Uterine Rupture at 18 Weeks in a Short Interval Pregnancy Following Uterine Surgery

Abstract

Study Objective We examine a case of uterine rupture at 18 weeks gestation in a short interval pregnancy following uterine surgery and review literature on uterine rupture following myomectomy. Design N/A. Setting N/A. Patients or Participants N/A. Interventions N/A. Measurements and Main Results Rates of uterine rupture following myomectomy are around 1%. There is a paucity of data and risk factors remain ill-defined. One study found that 50% of cases occurred with resection of subserosal or pedunculated fibroids alone and that the endometrial cavity was not entered in 80% of cases of rupture. Data loosely suggests that single layer closure, extensive electrocautery use, and lack of hemostasis with hematoma formation may increase risk. Rupture following myomectomy is difficult to predict because the majority occur prior to the onset on labor. There is no consensus on recommended interval to conception given limited data, however 3 to 24-month intervals have been used. One study found full uterine healing in 86% of patients on MRI at 12 weeks post-op with 14.2% of patients having persistent hematoma or edema formation. Entry into the endometrial cavity is widely thought to necessitate delivery by c-section. ACOG recommends c-section from 37w0d to 38w6d for a previous myomectomy but notes that delivery as early as 36w0d may be indicated for an extensive myomectomy. Conclusion Abdominal pain in the setting of second trimester uterine rupture is often attributed to alternative etiologies however suspicion for rupture must remain high. Patients should be counseled explicitly on interval to conception, delivery method, and risk for possible uterine rupture at time of initial myomectomy. In the setting of postsurgical sequelae such as hematoma formation, a longer interval to conception should be considered. Additional data is needed on uterine rupture following myomectomy to better understand risk factors so we can more uniformly counsel patients and decrease the morbidity and mortality associated with rupture. We examine a case of uterine rupture at 18 weeks gestation in a short interval pregnancy following uterine surgery and review literature on uterine rupture following myomectomy. N/A. N/A. N/A. N/A. Rates of uterine rupture following myomectomy are around 1%. There is a paucity of data and risk factors remain ill-defined. One study found that 50% of cases occurred with resection of subserosal or pedunculated fibroids alone and that the endometrial cavity was not entered in 80% of cases of rupture. Data loosely suggests that single layer closure, extensive electrocautery use, and lack of hemostasis with hematoma formation may increase risk. Rupture following myomectomy is difficult to predict because the majority occur prior to the onset on labor. There is no consensus on recommended interval to conception given limited data, however 3 to 24-month intervals have been used. One study found full uterine healing in 86% of patients on MRI at 12 weeks post-op with 14.2% of patients having persistent hematoma or edema formation. Entry into the endometrial cavity is widely thought to necessitate delivery by c-section. ACOG recommends c-section from 37w0d to 38w6d for a previous myomectomy but notes that delivery as early as 36w0d may be indicated for an extensive myomectomy. Abdominal pain in the setting of second trimester uterine rupture is often attributed to alternative etiologies however suspicion for rupture must remain high. Patients should be counseled explicitly on interval to conception, delivery method, and risk for possible uterine rupture at time of initial myomectomy. In the setting of postsurgical sequelae such as hematoma formation, a longer interval to conception should be considered. Additional data is needed on uterine rupture following myomectomy to better understand risk factors so we can more uniformly counsel patients and decrease the morbidity and mortality associated with rupture.