Case Report: Massive Hemoperitoneum Due to Ruptured Superficial Vein Overlying a Pedunculated Fibroid: A Rare Case Report

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Although they may remain asymptomatic, they can occasionally lead to acute complications, including sudden hemorrhage. Spontaneous hemoperitoneum due to fibroids is extremely rare and can be life threatening. Case Presentation We report the case of a 48-year-old multiparous woman with a history of hypertension who presented to the emergency department with acute abdominal pain, vomiting, and hypovolemic shock. An emergency computed tomography (CT) scan showed a large hemoperitoneum and a uterine mass measuring 10 cm. Emergency laparotomy revealed a pedunculated fundal fibroid with an actively bleeding superficial vein. Myomectomy was performed, followed by hemostatic control and abdominal washout. The patient required blood transfusion and recovered well without further complications. Histopathological examination confirmed the diagnosis of a benign leiomyoma. Conclusion Hemoperitoneum due to rupture of a superficial vein overlying a fibroid is an exceedingly uncommon but serious condition demanding prompt diagnosis and surgical management. Clinicians should consider this condition in patients with an acute abdomen and hypovolemic shock, especially in those with known fibroids. Early detection and timely surgical intervention are vital for achieving favorable outcomes. 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F1000Research 2025, 14 :450 ( https://doi.org/10.12688/f1000research.163911.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Case Report Case Report: Massive Hemoperitoneum Due to Ruptured Superficial Vein Overlying a Pedunculated Fibroid: A Rare Case Report [version 1; peer review: awaiting peer review] Chayma Rjiba https://orcid.org/0009-0001-0640-0027 1,2 , Nadia Marwen 1,2 , Khouloud Moulehi 1,2 , [...] Hafedh Touileb 2 , Yossra Massoudi 3 , Ktata Imen https://orcid.org/0009-0005-6159-2315 4 , Chafiaa Bouhamed 4 , Slah Souii 5 , Mohamed Ridha Fatnassi 1,2 Chayma Rjiba https://orcid.org/0009-0001-0640-0027 1,2 , Nadia Marwen 1,2 , [...] Khouloud Moulehi 1,2 , Hafedh Touileb 2 , Yossra Massoudi 3 , Ktata Imen https://orcid.org/0009-0005-6159-2315 4 , Chafiaa Bouhamed 4 , Slah Souii 5 , Mohamed Ridha Fatnassi 1,2 PUBLISHED 22 Apr 2025 Author details Author details 1 Department of Gynecology and obstetrics, Ibn El Jazzar university Hospital, Kairouan, Kairouan, Tunisia 2 Ibn El Jazzar Medical University, Sousse, Tunisia 3 Department of Cardiology, Ibn El Jazzar University Hospital, Kairouan, Kairouan, Tunisia 4 Emergency department, Ibn El Jazzar University Hospital, Kairouan, Kairouan, Tunisia 5 Department of Anesthesia and Intensive Care, Hopital University Ibn El Jazzar, Kairouan, Kairouan, Tunisia Chayma Rjiba Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Resources, Writing – Original Draft Preparation, Writing – Review & Editing Nadia Marwen Roles: Conceptualization, Data Curation, Methodology, Project Administration, Supervision, Validation, Visualization Khouloud Moulehi Roles: Data Curation, Writing – Original Draft Preparation Hafedh Touileb Roles: Resources, Writing – Original Draft Preparation Yossra Massoudi Roles: Resources, Supervision, Validation, Visualization Ktata Imen Roles: Resources, Supervision, Validation, Visualization Chafiaa Bouhamed Roles: Resources, Supervision, Validation, Visualization Slah Souii Roles: Resources, Supervision, Validation, Visualization Mohamed Ridha Fatnassi Roles: Resources, Supervision, Validation, Visualization OPEN PEER REVIEW REVIEWER STATUS AWAITING PEER REVIEW Abstract Abstract Background Uterine fibroids, also known as leiomyomas, are the most common benign tumors in reproductive-aged individuals. Although they may remain asymptomatic, they can occasionally lead to acute complications, including sudden hemorrhage. Spontaneous hemoperitoneum due to fibroids is extremely rare and can be life threatening. Case Presentation We report the case of a 48-year-old multiparous woman with a history of hypertension who presented to the emergency department with acute abdominal pain, vomiting, and hypovolemic shock. An emergency computed tomography (CT) scan showed a large hemoperitoneum and a uterine mass measuring 10 cm. Emergency laparotomy revealed a pedunculated fundal fibroid with an actively bleeding superficial vein. Myomectomy was performed, followed by hemostatic control and abdominal washout. The patient required blood transfusion and recovered well without further complications. Histopathological examination confirmed the diagnosis of a benign leiomyoma. Conclusion Hemoperitoneum due to rupture of a superficial vein overlying a fibroid is an exceedingly uncommon but serious condition demanding prompt diagnosis and surgical management. Clinicians should consider this condition in patients with an acute abdomen and hypovolemic shock, especially in those with known fibroids. Early detection and timely surgical intervention are vital for achieving favorable outcomes. READ ALL READ LESS Keywords uterine fibroid, Leiomyoma, Hemoperitoneum, Acute abdomen, vessel rupture. Corresponding Author(s) Chayma Rjiba ( [email protected] ) Close Corresponding author: Chayma Rjiba Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2025 Rjiba C et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Rjiba C, Marwen N, Moulehi K et al. Case Report: Massive Hemoperitoneum Due to Ruptured Superficial Vein Overlying a Pedunculated Fibroid: A Rare Case Report [version 1; peer review: awaiting peer review] . F1000Research 2025, 14 :450 ( https://doi.org/10.12688/f1000research.163911.1 ) First published: 22 Apr 2025, 14 :450 ( https://doi.org/10.12688/f1000research.163911.1 ) Latest published: 22 Apr 2025, 14 :450 ( https://doi.org/10.12688/f1000research.163911.1 ) Introduction Uterine fibroids are the most prevalent benign growth in women of reproductive age. They can remain symptom-free for a long time and are usually diagnosed because of chronic complications. However, acute complications due to fibroids are possible but are rare, torsion, degeneration, rupture, or hemorrhage, are rare. 1 , 2 Intra-abdominal hemorrhage due to leiomyoma is a rare occurrence. In the literature, it is mostly reported as sporadic cases, and there have been about a hundred cases, of which 30 cases are caused by a rupture of a superficial vessel on the fibroid. 3 , 4 It is difficult to diagnose preoperative hemoperitoneum caused by fibroids. In fact, various differential and more common diagnoses are usually suspected, including ectopic pregnancies and ruptured cysts. Clinically, the symptoms are the result of a peritoneal reaction to blood leakage, involving acute abdominal pain with signs of hypovolemia. Immediate intervention, including volume resuscitation and surgical hemorrhage control, is crucial. 5 Herein, we present a rare case of massive hemoperitoneum secondary to rupture of a superficial vein overlying a pedunculated fibroid that was successfully managed with emergency surgery. Case report Case presentation A 48-year-old woman with a medical history of high blood pressure treated with monotherapy and no prior surgical history, gravida 4, para 2, with two vaginal deliveries, presented to the emergency department with acute abdominal pain and vomiting starting 6 hours before consultation, which progressively aggravated, and the onset of vomiting and asthenia led the patient to seek urgent medical help. The initial examination revealed diffuse abdominal tenderness, low blood pressure (70/40 mmHg), tachycardia (140 beats per minute), and normal body temperature. The patient was diagnosed with a Glasgow score of 13/15 (E3V4M6). Owing to hypovolemic shock, recourse to vasoactive drugs was necessary. The patient required vasoactive support with 2 mg/h norepinephrine. Blood tests showed a hemoglobin level of 6 g/dl, TP of 76%, and negative beta-human chorionic gonadotropin level. An urgent CT scan was conducted, showing an extensive hemoperitoneum and a large mass dependent on the uterus measuring 100.3 × 90.4 mm ( Figures 1 and 2 ). Figure 1. CT scan images showing the presence of a fundal uterine fibroid measuring 90.4 * 100.3 mm. Figure 2. CT scan sections showing the massive hemoperitoneum (blue star). The patient was immediately transferred to the department of gynecology and obstetrics. Treatment Immediate blood transfusion was initiated, and the patient received a total of 4 units of red blood cells with 6 units of PFC. Immediate laparotomy with midline incision was performed, and the intra-operative findings were dark clotted blood filling the abdominal cavity up to Morrison’s pouch . The uterus was normal in size, and both ovaries appeared normal. A type 7 fundal myoma measuring 10 cm was found, and the pedunculated fibroid had an actively haemorrhaging superficial posterior vein, causing abundant hemoperitoneum. The myoma was resected, given its location and pedunculated nature, after coagulation of the bleeding vein ( Figure 3 ). Figure 3. (A) Intra-operative image showing a fundal pedunculated uterine fibroid with a ruptured superficial vein on its surface, (B) Photograph showing the successful removal of a 10 cm fibroid during myomectomy. Then an abdominal wash and evacuation of the blood clots was done rigorously. Postoperative care was carried out in collaboration with anesthesiology team, the patient remained hemodynamically stable, and the hemoglobin level increased to 9 g/dl. The patient was discharged after 3 days and returned after 2 weeks for check-up. Ultrasound was normal, and the final pathological examination confirmed a leiomyoma weighing 546 g and measuring 11 cm. Patient’s perspective: The patient was deeply grateful for the quick care she received and expressed great relief after the traumatic experience that she described as a near-death experience. She expressed that, after this ordeal, she became more aware of how important it was to seek help if something did not feel right. Discussion Uterine fibroids or leiomyomas are the most common benign uterine tumors. 6 , 7 It is assumed that they occur in more than 70% of women at the time of menopause. It has been reported that they are clinically pronounced in 25% of women of reproductive age. According to a meta-analysis conducted in 2017, the incidence ranged between 217 and 3745 cases per 100 000 women per year, while the prevalence ranged from 4.5% to 68.6%. They are also more common among black women. 7 The most affected age group was women during the reproductive period. They are very rare in the prepubertal years and usually reduce in size and fade in menopausal women. 7 , 8 However, the pathogenesis of leiomyomas is not well elucidated. They originate from individual uterine smooth muscle cells, also called myometrial cells, the expansion of which relies on hormonal production (estrogens). 8 , 9 This medical condition remains understudied given that many patients are asymptomatic or disregard their symptoms. 10 The clinical presentation of symptomatic fibroids depends on their location and size. They can present with abnormal uterine bleeding, which may lead to anemia, painful menstruation, persistent pelvic pain or pressure, back ache, and symptoms related to tumor compression such as bowel, bladder, or sexual discomfort and complications. They can also lead to infertility and compromise obstetric outcomes (abnormal fetal positioning, preterm labor, restricted fetal growth, cesarean section, and bleeding before labor). Moreover, quality of life can be really affected by this affection and can lead to significant morbidity and mortality, especially with late diagnosis and management. 10 , 11 Acute complications linked to leiomyomas are remarkably rare, and it is difficult to attribute a specific incidence to these complications due to their rarity. These encompass urinary retention, torsion of pedunculated fibroids, red degeneration in pregnant women, thrombosis of the mesenteric vein, thromboembolism, and sudden intraperitoneal or vaginal hemorrhage. Most of these complications lead to acute abdominal presentation and need urgent diagnostic surgery. 12 Intra-peritoneal hemorrhage due to fibroids is an exceptionally rare occurrence, in fact, according to a systematic review by Lim et al., only 125 cases have been identified in English published research since 1902, and four patients succumbed to this complication. The root of this manifestation is yet to be understood; thus, it is uncommon to suspect the diagnosis based on the clinical onset of a hypovolemic choc associated with acute abdominal pain, which is often discovered intra-operatively. 1 , 3 , 6 The pathogenesis of abdominal hemorrhage secondary to fibroids remains uncertain, with numerous speculations and theories proposed. Bleeding was linked to a subserosal or superficial vessel rupture or to avulsion/torsion of a pedunculated leiomyoma and rupture of a degenerated fibroid. 1 , 2 In cases where bleeding originated from a ruptured vessel, it was mainly veinous, and even a minor vein could lead to massive abdominal hemorrhage. However, arterial bleeding was reportedly associated with high blood pressure. Ruptures can be traumatic or spontaneous in nature. 4 – 6 In our case, there was no traumatic event reported by the patient. Rupture of vessels overlying leiomyomas usually affects multiparous women aged 30–49 years, who have large fibroids exceeding 10 cm in diameter. Our patient met the criteria for age and parity, and had a sizable fibroid measuring 11 cm. 13 Multiple speculations have been proposed regarding the spontaneous rupture of these vessels. First, elevated abdominal pressure could contribute to vessel congestion, which resulting in rupture. This situation could be caused by heavy exercise, intense sexual activity, difficult defecation, and menstruation. Second, larger leiomyomas were, allegedly, correlated with malformations and fragilization of superficial vessels due to the tension and stretching effect of a growing fibroid; thus, fibroids that exceed 10 cm in diameter are more likely to have weaker and distended vessels that may rupture. Finally, on a molecular level, recent reports have found that micro-RNAs, particularly miR-29b, play an essential role in the pathogenesis of leiomyomas, and that their downregulation is crucial for fibroid tumorigenesis. Progesterone plays a role in downregulating miR-29b and upregulating mRNAs for multiple collagens, which means that a decrease in progesterone may potentially weaken the blood vessels. 5 , 6 The typical clinical presentation is acute abdominal and pelvic pain with signs of hypovolemic shock. A precise preoperative diagnosis of this entity is uncommon. It is usually the result of exploration of an unexplained hemoperitoneum. 5 , 14 The management of such patients includes two crucial therapeutic components that are part of hemorrhagic shock management: the ‘titrated hypotensive resuscitation’ tactics and the ‘damage control surgery’ strategy. In fact, it is compulsory to promptly and definitively control the origin of bleeding and replace blood loss. 15 Urgent surgery is the cornerstone of treatment, and the chosen procedure depends on age, hormonal status, and fertility preservation in younger patients. Hysterectomy should be performed in postmenopausal women, while myomectomy should be prioritized in younger patients wishing to preserve their fertility. If bleeding is uncontrollable, hemostatic hysterectomy should be carried out. Lately, embolization of the uterine artery has been increasingly used owing to its minimally invasive nature and quick recovery. Open surgery is the typical technique; however, some successful laparoscopic approaches have been reported. Maemura et al. reported the first successful laparoscopic myomectomy for the management of hemoperitoneum of unknown origin. 4 , 5 Conclusion Although fibroids are extremely common, they are unlikely to cause acute complications that require surgical management. Abdominal hemoperitoneum is particularly quite rare and remains underdiagnosed until surgical exploration. Thus, rupture of a superficial vessel in a fibroid should be suspected in every patient presenting with acute hemoperitoneum, especially when a history of fibroids is reported. CT scans and MRI could be helpful for diagnosing stable patients, but urgent surgery prevails as the key approach to confirm the diagnosis and control bleeding without omitting the resuscitation component. Consent Consent for publication: Written informed consent was obtained from the patient for publication of this case, with assurances of anonymity and confidentiality. Data availability No data are associated with this article. The checklist used for the development of this care guideline can be found on our data guidelines page at Zenodo. The dataset is titled “CARE Checklist for Case Report of Chayma Rjiba” , available under the CC0 license. The working DOI for the dataset is https://doi.org/10.5281/zenodo.15204318 . 16 References 1. Hu H, Choi JDW, Arrage N: Unusual presentation of hemoperitoneum secondary to ruptured uterine leiomyoma: a case report. Gynecol. Pelvic Med. 2022; 5 . Publisher Full Text 2. Levai AM, Rotar IC, Muresan D: Torsion of a uterine leiomyoma - a rare cause of hemoperitoneum; a case report and review of the literature. Med. Ultrason. 2019; 21 : 77–82. PubMed Abstract | Publisher Full Text 3. Lim WH, Cohen SC, Lamaro VP: Intra-abdominal haemorrhage from uterine fibroids: a systematic review of the literature. BMC Surg. 2020; 20 : 70. PubMed Abstract | Publisher Full Text | Free Full Text 4. Elkbuli A, Shaikh S, McKenney M, et al. : Life-threatening hemoperitoneum secondary to rupture of a uterine leiomyoma: A case report and review of the literature. Int. J. Surg. Case Rep. 2019; 61 : 51–55. PubMed Abstract | Publisher Full Text | Free Full Text 5. Maemura T, Fujita S, Morita N, et al. : Successful laparoscopic management of acute abdominal pain due to spontaneous rupture of subserosal vessels overlying a uterine fibroid: a case report and surgical video. BMC Womens Health. 2022; 22 : 388. PubMed Abstract | Publisher Full Text | Free Full Text 6. Takaki E, Goto M, Hori K, et al. : Hypovolaemic shock due to intra-abdominal haemorrhage from multiple uterine fibroids. BMJ Case Rep. 2021; 14 : e241782. PubMed Abstract | Publisher Full Text | Free Full Text 7. Stewart EA, Cookson CL, Gandolfo RA, et al. : Epidemiology of uterine fibroids: a systematic review. BJOG. 2017; 124 : 1501–1512. Publisher Full Text 8. Barjon K, Mikhail LN: Uterine Leiomyomata. StatPearls, Treasure Island (FL): StatPearls Publishing; 2025. 9. Mettler L, Schollmeyer T, Tinelli A, et al. : Complications of Uterine Fibroids and Their Management, Surgical Management of Fibroids, Laparoscopy and Hysteroscopy versus Hysterectomy, Haemorrhage, Adhesions, and Complications. Obstet. Gynecol. Int. 2012; 2012 : 791248–791248. PubMed Abstract | Publisher Full Text | Free Full Text 10. Giuliani E, As-Sanie S, Marsh EE: Epidemiology and management of uterine fibroids. Int. J. Gynaecol. Obstet. 2020; 149 : 3–9. Publisher Full Text 11. McKendrick M, Rajadurai V, Weishaupt J, et al. : Hemoperitoneum caused by spontaneous rupture of a leiomyoma: A case report. Case Rep. Womens Health. 2024; 42 : e00609. PubMed Abstract | Publisher Full Text | Free Full Text 12. Gupta S, Manyonda IT: Acute complications of fibroids. Best Pract. Res. Clin. Obstet. Gynaecol. 2009; 23 : 609–617. Publisher Full Text 13. Swarray-Deen A, Mensah-Brown SA, Coleman J: Rare complication of fibroids in pregnancy: Spontaneous fibroid rupture. J. Obstet. Gynaecol. Res. 2017; 43 : 1485–1488. PubMed Abstract | Publisher Full Text 14. Antoine A, Kondagari L, Okada C, et al. : Large-volume hemoperitoneum and hemodynamic instability in uterine fibroid rupture: A case report. Case Rep. Womens Health. 2024; 41 : e00572. PubMed Abstract | Publisher Full Text | Free Full Text 15. Bonanno FG: Management of Hemorrhagic Shock: Physiology Approach, Timing and Strategies. J. Clin. Med. 2022; 12 : 260. PubMed Abstract | Publisher Full Text | Free Full Text 16. Rjiba C, Marwen N, Moulehi K, et al. : Massive Hemoperitoneum Due to Ruptured Superficial Vein Overlying a Pedunculated Fibroid: A Rare Case Report. Zenodo. 2025. Publisher Full Text Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 22 Apr 2025 ADD YOUR COMMENT Comment Author details Author details 1 Department of Gynecology and obstetrics, Ibn El Jazzar university Hospital, Kairouan, Kairouan, Tunisia 2 Ibn El Jazzar Medical University, Sousse, Tunisia 3 Department of Cardiology, Ibn El Jazzar University Hospital, Kairouan, Kairouan, Tunisia 4 Emergency department, Ibn El Jazzar University Hospital, Kairouan, Kairouan, Tunisia 5 Department of Anesthesia and Intensive Care, Hopital University Ibn El Jazzar, Kairouan, Kairouan, Tunisia Chayma Rjiba Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Resources, Writing – Original Draft Preparation, Writing – Review & Editing Nadia Marwen Roles: Conceptualization, Data Curation, Methodology, Project Administration, Supervision, Validation, Visualization Khouloud Moulehi Roles: Data Curation, Writing – Original Draft Preparation Hafedh Touileb Roles: Resources, Writing – Original Draft Preparation Yossra Massoudi Roles: Resources, Supervision, Validation, Visualization Ktata Imen Roles: Resources, Supervision, Validation, Visualization Chafiaa Bouhamed Roles: Resources, Supervision, Validation, Visualization Slah Souii Roles: Resources, Supervision, Validation, Visualization Mohamed Ridha Fatnassi Roles: Resources, Supervision, Validation, Visualization Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (1) version 1 Published: 22 Apr 2025, 14:450 https://doi.org/10.12688/f1000research.163911.1 Copyright © 2025 Rjiba C et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Rjiba C, Marwen N, Moulehi K et al. Case Report: Massive Hemoperitoneum Due to Ruptured Superficial Vein Overlying a Pedunculated Fibroid: A Rare Case Report [version 1; peer review: awaiting peer review] . 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