Characteristics of uterine rupture after laparoscopic surgery of the uterus: clinical analysis of 10 cases and literature review

Currently Available Treatment Modalities for Uterine Fibroids

Uterine fibroids (leiomyomas and myomas) are the most common benign gynecological condition in patients presenting with abnormal uterine bleeding, pelvic masses causing pressure or pain, infertility and obstetric complications. Almost a third of women with fibroids need treatment due to symptoms.

OBJECTIVES

In this review we present all currently available treatment modalities for uterine fibroids.

METHODS

An extensive search for the available data regarding surgical, medical and other treatment options for uterine fibroids was conducted.

REVIEW

Nowadays, treatment for fibroids is intended to control symptoms while preserving future fertility. The choice of treatment depends on the patient's age and fertility and the number, size and location of the fibroids. Current management strategies mainly involve surgical interventions (hysterectomy and myomectomy hysteroscopy, laparoscopy or laparotomy). Other surgical and non-surgical minimally invasive techniques include interventions performed under radiologic or ultrasound guidance (uterine artery embolization and occlusion, myolysis, magnetic resonance-guided focused ultrasound surgery, radiofrequency ablation of fibroids and endometrial ablation). Medical treatment options for fibroids are still restricted and available medications (progestogens, combined oral contraceptives andgonadotropin-releasing hormone agonists and antagonists) are generally used for short-term treatment of fibroid-induced bleeding. Recently, it was shown that SPRMs could be administered intermittently long-term with good results on bleeding and fibroid size reduction. Novel medical treatments are still under investigation but with promising results.

CONCLUSIONS

Treatment of fibroids must be individualized based on the presence and severity of symptoms and the patient's desire for definitive treatment or fertility preservation.

Cystic Adenomyoma in Pregnancy: A Case Report

Cystic adenomyomas (CA) are rare. They primarily affect adolescents and young women in their fertile years. Therefore, fertility and pregnancy outcome are of pivotal relevance in this patient collective. Apart from the guidelines of the European Society of Human Reproduction and Embryology (ESHRE) on the management of endometriosis in general, there are no specific treatment recommendations for CA and, as far as our research shows, no data illustrating the behavior of a CA over the course of pregnancy. Thus, we report the case of a 32-year-old 1-gravida, 1-para, preconceptionally diagnosed with a CA by ultrasound. After thoroughly discussing further treatment options, the decision was made to opt for a more conservative approach and not perform surgery before attempting a next pregnancy. The patient conceived spontaneously and sonographic monitoring of the CA throughout pregnancy showed complete regression of the cystic component during the second trimester. A healthy baby was delivered at term by an uncomplicated elective cesarean section. Following a review of the literature and taking into account the course of our case, we propose the feasibility of a conservative, non-surgical approach in women with a CA and the desire to conceive.

Pregnancy outcomes of adenomyotic patients with primary infertility after high-intensity focused ultrasound treatment

OBJECTIVE

To evaluate the therapeutic effect of high-intensity focused ultrasound (HIFU) treatment for adenomyotic patients with primary infertility and to explore the factors that affect the pregnancy outcomes.

MATERIALS AND METHODS

Twenty-seven adenomyotic patients with primary infertility who underwent HIFU at HUNAN Provincial Maternal and Child Health Care Hospital, China, between July 2018 and December 2022 were retrospectively reviewed. We evaluated the pregnancy outcomes and analyzed the factors that may affect pregnancy outcomes including time to conception, pregnancy approach, gestational age, delivery mode, neonatal outcomes, and complications during pregnancy and delivery.

RESULTS

Among the 27 adenomyotic patients with primary infertility, 10 patients had a total of 11 pregnancies after HIFU treatment. Of these, eight (72%) cases were natural pregnancies and three (23%) were in vitro fertilization (IVF) pregnancies. The median time to conception was 10 (range 4-25) months. There were eight (72%) successful deliveries. The rate of full-term deliveries was 90%. Of the eight live births, four (50%) were born vaginally and four (50%) by cesarean section. No severe complications occurred. The mean birth weight of newborns was 3.1 (range: 2.3-3.9) kg; all newborns developed well without complications during postpartum and breastfeeding.

CONCLUSIONS

HIFU treatment for adenomyosis could improve fertility of patients with primary infertility. HIFU is a promising therapeutic approach for patients with adenomyosis and infertility who wish to achieve pregnancy and have live birth deliveries.

Spontaneous Uterine Rupture and Adenomyosis, a Rare but Possible Correlation: Case Report and Literature Review

(1) Background: Uterine rupture during pregnancy is a serious obstetric complication with a high incidence of maternal morbidity and mortality. (2) Methods: The present case is a rare event of a uterine rupture occurring in an unscarred uterus in a nonlaboring primigravida woman in the second trimester. The only risk factor in this case was adenomyosis found in the preconceptional phase. (3) Results: The diagnosis of adenomyosis can often be difficult, so patients should be evaluated by a specialized gynecologist. After careful amnestic collection, a gynecological examination and II level ultrasound should be performed in accordance with the Morphological Uterus Sonographic Assessment classification. (4) Conclusions: This evaluation allows us to identify classes of patients at high risk of uterine rupture who, therefore, must be properly informed of the risks both during preconceptional counseling and during pregnancy.

Computed tomography and magnetic resonance imaging findings of gynaecologic emergencies: A pictorial essay

Gynaecologic emergencies include diseases resulting from adnexal and uterine disorders. Some emergencies are life threatening; however, they often have non-specific symptoms and physical findings. Thus, imaging diagnosis is important for evaluating these conditions. The first-choice modality for obstetrics and gynaecology is ultrasonography; however, some cases require computed tomography (CT) and magnetic resonance imaging (MRI) for correct diagnosis. Treatment options for gynaecologic emergencies vary from conservative therapy to emergency surgery, thus a correct diagnosis is critical. The purpose of this article is to describe notable CT and MRI findings of gynaecologic emergencies, which will help emergency department physicians arrive at the correct diagnosis and thus facilitate optimal treatment for patients.

Analysis of Pregnancy Outcomes after Laparoscopic Myomectomy: A Retrospective Cohort Study

Objective. This study aimed to investigate the factors related to pregnancy outcomes after laparoscopic myomectomy. Methods. A retrospective review was conducted on 156 patients aged 18 to 45 years who underwent laparoscopic myomectomy in Ningbo Women and Children’s Hospital from January 2010 to December 2016. Follow-up medical records and information were collected on demographic variables, clinical variables, and postoperative pregnancy rate. The logistic regression model was used to assess the association between related factors and postoperative pregnancy rate or pregnancy outcome. The outcome indicators included $\text{abortion}=0$ , $\text{premature}\text{birth}=1$ , and $\text{full}\text{term}=2$ . The chi-squared test or Fisher’s exact test was used to compare the differences in pregnancy outcomes, postpartum hemorrhage, and placenta adhesion between the cohorts. Results. The size of fibroids correlated with the postoperative pregnancy rate. The larger the fibroids, the lower the postoperative pregnancy rate, and the difference was statistically significant. The number of fibroids and placental adhesions was positively associated with postoperative pregnancy; the higher the number of fibroids, the higher the incidence of placental adhesions. However, the postoperative interval of pregnancy, fibroid size, and number and type of fibroids are not correlated with the pregnancy outcomes of postoperative patients. Conclusions. The size of myoma may influence the pregnancy rate of patients after laparoscopic myomectomy. The number of fibroids can affect the incidence of placental adhesions during postoperative pregnancy.

The effects of laparoscopic myomectomy and open surgery on uterine myoma patients' postoperative immuno-inflammatory responses, endocrine statuses, and prognoses: a comparative study

OBJECTIVE

To explore the effects of laparoscopic myomectomy and open surgery on the postoperative inflammatory responses, endocrine statuses, and prognoses of uterine myoma patients.

METHODS

Uterine myoma patients (n=126) admitted to the Department of Gynecology in our hospital were recruited as the study cohort and divided into an observation group (n=63), and a control group (n=63). The patients in the observation group underwent laparoscopic myomectomies, and the patients in the control group underwent open surgery. The completion times, intraoperative blood loss volumes, postoperative hospital stay durations, postoperative exhaust times, preoperative and postoperative immune function, inflammatory factors, sex hormone levels, postoperative complications, and prognoses were observed.

RESULTS

The observation group showed shorter hospital stays, lower intraoperative blood loss volumes, and shorter postoperative exhaust times (P<0.001). After the surgery, CD3⁺%, CD4⁺%, and CD4⁺%/CD8⁺% were decreased, but the CD8⁺% was increased in the two groups (all P<0.01). The observation group had higher CD3⁺%, CD4⁺% and CD4⁺%/CD8⁺%, and lower CD8⁺% than the control group (all P<0.001). The C-reactive protein, TNF-α, and IL-6 levels were higher after the surgery in the two groups (all P<0.05), but the observation group had lower levels (all P<0.001). The follicle-stimulating hormone and luteinizing hormone levels were lower, but the estradiol levels were higher in the observation group compared to the levels in the control group (all P<0.001). The total number of complications in the observation group was significantly lower than it was in the control group (P<0.05).

CONCLUSION

Laparoscopic myomectomy contributes to quick recoveries and short hospital stays, reduces the postoperative inflammatory response and immunosuppression, has little effect on the postoperative sex hormone levels, and has a low incidence of complications. It is worthy of clinical application.

Time to conceive after myomectomy: should we advise a minimum time interval? A systematic review

The optimal time interval between myomectomy and pregnancy is unclear and no specific guidelines exist. The aim of this review was to study the time interval from myomectomy to pregnancy and the occurrence of uterine rupture after myomectomy. Randomized controlled trials, cohort studies and retrospective studies were used to assess the primary objective, and case reports, cases series or letters to the editor for the secondary objective. Only articles reporting myomectomy performed via the vaginal route, laparotomy, laparoscopy or robot-assisted surgery were selected for inclusion. Among 3852 women who wanted to become pregnant after the surgery, 2889 became pregnant, accounting for 3000 pregnancies (77.9%) and 2097 live births (54.4%). Mean time between myomectomy and pregnancy was estimated at 17.6 months (SD 9.2) for 2451 pregnant women. Among 1016 women, a third were advised to delay attempting to conceive for between 3 and 6 months and another third for between 6 and 12 months. A total of 70 spontaneous uterine ruptures with a mean gestational age of 31 weeks at occurrence were identified. No linear relationship was found between gestational age at the event and time interval from myomectomy to conception (P = 0.706). There are insufficient data to advise a minimal time interval between myomectomy and conception.

Ultrasonic diagnosis of asymptomatic rupture of uterine in second trimester of pregnancy after laparoscopic surgery for interstitial pregnancy: a case report

BACKGROUND

Uterine rupture is a rare, life-threatening event in obstetrics that may be fatal for the mother and fetus. Therefore, obstetricians need to pay attention to and should consider the antenatal diagnosis of uterine rupture in women having its risk factors. Successful conservative management for asymptomatic uterine rupture due to previous laparoscopic surgery for interstitial pregnancy has already been reported but remains understudied.

CASE PRESENTATION

A 39-year-old woman was diagnosed asymptomatic uterine rupture at 22 weeks gestation by a routine second-trimester ultrasound scan. She had a history of laparoscopic salpingectomy with cornual wedge resection for interstitial pregnancy 10 months before this pregnancy. Refusing doctor's twice advice of terminating the pregnancy, the patient insisted carrying on the pregnancy, and followed up by ultrasound and magnetic resonance imaging. Fetal growth was appropriate, fetal movements were good and the patient had no symptoms, without uterine contraction or amniotic fluid loss throughout follow-up period. Caesarean section was carried out at 34 + 1 weeks with a good maternal and neonatal outcome.

CONCLUSIONS

A previous history of laparoscopic salpingectomy with cornual wedge resection could be a risk factor for uterine rupture in pregnant women. Sonographers should be alert to this potential risk in pregnant women with a history of laparoscopic salpingectomy with cornual wedge resection even in asymptomatic patients.

Resection of deep-infiltrating endometriosis could be a risk factor for uterine rupture: a case series with review of the literature

Objective

To highlight the possible correlation between deep-infiltrating endometriosis (DIE) resection and subsequent uterine rupture.

Design

Case series and review of the literature.

Setting

Endometriosis referral hospitals.

Patient(s)

Seven young women who underwent laparoscopic resection of DIE, six of whom had uterine rupture before or during labor; the seventh patient had a posterior wall defect that placed her at increased risk of future uterine rupture.

Intervention(s)

Diagnosis of uterine rupture before or during labor in patients with a history of prior resection of DIE, leading to delivery by emergency delivery section or emergency laparotomy for exploration and repair.

Main Outcome Measure(s)

Immediate neonate and maternal salvaging caesarean delivery or laparotomy followed by surgical correction of the rupture.

Result(s)

As of 2019, no publications in the literature had considered uterine rupture among the obstetric complications of endometriosis. The reporting of such findings is crucial because of the increase in surgical management of endometriosis. We report seven cases of uterine rupture in pregnancy in women who had undergone resection of DIE. In six patients, surgeons found uterine rupture at the level of the previous resected endometriosis and diagnosed a posterior wall defect at the same level in one patient.

Conclusion(s)

Our case series sheds light on the potential increased risk of uterine rupture during pregnancy among women who have had a prior resection of DIE. In future, if these patients are considered high-risk pregnancy cases, their care should be managed by high-risk obstetric specialists.

Misdiagnosis of a twin pregnancy with double-corner uterine rupture following salpingectomy and protrusion of the amniotic sac as an adnexal cyst: a case report

Background

Salpingectomy-associated uterine rupture during intrauterine pregnancy is rare in the clinic. We report a case of pregnancy with bilateral rupture of the uterine horns after bilateral salpingectomy.

Case presentation

A 30-year-old woman of Han ethnicity presented with right epigastric pain at 28 weeks and 6 days of gestation. Examination by colour Doppler ultrasound showed the following: “Twin live births with normal foetal umbilical artery blood flow indexes and a 183 mm × 112 mm anechoic zone in the right front of the uterus”. Initially, we made an incorrect judgement wherein we considered the amniotic sac that was protruding into the abdominal cavity to be an adnexal cyst. Fortunately, the diagnosis of uterine rupture was confirmed before the protruded amniotic sac broke. The mother did not bleed much, and the twin foetuses survived in our case.

Conclusion

A previous history of salpingectomy via laparoscopy could be a risk factor for uterine rupture in pregnant women. Attention should be paid to rare complications of pregnancy. To avoid adverse events, we should pay special attention to women with a history of laparoscopic salpingectomy who complain about abdominal discomfort and offer them a relevant ultrasound examination.

Spontaneous rupture of the uterus following salpingectomy: a case report and literature review

Laparoscopic salpingectomy (LPSC) is the main treatment for ectopic pregnancy, which leads to spontaneous uterine rupture (UR) during pregnancy. We report the characteristics of a woman who had spontaneous UR during pregnancy with a history of salpingectomy. We experienced a 31-year-old woman with a UR in pregnancy with a history of LPSC twice. The patient had a successful pregnancy. We also performed a literature review including cases with spontaneous UR after LPSC. Twenty-seven case reports of 48 women were included in our review. Thirty-five (83.33%, 35/42) women previously received LPSC and 15 (31.25%) developed interstitial pregnancies. The interval between pregnancy and the last surgery did not affect the frequency of interstitial pregnancy and gestational age. Fetal outcomes in patients with UR at the third trimester were better than those at the first and second trimesters. We suggest that close observation and timely treatment by experienced clinicians lead to good outcomes of pregnant women with suspected UR.