Spontaneous Hemoperitoneum From a Ruptured Vessel Overlying a Sub-Serosal Myoma: A Rare and Life-Threatening Emergency in Women.

A 41‐year‐old non‐pregnant Ghanaian female, para 3 + 0, last menstrual period 20th February 2024, presented to the emergency department a month later. She had undergone bilateral tubal ligation following her last caesarean delivery two years prior and presented to the emergency department, reporting a history of syncope. The syncopal episode lasted for less than a minute with no associated abnormal jerky movements or loss of bowel or bladder continence. Preceding the syncope, she experienced a gradual onset of lower abdominal pain, which persisted afterwards. The pain was severe (graded as 10/10), non‐radiating or migratory, and mildly relieved by flexing her knees. She was initially evaluated at a peripheral facility where an ultrasound revealed uterine myomas of varying sizes and locations, prompting her referral. Upon arrival at the emergency department, the patient appeared lethargic and acutely ill. Initial assessment showed a patent airway, oxygen saturation of 98% on ambient room air, and a respiratory rate of 18 breaths per minute with clear lung fields bilaterally. She presented with hypotension and tachycardia, with a blood pressure of 86/59 mmHg and a pulse rate of 121 beats per minute. Although pale and lethargic, she maintained full consciousness. There was no history of trauma or falls, abdominal distention, jaundice, or fever noted. Laboratory investigations revealed elevated glucose levels (14.2 mmol/L, normal range: 7–11 mmol/L) with serum ketones of 0.3 mmol/L (normal range:< 0.6 mmol/L). Full blood count results revealed a hemoglobin level of 6.4 g/dL (normal range: 11–14 g/dL), and a urine pregnancy test returned negative while her temperature remained within normal limits at 36.8°C. The patient did not exhibit signs of chronic illness; rather, she appeared well‐fed and not cachectic. This observation was particularly significant from a surgical standpoint, as it prompted consideration of alternative diagnoses such as a ruptured hepatoma or a ruptured aortic aneurysm. Abdominal examination revealed abdominal distension, generalized tenderness, worse in the suprapubic region, with guarding but no rebound tenderness observed. The femoral pulses were palpable and were of equal volume. In response to fluid resuscitation, her hemodynamic status improved after administering 1 L of intravenous normal saline, with subsequent blood pressure readings of 91/66 mmHg and a pulse rate of 119 beats per minute. A point‐of‐care ultrasound (POCUS) using rapid ultrasound for shock and hypotension (RUSH) protocol revealed a collapsed inferior vena cava and significant free fluid containing low‐level internal echoes, predominantly in the right subphrenic region with mild collections in the hepatorenal pouch (see Figures  1 and 2 ). Additionally, a mass‐like organized lesion with multiple thick septations, likely organized clots, was noted in the hepatorenal pouch and pelvis. The uterus appeared bulky with uterine myomas, and a positive enhanced peritoneal stripe sign suggested pneumoperitoneum. An urgent formal ultrasound done by the radiologist revealed similar findings. Free fluid at the supra hepatic recess. Fairly defined collection of varying echogenicity in the posterior sub hepatic recess suggestive of hematoma in different stages of organized clot formation. There were urgent consultations with the general surgical and obstetric gynecology team due to suspicion of an acute abdomen and significant free fluid intraperitoneally with suspected clots around the uterus and hepatorenal pouch. Subsequent emergency exploratory laparotomy was done, which revealed an active bleed from a dilated vein overlaying a large uterine fibroid, resulting in 5 L of hemoperitoneum with blood clots. The liver, spleen and bowel were all normal. Initially, the abdomen was packed with abdominal towels in all four quadrants, followed by the evacuation of clots. Once the blood was completely evacuated and pressure was applied to the bleeding vessel over the myoma, no further blood was collected in the peritoneal cavity. There were multiple myomas, with the largest size being 20 × 15 cm. A subtotal hysterectomy with bilateral salpingectomy was performed, and the patient received seven units of red blood cell concentrate and five units of fresh frozen plasma. She was discharged eight days post‐operation, and her subsequent follow‐up at the gynecology clinic was uneventful. She was eventually discharged from the unit 6 weeks after the surgery.

Eugene Kojo Adomako: conceptualization, investigation, validation, writing – original draft, writing – review and editing. Nana Serwaa Quao: conceptualization, data curation, supervision, writing – original draft, writing – review and editing. Janet Naki Opare: conceptualization, data curation, writing – original draft, writing – review and editing. Maurice Dordunoo: data curation, formal analysis, investigation.

Leiomyomas or uterine fibroids are the most common pelvic tumors in women [ 5 ]. These tumors are often asymptomatic but can lead to abnormal uterine bleeding with anemia, pelvic pressure and pain, urinary frequency, and adverse reproductive outcomes [ 6 ]. Despite their prevalence among women of reproductive age, there is limited awareness of their potential to cause hypovolemic shock [ 7 ]. Acute complications of leiomyomas include torsion of a subserosal pedunculated myoma, urinary retention, venous thromboembolism, acute abdomen, and bleeding due to myoma degeneration [ 5 ]. Massive bleeding from the spontaneous rupture of a vessel overlying a myoma is uncommon [ 8 ]. Despite its rarity, due to the high prevalence of fibroids, it is vital to consider this potentially life‐threatening complication to provide optimal care [ 7 , 8 ]. Patients typically present with abdominal pain, syncope, hemodynamic instability, and an intra‐abdominal mass [ 7 ]. Our patient did not know she had uterine fibroids, and she had been asymptomatic of any of the symptoms of uterine fibroids. The fibroids were only picked up during the point‐of‐care ultrasound using rapid ultrasound for shock and hypotension (RUSH) protocol when she presented to the emergency room. Although rare, bleeding from fibroid vessels should be considered in the differential diagnosis for women with large fibroids who present with hemoperitoneum of unknown origin [ 9 ]. For this reason, both the general surgeon and the gynecologist were initially involved in the patient's management. A crucial aspect of this patient's management was the swift response of the surgical team on duty, who opted for a laparotomy due to the patient's profound hemodynamic instability. Diagnostic challenges arose because the patient did not exhibit signs of chronic illness, ruling out the possibility of a ruptured hepatoma, and the femoral pulses were equal in intensity and comparable to the radial pulse, excluding a ruptured abdominal aortic aneurysm. The decision to proceed with laparotomy was made following a test aspiration of the abdomen, which yielded 10 mL of non‐clotting blood, coupled with significant ultrasound findings of hemoperitoneum and marked hemodynamic instability. The gynecologists were then called intraoperatively when an extensive search for the source of bleeding revealed engorged bleeding vessels over the uterine myoma. Sudden rupture of a vascular supply to a uterine fibroid can mimic acute ruptured ectopic pregnancy [ 10 ]. Despite having undergone bilateral tubal ligation for permanent contraception during her last delivery, a urine pregnancy test was conducted, yielding a negative result. Approximately 125 cases of hemoperitoneum due to fibroids have been documented in the literature, with most arising from either a ruptured degenerated fibroid or torsion, leading to hemoperitoneum or spontaneous rupture which is rare [ 11 ]. About 30 of these cases were due to the rupture of a superficial vessel on the fibroid [ 12 ]. A review of 25 previously reported cases by Levai et al. in Table  1 showed that most patients were in their late 20s–40s, with ages ranging from 22 to 62 years [ 9 ]. The majority of leiomyomas were subserosal or pedunculated, often large in size, and frequently associated with rupture or avulsion of superficial vessels as the immediate cause of hemoperitoneum [ 9 ]. Management was predominantly surgical, most often myomectomy or hysterectomy, with selective use of uterine artery embolization or vessel ligation in some cases [ 9 ]. These findings highlight common patterns of tumor type, size, and vascular vulnerability that predispose to acute hemorrhage requiring urgent intervention. Published cases of hemoperitoneum due to fibroids from 2008 to 2018. Abbreviation: UA, uterine artery. Source: Levai et al. [ 9 ]. Hemoperitoneum from ruptured superficial fibroid vessels can occur spontaneously or due to trauma, typically involving the rupture of a subserosal or superficial dilated vein and rarely from the rupture of an arterial aneurysm or an arterial vessel originating from uterine arteries [ 13 ]. Several factors may contribute to vessel rupture; for instance venous congestion due to pregnancy, raised intra‐abdominal pressure from constipation or weightlifting, ultimately leading to rupture [ 14 ]. The large size of the fibroid itself, particularly when ≥ 10 cm, stretches and thins the overlying vessels, rendering them more fragile and prone to rupture [ 13 ]. Our patient did not have any history of trauma of any kind, especially to the abdomen. The large size of the fibroid stretches the superficial vessel, making it more prone to bleeding due to the thinning and weakening of the vessel wall [ 11 , 13 ]. The patient presented with signs of hemorrhagic shock with low blood pressure, a high pulse rate and an episode of syncopal attack. Other potential causes of hemoperitoneum were considered, including a ruptured viscus due to hypersplenism, which is prevalent in malaria‐endemic regions like Ghana, as well as a ruptured hepatoma, a ruptured visceral artery and a ruptured abdominal aortic aneurysm. Apart from the ultrasound scan that was done as part of her assessment, other advanced investigations, such as Computerized Tomography (CT) scan and Magnetic Resonance Imaging (MRI), could not be conducted but were unnecessary due to the emergent nature of the patient's presentation, which did not allow us the luxury of waiting for these investigations. Moreover, they are not readily available in our settings. An emergency laparotomy was performed for her. This was both diagnostic and therapeutic at the same time. During the intraoperative period, other differentials were ruled out, and the cause was identified, leading to the performance of a hysterectomy. The choice of surgery typically depends on the reproductive wishes of the patient. In our case, the client had completed her family and had previously undergone bilateral tubal ligation. Therefore, the decision to proceed with a hysterectomy was straightforward; however, consent was still sought from the husband. Although laparoscopy is not readily available in our setting, it provides an alternative management for hemodynamically stable patients. Laparoscopy plays an important role in identifying the source of hemoperitoneum, and when a timely preoperative diagnosis is established before hemodynamic instability occurs, conservative surgical management, such as myomectomy facilitated by vasopressin injection, can be performed [ 15 ]. In our case, the patient's hemodynamic instability precluded the possibility of utilizing laparoscopy.

Informed verbal and written consent was obtained from the patient for the publication of this case report, including accompanying images or data. A copy of the written consent is available upon request.

Spontaneous hemoperitoneum represents a rare yet critical condition characterized by blood accumulation in the peritoneal cavity without a traumatic etiology [ 1 , 2 ]. This condition, if not promptly diagnosed, can lead to fatal consequences [ 1 ]. It typically manifests with severe abdominal pain, abdominal distension, and hypovolemic shock, often accompanied by a decrease in hematocrit levels [ 2 ]. Diagnosis is frequently established through imaging studies due to its rarity [ 1 ]. Spontaneous hemoperitoneum commonly originates from hepatic, splenic, vascular, or gynaecologic sources [ 1 ]. Gynecological causes may include ovarian cyst rupture, endometriosis, ruptured ectopic gestation, leiomyoma (uterine fibroids) or uterine vessel rupture. Although the rupture of a leiomyoma is uncommon, it appears to result from a spontaneous rupture of a leiomyoma vessel [ 3 ]. Notably, spontaneous hemoperitoneum occurs more frequently during pregnancy than in non‐pregnant individuals [ 2 ]. Although it is rare, it is crucial to consider the diagnosis of spontaneous hemoperitoneum in women presenting with abrupt onset of abdominal pain, hypotension, and signs of significant free intraperitoneal fluid accumulation [ 4 ]. We present a 41‐year‐old female who presented with sudden onset of abdominal pain with hemodynamic instability with free fluid in the abdomen and no associated trauma resulting from a bleeding uterine vessel overlying a uterine fibroid.

The authors declare no conflicts of interest.