<div>Title: Spontaneous rupture of a degenerated leiomyoma causing
panperitonitis and ileus during pregnancy: A case report</div><div>Authors: Mizuha Odagami<sup>1</sup>*, Mutsuko
Makino<sup>1</sup>, Etsuko Miyagi<sup>2</sup>, Shigeru
Aoki<sup>1</sup></div><div><sup>1</sup> Perinatal Center for Maternity and Neonate, Yokohama
City University Medical Center, Yokohama, Japan</div><div><sup>2</sup> Department of Obstetrics and Gynecology, Yokohama
City University Hospital, Yokohama,</div><div>Japan</div><div>*Corresponding Author: Mizuha Odagami, M. D.</div><div>Perinatal Center for Maternity and Neonate</div><div>Yokohama City University Medical Center</div><div>4-57 Urafune-cho, Minami-ku, Yokohama City</div><div>Kanagawa 232-0024, Japan</div><div>Tel: +81-45-261-5656</div><div>Fax: +81-45-253-5784</div><div>E-mail: <i>mmmizuha@yahoo.co.jp</i></div><div>[Key Clinical Message]</div><div>A degenerated leiomyoma rarely ruptures during pregnancy. As the rupture
of a degenerated leiomyoma can cause panperitonitis due to the leakage
of fluid content into the peritoneal cavity, prompt diagnosis and
surgical intervention are required.</div><div>[Key Words]</div><div>Ruptured leiomyoma, degenerated leiomyoma, panperitonitis, myomectomy,
pregnancy.</div><div>[Introduction]</div><div>Leiomyomas are found in approximately 10% of pregnant women (1). Pain
caused by a degenerated leiomyoma is considered to be the most common
complication of pregnancy in women with leiomyomas (2). In many cases,
the symptoms of a degenerated leiomyoma improve with conservative
therapy; thus, surgical treatment is rarely required (3,4). We report
the case of a 38-year-old primiparous woman who underwent a myomectomy
during pregnancy as a result of panperitonitis and ileus secondary to
the rupture of a degenerated leiomyoma.</div><div>[Case]</div><div>A 38-year-old primiparous woman was diagnosed with a leiomyoma prior to
her pregnancy. At a gestational age of 14+3 weeks, she had lower
abdominal pain and was admitted to a primary health facility with a
diagnosis of pain due to a degenerated leiomyoma, for which conservative
therapy was started. Because of increased abdominal pain, she was
transported to our hospital at a gestational age of 15+0 weeks. On
admission, she complained of severe abdominal pain and vomited several
times. In addition to the peritoneal irritation sign, a goose egg-sized
mass was palpated in the right upper abdomen, and severe tenderness was
observed at the same site. Abdominal ultrasonography revealed an
intramural leiomyoma measuring 7 cm in diameter at the uterine fundus.
Blood tests showed the following results: white blood cells (WBC),
12300/mm<sup>3</sup>; red blood cells, 411 ×
104/mm<sup>3</sup>; hemoglobin, 13.1 g/dL; and c-reactive protein
(CRP), 8.52 mg/dL.</div><div>Plain abdominal radiography revealed marked dilatation of the small
intestine and ileus was diagnosed. Pelvic magnetic resonance imaging
(MRI) revealed a leiomyoma with partial high-signal intensity at the
uterine fundus; it was considered a degenerated leiomyoma (Fig 1). Based
on the above findings, the patient was diagnosed with pain from a
degenerated leiomyoma, peritonitis associated with infection of the
degenerated leiomyoma, and ileus; hence, the conservative therapy was
continued. The patient was afebrile after admission and various culture
tests, including blood and urine cultures, were negative, indicating no
signs of infection. The levels of inflammatory markers decreased after 1
week (WBC: 9600/mm<sup>3</sup>; CRP: 2.3 mg/dL). However, because
of the poor improvement in abdominal pain and prolonged ileus, it was
suspected that the patient had panperitonitis and ileus caused by the
rupture of the degenerated leiomyoma and emergency surgery was decided.</div><div>The intraoperative examination revealed an intramural leiomyoma
measuring 7 cm in diameter at the uterine fundus. When the omentum and
small intestine adhering to the surface of the leiomyoma were dissected,
the leiomyoma, with its capsule ruptured, was exposed (Fig 2).
Accordingly, the patient was diagnosed with a ruptured, degenerated
leiomyoma and a myomectomy was performed. The pathological findings of
the resected specimen indicated a leiomyoma with degeneration. After the
surgery, the symptoms rapidly improved and the pregnancy course was
uneventful. At a gestational age of 37+4 weeks, elective cesarean
delivery was performed because of the myomectomy during pregnancy. The
patient delivered a female infant weighing 2870 g, which was appropriate
for the gestational age. The Apgar score was 9 at both 1 and 5 minutes.
The postoperative course was uneventful.</div><div>[Discussion]</div><div>This case highlighted the following two findings: first, leiomyomas can
rupture during pregnancy. There have been cases reported of the rupture
of a blood vessel overlying the leiomyoma during pregnancy (5, 6) and
after labor (7), resulting in intra-abdominal bleeding; a case of
non-reassuring fetal status and intra-abdominal bleeding due to the
rupture of a leiomyoma during labor has also been reported (4). Thus,
the rupture of a leiomyoma can occur at any time. The mechanism of
leiomyoma rupture has not been clarified. One of the possible mechanisms
is that necrosis associated with the degenerated leiomyoma occurs in the
uterine serosa and causes a rupture in the serosa. It is also considered
that pregnancy, vigorous exercise, and defecation, which increases
abdominal pressure, may cause the congestion of a blood vessel overlying
the leiomyoma, resulting in its rupture (8, 9). Therefore, the rupture
of a leiomyoma should always be kept in mind when treating a pregnancy
complicated by a leiomyoma. Second, as the rupture of a leiomyoma causes
panperitonitis, it is an indication for prompt surgical treatment.
Leiomyoma rupture usually results in intra-abdominal bleeding due to the
rupture of a blood vessel overlying the leiomyoma, often leading to an
acute abdomen (5, 6, 9, 10). However, according to some reports, the
rupture of a degenerated leiomyoma caused no intra-abdominal bleeding
but caused panperitonitis due to leakage of the fluid content of the
degenerated leiomyoma into the peritoneal cavity (11, 12). Our case is
considered similar to the latter case. Conservative therapy can improve
the pain caused by a degenerated leiomyoma but not the symptoms of a
ruptured leiomyoma. Therefore, in addition to the pain caused by
leiomyoma degeneration, if intraperitoneal bleeding, peritonitis, or
ileus is present, leiomyoma rupture should be considered. In such cases,
prompt diagnosis and surgical treatment are required to avoid an adverse
outcome.</div><div>[Conclusion]</div><div>A degenerated leiomyoma rarely ruptures during pregnancy. As the rupture
of a degenerated leiomyoma can cause panperitonitis, prompt diagnosis
and surgical intervention are required.</div><div>［Acknowledgment］</div><div>We would like to thank HONYAKU CENTER (www.honyakuctr.com) for English
language editing.</div><div>［Conflict of interest］</div><div>None declared.</div><div>［Author Contributors］</div><div>MO drafted the manuscript contributed and performed the surgery.</div><div>MM performed the surgery.</div><div>SA contributed to the first draft and finalization of the manuscript.</div><div>EM supervised the case report.</div><div>［Patient consent］</div><div>Obtained</div><div>[References]</div><ol><li>Lee HJ, Norwitz ER, Shaw J. Contemporary management of fibroids in
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98(5):961-963.</li></ol><div>[Figures]</div><div>Figure 1: Coronal T2-weighted magnetic resonance imaging showing a
leiomyoma with partial high-signal intensity at the uterine fundus,
which was considered to be a degenerated leiomyoma.</div><div>Figure 2: Intraoperative examination revealed an intramural leiomyoma at
the uterine fundus, with the upper half of its capsule ruptured.</div>