Rupture of a Subserosal Vein Overlying a Leiomyoma Causing Hemoperitoneum

Background: Leiomyomas are the most common tumors in women of reproductive age but rarely lead to hemoperitoneum. A total of 95 cases of hemoperitoneum associated with uterine leiomyomas have been described in the literature since 1861. Of these, 66 cases were caused by rupture of a subserosal vein overlying a leiomyoma. Despite previous knowledge of the presence of leiomyomas, very few of these cases were diagnosed correctly prior to surgical exploration. Case: A 46-year-old woman presented with acute-onset abdominal pain and bilateral cold and painful feet. A physical examination revealed tachycardia and an acute surgical abdomen. A computed tomography scan showed an enlarged uterus with multiple leiomyomas, as well as a hemoperitoneum of unknown origin. Upon exploratory laparotomy, the origin of the bleeding was found to be a ruptured subserosal vein overlying an anterior leiomyoma, causing ∼1500 mL of hemoperitoneum. An attempt to suture the bleeding vessel was unsuccessful, and a total abdominal hysterectomy was performed. Results: The patient developed a left iliac vein thrombus postoperatively. On postoperative day 16, this patient was stable for discharge and she was placed on therapeutic anticoagulation for 6 months for treatment of the left-iliac thrombus. Pathology testing revealed uterine leiomyomas, with the largest measuring 15 cm, as well as focal adenomyosis, and an unremarkable cervix and Fallopian tubes. Conclusions: Although rare, a bleeding vessel on a leiomyoma should be kept in the differential diagnosis of hemoperitoneum of unclear origin. A careful history should be elicited to search for precipitating factors, and the patient should be advised of the possibility of infertility following the procedure. (J GYNECOL SURG 30:367)