UTERINE RUPTURE DURING CESAREAN SECTION IN PATIENT WITH PREVIOUS EXTENSIVE LAPAROSCOPIC MYOMECTOMY

Abstract

Uterine rupture following myomectomy is an uncommon but potentially life-threatening obstetric complication associated with severe maternal and fetal morbidity. Although the overall incidence is estimated to be below 1%, rupture after myomectomy differs from rupture of a previous cesarean scar by its tendency to occur before the onset of labor and, in some cases, to remain clinically silent. Several surgical factors have been implicated in impaired uterine scar healing, including removal of large intramural fibroids, entry into the endometrial cavity, extensive use of electrosurgery, and inadequate multilayer myometrial closure.
We report the case of a 42-year-old primigravid woman who conceived through in vitro fertilization using a donor oocyte following previous laparoscopic myomectomy for multiple uterine fibroids, including two large intramural lesions approximately 6 cm in diameter. Pregnancy was additionally complicated by prothrombin-associated thrombophilia and cervical shortening requiring cervical pessary placement. At 35 weeks of gestation, the patient was admitted with preterm premature rupture of membranes and mild irregular uterine contractions. She was hemodynamically stable, asymptomatic, and cardiotocography demonstrated a reassuring fetal heart rate pattern. Cesarean delivery was performed because of the obstetric findings and the history of previous uterine surgery. Following delivery of a healthy male infant weighing 3040 g, routine uterine exploration raised suspicion of a uterine defect. Further inspection revealed a large full-thickness fundal rupture measuring approximately 7–8 cm, covered by membranous omental adhesions. The defect did not show active bleeding and was characterized by fibrous and necrotic edges, suggesting with high probability a process that began before the onset of labor. Surgical repair was successfully performed, and both maternal and neonatal outcomes were favorable.
This case demonstrates that extensive uterine rupture after laparoscopic myomectomy may remain completely asymptomatic and be diagnosed only incidentally during cesarean delivery. Multiple myomectomies, removal of large intramural fibroids, probable entry into the uterine cavity, and fundal localization likely contributed to scar failure. Clinicians should maintain a high index of suspicion in pregnancies following complex myomectomy, even in the absence of classical symptoms of uterine rupture