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Uterine rupture before the onset of labor following extensive resection of deeply infiltrating endometriosis with myometrial invasion

Uterine rupture before the onset of labor following extensive resection of deeply infiltrating endometriosis with myometrial invasion
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  BRIEF COMMUNICATION Uterinerupturebeforetheonsetoflaborfollowingextensiveresectionof deeply in 󿬁 ltrating endometriosis with myometrial invasion Paula B. Fettback a , Ricardo M.A. Pereira b , Thais S. Domingues c , Karla G. Zacharias c ,Luciana P. Chamié d , Paulo C. Sera 󿬁 ni c,e, ⁎ a Private practice, São Paulo, Brazil b Centro de Endometriose, Santa Joana Hospital, São Paulo, Brazil c Huntington Centro de Medicina Reprodutiva, São Paulo, Brazil d Chamié Imagem da Mulher, São Paulo, Brazil e Discipline of Gynecology of São Paulo School of Medicine, Center for Human Reproduction, University of São Paulo Medical School, São Paulo, Brazil a r t i c l e i n f o  Article history: Received 6 March 2014Received in revised form 4 November 2014Accepted 6 March 2015 Keywords: Myometrial endometriosisResectionUterine rupture The risk of uterine rupture (UR) before the onset of labor has beeninvestigated in women who have undergone cesarean deliveries withprevious classical incision and in those with thin lower-uterine-segment defects [1,2]. Previous myomectomies are also a known riskfactor for UR  [1]. Additionally, evidence published in the past threedecades suggests that extensive resection of endometriosis developingwithin the uterine wall could increase the chances of UR  [3 – 6].Deeply in 󿬁 ltrating endometriosis (DIE) is characterized by thepresence of endometrial glands and stroma outside the uterus. Deepin 󿬁 ltration into the myometrium is a form of DIE that begins at theuterine serosa and advances toward the endometrium. The richlyvascularized uterine smooth muscle offers a favorable pathway for DIEto develop [7]. Surgical radical resection is the best option to controlDIE. Unfortunately, complete resection of DIE within the uterus cancause substantial thinning of the uterine wall, leaving these areassusceptible to UR during pregnancy. Additionally, the modi 󿬁 ed bloodsupply in the scar tissue is associated with local ischemia.Theaimof the present report istodescribe two casesof UR followingradicalexcisionofDIE.InMarch2010,anulliparouswomanaged31years(G0P0) who had been experiencing dysmenorrhea, dyspareunia, andinfertility for 3 years presented to Huntington Centro de MedicinaReprodutiva, São Paulo, Brazil. Frozen pelvis was diagnosed by a laparos-copy. She subsequently underwent four unsuccessful rounds of in vitrofertilization (IVF).Two years later, she was evaluated for intense pelvic pain bytransvaginal ultrasonography with bowel preparation, which demon-strated severe DIE. After counseling, she underwent extensive laparo-scopic treatment of grade IV endometriosis (American Society forReconstructive Microsurgery staging criteria). Extensive uterine endo-metriosis was identi 󿬁 ed at the posterior uterine fundal wall, in additiontoDIElesionspresentintheretrocervicalspace,posteriorvaginalfornix,anduterosacralligaments.Far-reachingresectionofuterineDIEresultedin a considerable thinning of the uterine wall. Bilateral salpingectomiesdue to hydrosalpinges and removal of small subserosal leiomyomaswere also performed. Endocavitary single layer sutures were placedusing polydioxanone suture (PDS 2 – 0, Ethicon, Johnson & Johnson, CA,USA).Rectosigmoidresection,appendectomy,andpartialcecalresectionwere performed by a laparoscopy-assisted transvaginal segmentalapproach. The estimated blood loss was 250 mL.Five months later, the patient underwent IVF with the transfer of three embryos. Pregnancy was achieved and was uneventful until the32nd week, when the patient experienced acute abdominal pain. Shewas promptly admitted to hospital and stable vital signs, weak uterinecontractions, and abdominal wall tenderness were recorded. Ultraso-nographyshowedonefetuswithanormalheartrate.Onehourlater,re-peat ultrasonography demonstrated UR with prolapse of the amnioticmembranes across the uterine wall near the posterior left uterinehorn(Fig.1).Anemergencycesareanwasperformedunderspinalanes-thesia. A male newborn weighing 2175 g was delivered with Apgarscores of 1 and 10 at 1 and 5 minutes, respectively. UR was noted atthe left cornual wall (Fig. 2), which was effectively closed with coated0-Vicryl sutures (Ethicon, Johnson & Johnson, CA, USA). Mother andnewborn were admitted to the intensive care unit (ICU). The motherunderwent an uneventful recovery and the newborn was dischargedfrom the ICU after 2 weeks, weighing 2105 g. International Journal of Gynecology and Obstetrics xxx (2015) xxx – xxx ⁎  Corresponding author at: Huntington Medicina Reprodutiva and Disciplina deGinecologia da Faculdade de Medicina da Universidade de São Paulo, Avenida Repúblicado Líbano, 529, Ibirapuera, São Paulo, São Paulo 04501000, Brazil. Tel.: +55 1130596100;fax: +55 11985344399. E-mail addresses:, paulo 󿬁 (P.C. Sera 󿬁 ni). IJG-08250; No of Pages 3© 2015 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. Contents lists available at ScienceDirect International Journal of Gynecology and Obstetrics  journal homepage: Please cite this article as: Fettback PB, et al, Uterine rupture before the onset of labor following extensive resection of deeply in 󿬁 ltratingendometriosis with myometrial invas..., Int J Gynecol Obstet (2015),  In June 2012, another patient (G1Ab1P0), who was aged 35 years,presented to Huntington Centro de Medicina Reprodutiva after 4 yearsofinfertilityforlaparoscopictreatmentofpelvicendometriosis.Bilateraltubovarian adhesions and super 󿬁 cial endometriosis were treatedbyadhesiolysisandfulguration.Thereafter,sheunderwentthreeunsuc-cessfulIVFattempts.Transvaginalultrasonographywithbowelprepara-tion was performed due to dyspareunia and revealed advanced DIE.Additionally, laparoscopy revealed a frozen pelvis, widespread DIEthroughout the pelvis, and an endometrioma concealed within the leftiliac vein, obturator nerve, and spreading to the ipsilateral ureter.Hemostasis of the DIE was accomplished using bipolar cauterizationfollowed by intracorporeal suturing. Extensive resection of DIE lesionsat the left fallopian tube was carried out with monopolar energy.The uterine wall was reapproximated via intracorporeal suturing with2 – 0 absorbable polyglactin (Ethicon, Somerville, NJ, USA).Ninemonthslater,threefreshembryosweretransplanted aspart of IVF. A single gestation was identi 󿬁 ed and an embryonic heartbeat wasdetected by ultrasonography at 6 weeks of pregnancy. There were nofurthercomplicationsuntilweek33,whenthe patientwashospitalizedto inhibit preterm labor.Twelvehoursafter intravenous administrationof the tocolytic agent, the patient became pale, her blood pressuredroppedto80/50mmHg,andabdominalultrasonographydemonstrat-edmassivehemoperitoneum,UR,andfetalbradycardia.Acesareanwasperformed and a newborn weighing 2710 g was delivered in cardiore-spiratory arrest. The newborn was actively resuscitated and did favor-ably in the neonatal ICU. UR was visualized at the posterior uterinewall next to the left uterine cornua (Fig. 3), and the placenta was 90%abrupted. Because of uterine atony, a hysterectomy was performed.The mother was discharged from the hospital 7 days later and thenewborn after 32 days.Laparoscopy is an effective treatment for either reduction or cure of endometriosis associatedwith pelvic pain,dysmenorrhea, and infertili-ty. Endometriosis has also been associated with pregnancy complica-tions (e.g. spontaneous hemoperitoneum, preterm birth, prepartumhemorrhage, placenta accreta, and pre-eclampsia [9]) after extensiveresection of DIE. However, uterine dehiscence and UR have beendescribed as late complications of DIE surgery [6,8,9]. Furthermore,thesecomplicationscanleadtosigni 󿬁 cantmaternalandfetalmorbidityand mortality [8,9].The outcomes of pregnancies following surgery for DIE have notbeen entirely evaluated. Furthermore, the cases of UR reported herewere through-and-through tears of the uterine muscle throughout theserosa at the site of extensive and deepest resections. There were anumber of commonalities between the two cases. Both patientspresented with extensive DIE characterized by deep in 󿬁 ltration into themyometriumattheposterioruterinewall(Fig.4).Toachieveintraopera-tive hemostasis, these patients required extensive electrocoagulation,leading to decreased vascularization in a thin uterine wall due to exten-sive myometrial resection, thus increasing the uterine wall vulnerabilityleading to UR.Asupplementaryvideoisavailableonline,showingthecesareansforboth cases (Supplementary Material S1). Fig. 1.  Transabdominal ultrasonography demonstrating uterine rupture associated withprolapseoftheamnioticmembranesacrosstheuterinewallneartheposteriorleftuterinehorn (arrow). Fig. 2. Uterine exposureduringcesareanrevealing uterine rupture at theleft cornualwall(arrow) with amniotic sac prolapsed. Fig. 3.  Uterine exposure during the cesarean demonstrating the site of uterine rupture atthe posterior uterine wall next to the left cornua (arrow).2  P.B. Fettback et al. / International Journal of Gynecology and Obstetrics xxx (2015) xxx –  xxx Please cite this article as: Fettback PB, et al, Uterine rupture before the onset of labor following extensive resection of deeply in 󿬁 ltratingendometriosis with myometrial invas..., Int J Gynecol Obstet (2015),  Supplementary data to this article can be found online at Con 󿬂 ict of interest The authors have no con 󿬂 icts of interest. References [1] Landon MB, Lynch CD. Optimal timing and mode of delivery after cesarean withprevious classical incision or myomectomy: a review of the data. Semin Perinatol2011;35(5):257 – 61.[2] Gyam 󿬁 -Bannerman C, Gilbert S, Landon MB, Spong CY, Rouse DJ, Varner MW, et al.Risk of uterine rupture and placenta accreta with prior uterine surgery outside of the lower segment. Obstet Gynecol 2012;120(6):1332 – 7.[3] Kawabara H, Yazaki H, Hosobe S. Endometriosis of the uterine wall and spontaneousrupture of the pregnant uterus. Jpn J Med Sci Biol 1962;48:177 – 80.[4] BiernackiW,FilipowiczK.Interstitialuterineendometriosisasacauseofasymptomaticrupture of the uterus in pregnancy. Ginekol Pol 1967;38(3):287 – 90.[5] Donna A, Bosi D, Sommariva F. Rupture of the endometriosis uterus in pregnancy.Cancro 1967;20(4):400 – 10.[6] Van De Putte I, Campo R, Gordts S, Brosens I. Uterine rupture following laparoscopicresection of rectovaginal endometriosis: a new risk factor? Br J Obstet Gynaecol1999;106(6):608 – 9.[7] Anaf V, Simon P, Fayt I, Noel J. Smooth muscles are frequent components of endometriotic lesions. Hum Reprod 2000;15(4):767 – 71.[8] Lang CT, Landon MB. Uterine rupture as a source of obstetrical hemorrhage. ClinObstet Gynecol 2010;53(1):237 – 51.[9] Brosens I, Brosens JJ, Fusi L, Al-Sabbagh M, Kuroda K, Benagiano G. Risks of adversepregnancy outcome in endometriosis. Fertil Steril 2012;98(1):30 – 5. Fig. 4.  Macroscopic longitudinal section of myometrial tissue resected from the posterioruterine wall during laparoscopy, showing deep in 󿬁 ltration of endometriosis.3 P.B. Fettback et al. / International Journal of Gynecology and Obstetrics xxx (2015) xxx –  xxx Please cite this article as: Fettback PB, et al, Uterine rupture before the onset of labor following extensive resection of deeply in 󿬁 ltratingendometriosis with myometrial invas..., Int J Gynecol Obstet (2015),
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