In the current case, we were able to successfully diagnose spontaneous bleeding from the rupture of the superficial vessels overlying a uterine fibroid and then treat the uterine fibroid by laparoscopic enucleation to remove the origin of the bleeding.
Intra-abdominal bleeding due to uterine fibroids is rare in the literature, with around 125 cases reported to date [11, 12]. According to a recent review, women who experience this complication typically suffer from hypovolemic shock and abdominal pain with no clear preoperative diagnosis, and the mortality rate is approximately 3.2%. . In most cases, bleeding from a uterine fibroid has been associated with trauma or torsion of pedunculated fibroids, while spontaneous rupture of superficial vessels is extremely rare [13, 14]. In cases associated with bleeding, the source was primarily venous in origin . There have been several hypotheses regarding the cause of the spontaneous vascular rupture associated with uterine fibroids. One hypothesis is that rupture of superficial vessels overlying the fiborid may be due to passive venous congestion associated with increased abdominal pressure during menses or during defecation, heavy weight lifting, or exercise [15,16,17]. Another hypothesis is that uterine fibroids larger than 10 cm in diameter may be associated with stretching and straining of the overlying vessels, which could lead to rupture . The third hypothesis is that micro-RNAs, specifically miR-29b, which play a central role in promoting fibroid formation, and upregulate mRNAs for several collagens in uterine fibroids is recently reported to lead to the pathogenesis of leiomyomas and progesterone down-regulated miR-29b and up-regulated mRNAs for several collagens in fibroids can result in uterine fibroid growth being inhibited . In the current case, we suspect that the extreme congestion of the superficial veins of uterine fibroids from progesterone deprivation during late menses, together with the size of the uterine fibroid, which was >10 cm in diameter, may have contributed to the venous rupture. Furthermore, the decrease in progesterone in late menses may contribute to upregulating miR-29b and downregulating mRNAs as an epigenetic change. and led to the rupture of the superficial vessels overlying a uterine fibroid.
Accurate preoperative diagnosis is extremely difficult due to the rarity of this entity [12, 21]. Imaging tests such as ultrasonography and computed tomography are often used for preoperative evaluation, but in most cases the preoperative diagnosis is unexplained hemoperitoneum. Recently, Scioscia and colleagues [22, 23] commented that vascularity with Doppler ultrasound can improve the detection rate of endometrial cancer, which is a relevant cause of abdominal uterine bleeding in women before or during menopause, since the vascularity of myometrium is not altered in fibroids while it is abnormal in infiltrating endometrial cancer . In addition, Stabile et al. recommended that Meigs syndrome be considered as a differential diagnosis in the detection of unexplained hemoperitoneum since ovarian cancer was misdiagnosed due to the presence of a pelvic tumor, elevated CA-125 and ascites and the patient was undergoing total abdominal hysterectomy, salpingoophorectomy and pelvic removal underwent mass, pelvic lymphadenectomy and peritoneal biopsies. Peritoneal biopsies, although it was Meigs syndrome with ovarian fibroma . In this case, unfortunately, we misdiagnosed it as hemoperitoneum associated with torsion of subserosal fibroids. Therefore, clinical examination with ultrasound, especially Doppler ultrasound, is sufficient for preoperative diagnosis, since the operation should not be delayed, especially in the case of pronounced hemodynamic instability .
While supportive and resuscitative measures are critical in the management of patients with massive intra-abdominal hemorrhage, surgeries such as hysterectomy and myomectomy should be performed promptly. The preferred procedure is hysterectomy in postmenopausal women and myomectomy in women of reproductive age, as preservation of the uterus should be the priority. If the bleeding cannot be controlled, a hysterectomy must be considered . In the present case, we chose the laparoscopic surgical approach to identify the bleeding source, followed by haemostasis at the bleeding site and myomectomy with repair of the uterine defect.
To our knowledge, this is the first report of a case in which a hemoperitoneum of uncertain origin was diagnosed laparoscopically and treated by laparoscopic myomectomy to remove the bleeding source. However, a previous report has described the use of laparoscopy to diagnose the source of bleeding and excision of the uterine fibroid by laparotomy .
In conclusion, although acute complications of uterine fibroids requiring surgical intervention are exceptionally rare, bleeding from rupture of the superficial vessels overlying a uterine fibroid should be included in the differential diagnosis of unexplained hemoperitoneum. Surgeons should quickly diagnose and treat women with acute abdominal pain and a history of uterine fibroids to prevent severe morbidity or even mortality. Based on our experience with this case, we recommend laparoscopic surgery in patients with stable hemodynamics.