Spontaneous uterine rupture in the 35th week of gestation after laparoscopic adenomyomectomy

Uterine Rupture With Placenta Percreta Following Multiple Adenomyomectomies

Pregnancy following adenomyomectomy is challenging because uterine rupture or placenta accreta spectrum (PAS) is more likely to occur; however, optimal management has not yet been established. We herein present a case of uterine rupture with placenta percreta in a pregnant woman who underwent adenomyomectomy twice before pregnancy. Magnetic resonance imaging (MRI) was performed in the second trimester and imminent uterine rupture concomitant with PAS was suspected. The patient was immediately admitted to hospital for careful management. Although failed tocolysis forced delivery at 29 weeks of gestation, managed hospitalization allowed cesarean hysterectomy to be performed uneventfully. Extensive PAS was proven pathologically in the removed uterus. Pregnancies following multiple adenomyomectomies are considered to be high-risk. Therefore, a sufficient explanation of the risks associated with future pregnancies is needed, particularly following second adenomyomectomy.

MED12 mutations and fumarate hydratase inactivation in uterine adenomyomas

STUDY QUESTION

Do the uterine leiomyoma driver events – mediator complex subunit 12 (MED12) mutations, high mobility group AT-hook (HMGA2) overexpression, and fumarate hydratase (FH) inactivation – also contribute to the development of uterine adenomyomas?

SUMMARY ANSWER

MED12 mutations and FH deficiency occur in a subset of uterine adenomyomas, but at lower frequencies than in leiomyomas.

WHAT IS KNOWN ALREADY

Uterine adenomyomas are benign tumours with clinical features very similar to uterine leiomyomas. Mutations affecting MED12, HMGA2 and FH account for up to 80–90% of leiomyomas, but their contribution to adenomyomas is not known.

STUDY DESIGN, SIZE, DURATION

Formalin-fixed paraffin-embedded adenomyoma samples from 21 patients operated on during 2012–2014 were collected at the pathology department’s archives and analysed for uterine leiomyoma driver events.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Adenomyoma diagnoses were verified by a specialized pathologist and representative areas were marked on haematoxylin-eosin slides. DNA was extracted from the tissue samples and sequenced to detect mutations in MED12. Expression levels of HMGA2 and 2SC, a robust indirect method to detect FH inactivation, were analysed by immunohistochemistry (IHC). The coding region of FH was sequenced in one adenomyoma sample showing strong 2SC staining as well as in the same patient’s normal tissue sample. All patients’ medical histories were collected and reviewed.

MAIN RESULTS AND THE ROLE OF CHANCE

MED12 mutation c.131G > A, p.G44D, the most common mutation in uterine leiomyomas, was identified in two samples (2/21; 9.5%). One adenomyoma displayed strong 2SC positivity and subsequent sequencing revealed a frameshift FH mutation c.911delC, p.P304fs in the tumour. The mutation was also present in the patient’s normal tissue sample, indicating that she has a hereditary leiomyomatosis and renal cell cancer (HLRCC) syndrome. HMGA2 protein expression was normal in all adenomyomas.

LIMITATIONS, REASONS FOR CAUTION

Restricted sample size limits the determination of exact mutation frequencies of the studied aberrations in adenomyomas.

WIDER IMPLICATIONS OF THE FINDINGS

Uterine leiomyoma driver mutations do contribute to the development of some adenomyomas. We also report an adenomyoma in the context of hereditary HLRCC syndrome. Despite clinical similarities, the pathogenic mechanisms of adenomyomas and leiomyomas are likely different. Large-scale genomic analyses are warranted to elucidate the complete molecular background of adenomyomas.

STUDY FUNDING/COMPETING INTERESTS

This study was supported by The Academy of Finland, the Sigrid Jusélius Foundation, and the Cancer Society of Finland. The authors declare no conflict of interest.

Uterine Rupture after Laparoscopic Myomectomy in Two Cases: Real Complication or Malpractice?

We describe two cases of uterine rupture in pregnancy after laparoscopic myomectomy and analyze all the aetiological factors involved in this circumstance according to the recent literature, focusing above all on the surgical procedures and the characteristics of the excised myomas. The two cases of uterine rupture in pregnancy following laparoscopic myomectomy occurred at 36 and 18 weeks of gestation, respectively. Both women had undergone laparoscopic multiple myomectomy and uterine rupture occurred along the isthmic myomectomy scars, despite the fact that compliance with all the recent technical surgical recommendations for the previous laparoscopic multiple myomectomy had been fully observed. In our cases we identified the isthmic localization, size of the excised myomas (≥4 cm), and individual characteristics of the healing process as possible risk factors for “a real complication.” Larger studies and robust case-control analyses are needed to draw reliable conclusions; special care should be paid when performing laparoscopic myomectomy in women planning a later pregnancy.

Monochorionic twin delivery after conservative surgical treatment of a patient with severe diffuse uterine adenomyosis without uterine rupture

A 31-year-old nulliparous woman with severe diffuse uterine adenomyosis, which replaced nearly the whole uterine myometrium, visited our hospital due to severe dysmenorrhea, menorrhagia, and a desire to have a baby. The patient had a history of two spontaneous abortions. Laparotomic adenomyomectomy with transient occlusion of uterine arteries (TOUA) was performed safely and the patient tried in vitro fertilization and achieved a intrauterine twin pregnancy after recovery time of the operation. At 31+6 weeks of gestation, a male neonate baby weighing 1,620 g and a male neonate baby weighing 1,480 g were born by transverse lower segment cesarean delivery. There was no complication after the operation. The babies were discharged after receiving routine neonatal intensive care for neonatal respiratory distress syndrome. Adenomyomectomy with TOUA technique would be an option for conservative surgical treatment in patients with severe diffuse whole uterine adenomyosis. This is the first report of twin pregnancy after diffuse whole uterine adenomyomectomy with TOUA.

US-color Doppler early diagnosis of uterine rupture with protrusion of umbilical cord

OBJECTIVE

to analyze a case of uterine rupture in a pregnant woman that had a previous laparoscopic myomectomy.

METHODS

pregnant woman at 34 weeks gestation came to our emergency room for abdominal pain. She had undergone a previous laparoscopic multiple myomectomy. Patient was evaluated in our Department, that is a tertiary center, by a team of experienced ultrasonographers.

RESULTS

at a first clinical examination, the findings were a deep abdominal pain, dysuria and a positive Giordano's sign on the right. 2D ultrasound showed an alive intrauterine foetus, normal anterior fundal placenta and mild reduction of amniotic fluid. It revealed also a maternal right pyelectasis. A further meticulous ultrasound evaluation plus color Doppler revealed on the left side of the uterus the presence of a small vascularised area with venous and arterial flow that seemed to be in continuity with umbilical cord and that had its ultrasound characteristics. Emergency laparotomy was performed and confirmed the hypothesis of uterine rupture.

DISCUSSION

uterine rupture seems to occur more frequently as a consequence of a laparoscopic myomectomy and the classic signs and symptoms are fetal distress, loss of uterine contractility, abdominal pain, hemorrhage and shock, so the early US suspect of uterine rupture was extremely important in the decision to perform an emergency caesarean section.

CONCLUSION

the correlation between clinical examination and ultrasound-Doppler findings has been essential to recognise an obstetrical emergency and to perform prompt surgery.