3 units of blood plasma and 3 units of cryoprecipitate were transfused.
The patient gave birth to premature twin boys, both assessed at 10 points using the Apgar score. The birth weights of the neonates were 1,700 g and 1,980 g.
The rupture was located at the site of a previous myomectomy in the front uterine wall. An abdominal scan performed one day after delivery showed an accumulation of fluid above the muscular tissue in the area of the incision as well as beneath the muscle.
Discussion
This clinical example demonstrates complications of twin pregnancy in a woman with a history of leiomyomas and shows the influence of benign tumors of the uterus on female reproductive system.
Firstly, the patient's fertility potential could have been reduced by altering uterine function, which is essential for implantation and maintenance of pregnancy (12, 17). Additionally, long-term side-effects of laparoscopic myomectomy include uterine scars, which are composed of weaker tissue than that of native uterine tissue (8). In this case, the tensile strength of uterus was reduced and resulted in rupture during contractions.
The risk of uterine rupture in this patient was even higher because of the multiple pregnancy following in vitro fertilization. Application of assisted reproductive technology was required after previously inefficient infertility treatment, including two myomectomies.
Conclusion
Treatment of leiomyomas is a challenge not only because of possible recurrence, but also due to the long-term consequences of successful myomectomy. Surgical treatment of fibroids is not always an effective method for treating infertility, and patients should be selected with great care. Management of pregnant patients with prior myomectomy should include careful planning of the route of delivery, as the risk of rupture may be increased.
Footnotes
↵* This paper was presented at the 5th International Charité-Mayo Conference, 15-18 April 2015, Berlin, Germany.
- Received December 6, 2015.
- Revision received January 18, 2016.
- Accepted January 19, 2016.
- Copyright© 2016 International Institute of Anticancer Research (Dr. John G. Delinassios), All rights reserved
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