Spontaneous uterine rupture after myomectomy in patients during pregnancy: Clinical cases in a single university center

Uterine rupture is an infrequent yet sometimes fatal complication of a subsequent vaginal birth attempt following a previous uterine surgery. We have chosen to write about spontaneous uterine ruptures following myomectomy due to the scarcity of data on this subject, stemming from the limited number of reported cases. Furthermore, with the increasing trend of advanced maternal age, there is a growing cohort of pregnant women with a history of myomectomy, thereby presenting a timely opportunity to examine this phenomenon in greater depth. A total of 28 studies reporting pregnancies after prior myomectomy, resulting in 3.502 viable (≥24 weeks) deliveries, were reviewed. The overall incidence of uterine rupture after myomectomy of 0.6%, comparable with those reported in other reviews. Our review confirmed that the incidence of uterine rupture is very low, 0.4%, in the group of women who experienced a trial of labor after myomectomy (TOLAM). In particular, the difference of incidences of uterine rupture before or during labor was not statistically significant. Therefore, uterine rupture may not be significantly influenced by a TOLAM and so this option could be considered in pregnant women as feasible and relatively safe. This study presents three medical cases that occurred at our institution in 2023 of pregnant patients who had undergone surgery for myomectomy and experienced uterine rupture out of labor. The first is a clinical case of a 42-year-old woman affected by endometriosis who had undergone laparoscopic myomectomy 1 year before conception. The actual pregnancy was conceived by intracytoplasmatic sperm injection (ICSI). The patient presented at 22+4 weeks' gestation to the emergency department (ED) for abdominal pain. On hospital presentation, transabdominal ultrasound evidenced a single fetus, with fetal heart rate 163 beats/min and free fluid in the Morrison's pouch with a blood clot at the uterine fundus. Abdominal computed tomography (CT) scan with and without contrast was performed due to the unclear origin of the hemoperitoneum. CT scan revealed abundant abdominal free fluid, especially perihepatic (3 cm), in the left hypochondrium (2 cm), parieto-colic gutter and anterior the uterus, without contrast spreading; the uterus had inhomogeneous density and profiles. One hour after hospitalization, the patient was admitted to the operating room: a 10 cm fundal uterine rupture with protruding amniotic sac was present. The second is a clinical case of a 32-year-old woman who had undergone laparoscopic myomectomy 23 months before conception. An intramural myoma 6 cm in diameter was located on the posterior wall of the uterus. The patient conceived spontaneously 23 months later. The woman presented at 36+3 weeks' gestation to the ED for irregular uterine contractions (1 uterine contraction every 10–15 min). Three hours after admission, irregular uterine contractions were still present (1 uterine contraction every 10–15 min): the patient was thereby hospitalized. One hour after hospitalization, the patient reported a prolonged contraction and the transabdominal ultrasound check evidenced fetal bradycardia. An immediate cesarean section was performed, showing a massive hemoperitoneum which was promptly drained. After fetal extraction and manual removal of the placenta, a close uterine inspection was performed, showing a 15 cm uterine rupture involving the posterior wall. The third is a clinical case of a 28-year-old woman who had undergone laparoscopic myomectomy 2 years before conception. The patient reported that the uterine cavity was opened to remove an intramural myoma of 6 cm in diameter located on the left anterolateral wall of the uterus. She conceived spontaneously 2 years later, and the course of the pregnancy was uncomplicated. The patient presented at 31+0 weeks' gestation to the ED for abdominal pain. On hospital presentation, transabdominal ultrasound scan evidenced a single fetus with normal heart rate and a growing blood clot at the uterine fundus. The patient was admitted to the operating room for exploratory laparotomy, confirming a massive hemoperitoneum. A 7 cm uterine rupture with protruding amniotic sac was present in the left posterolateral uterine wall. The surgeon hence proceeded to perform hysterotomy, amniorrhexis, fetal extraction of a fetus alive and vital, and manual removal of the placenta. The patient's uterus was surgically repaired with double layer suture. The amount of total blood loss was 1800 mL. A total of four units of packed red blood cells and two units of fresh frozen plasma were transfused. The patient recovered well and was discharged 7 days after surgery.