Consecutive intrapartum uterine rupture following endoscopic resection of deep rectovaginal and bladder endometriosis

Summary

Objective:

To present case report of patient with repeted endoscopic resections of deep infiltrating endometriosis (DIE) to demonstrate its possible risks for subsequent delivery.

Design:

Case report.

Setting:

Department of Obstetrics and Gynecology, Central Moravian Hospital Trust, Member of Agel holding, Prostějov, Czech Republic; Department of Obstetrics and Gynecology, Vyškov Hospital, Czech Republic; Department of Pathology, Vyškov Hospital, Czech Republic; Department of Pathology, University Hospital Brno, Medical faculty, Masaryk University Brno, Czech Republic; Department of Obstetrics and Gynecology, Palacky University, Faculty of Medicine and Dentistry, Olomouc, Czech Republic.

Methods and results:

We are presenting a case of 29 years old patient with multiple laparoscopic surgery for deep infiltrating endometriosis (DIE). At the same time, new risks are posed to the delivery process like a severe injuries of the uterine attachment aparate, vagina, parametria with the risk of developing life threatening bleeding. These case we presented here demonstrates the emergence of new risks and complications for another pregnancy with such women.

Conclusion:

Our case report demonstrates new possible obstetric risk factors as consequence of increasing radicality in surgical treatment of DIE.

Keywords:

deep infiltrating endometriosis, DIE, intrapartal uterine rupture, life-threatening peripartal bleeding, laparoscopy

INTRODUCTION

Endometriosis is one of the most frequently encountered benign gynecological diseases, known to occur in 7–10% of women of reproductive age [11]. It is well established that three different forms of endometriosis can coexist in the pelvis: peritoneal endometriosis, ovarian endometriosis, and deep endometriosis (DIE) of the rectovaginal septum [22]. Deep infiltrating endometriosis is defined as subperitoneal invasion by endometriotic lesions that exceed 5 mm in depth [17]. DIE is a common cause of pelvic pain, dysmenorrhea, dyspareunia, dyschezia, and urinary symptoms and is associated with infertility. Rectovaginal endometriosis, which is the most important type of deep endometriosis, consists of endometriotic nodules, in which the fibrotic component is prevalent, within the connective tissue between the anterior rectal wall and the vagina [12]. There is limited evidence supporting the sustained effectiveness and acceptability of medical therapies in improving the symptoms of rectovaginal endometriosis [8, 24].

When possible, excision of the endometriotic nodule is the proper solution for simple cases; in the most complex cases, with rectal wall involvement, resection of the affected intestinal tract may be necessary [16]. With the rise of minimally invasive technology, laparoscopic treatment has become the dominant approach in the treatment of endometriosis because of its recognized superiority in terms of blood loss, postoperative analgesic requirements, febrile morbidity, and recovery time [7, 25]. Pregnancy does not seem to prevent disease progression, and resection of rectovaginal DIE seems to improve fertility outcomes [3, 5, 21]. Moreover, among pregnant women with endometriosis, rectovaginal DIE is associated with prematurity, hospitalization, and low birthweight [2, 13]. Uterine rupture is a rare obstetrical complication implicating worsen maternal and fetal prognosis during labor. Although, some risk factors are well known, usually it appears unexpected and no consensus regarding the risk factors for uterine rupture has been established [19]. Its incidence is estimated to be 0.035% of deliveries in the general population [1]. In recent decades, however, the incidence of uterine rupture after laparoscopic surgery of the uterus has increased, mostly in the late stages of pregnancy or during labor, potentially leading to hemorrhage, hysterectomy, preterm labor, neonatal asphyxia, and a high fetal mortality rate [1, 15, 27].

Herein we report the first case of two consequent intrapartal uterine ruptures after laparoscopic treatment of deep infltrating endometriosis of rectovaginal septum and bladder, resulting in two healthy newborns and final hysterectomy after the second delivery followed by complete uterine rupture.

CASE REPORT

On June 2010 a 29-year-old nuliparous woman complaining of dysmenorrhea and dyspareunia was diagnosed as having deep infiltrating endometriosis of the bladder and enlarged painful right inguinal lymphonode. She underwent laparoscopic resection of endometriotic lesions of the left uterosacral ligament followed by a transvesical resection of urinary bladder endometriosis with bilateral salpingo-ovariolysis and excision of the right superficial inguinal lymphonode. The post-operative period was uneventful and subsequent cystoscopy performed four weeks‘ after laparoscopy revealed complete healing of the bladder wall. Histological examination confirmed endometriosis of the bladder, uterosacral ligament and the right inguinal lymphonode.

After four months she was invited to the second look laparoscopy with tube patency testing and cystoscopy. The integrity of the bladder wall was confirmed and patency of both tubes has been shown. Subsequently she underwent unsuccessful artificial insemination. One year after the primary surgery, she was refered by her gynecologist with an endometrioma on the right ovary, 4 cm in diameter. She underwent laparoscopic resection of bilateral ovarian endometriomas and right side sacrouterine ligament endometriotic nodule. Endometriosis without evidence of malignancy was described histologically in all samples. The first day after surgery, she has developed urine retention. An ultrasound scan had shown a hematoma in cul-de-sac. Hematoma was evacuated during subsequent laparocopy with posterior vaginal wall electrocautery and suture of 1cm large bleeding lesion of posterior vaginal wall. After one year she successfully conceived after IVF and embryo transfer. On November 2012 the patient was admitted with premature rupture of membranes at 37 weeks gestation and regular uterine contractions. Cardiotocography showed no abnormalities, cervix was dilated by about 2 cm and she was admitted to our ward for a trial of vaginal delivery. She has gradually developed very strong uterine contractions with precipitous labor and delivery. For atypical pelvic pain persisted even after the end of contractions. The labor was accomplished by vacuum extraction resulting in delivery of healthy boy baby, weighing 2690 g with Apgar score of 10, 10 and 10 points at 1, 5 and 10 minutes respectively. Despite the application of intravenous oxytocin infusion and ergometrine placenta could not be delivered. Manual removal od placenta in general anesthesia was performed together with vaginal suturing of a 7 cm transverse complete uterine rupture on the posterior lower uterine segment with a total blood loss of approximately 1200 ml. The patient’s postoperative course was uneventful.

Two years later patient conceived after IVF and embryo transfer. On February 2015 the patient was admitted for regular uterine contractions at 40 weeks 3 days gestation. On arrival, cardiotocography, ultrasound for fetal well-being and growth were all normal. Patient strongly preferred vaginal trial of labor. After 15 hours of close observation, the cervix was dilated by 8cm. Fetal monitor showed repeat variable and then late deceleration and emergent caesarean section was arranged. A viable male weighing 3620g delivered with Apgar score 8, 9 and 10 points at 1, 5 and 10 minutes respectively. Immediately after delivery, enormous bleeding was found without bleeding from hysterotomy. Complete transverse uterine rupture of the lower uterine segment and cardinal ligaments was found with active bleeding from uterine arteries and veins bilateraly. Total hysterectomy with bilateral uterine and internal iliac arteries ligation and conservation of adnexae was performed. Estimated total blood loss was 5000 ml. Consequently patient received red blood cell and fresh frozen plasma transfusion and afterwards patient recovered with no difficulty. Histopathologic examination revealed decidual transformation at the level of the cervix and istmus.

DISCUSSION

Uterine rupture is a major obstetric hazard and more commonly involves a scarred uterus. Most cases are associated with a previous cesarean delivery or myomectomy with entry into the uterine cavity [20].

Xiaoxia et al. published 67 cases of uterine rupture out of 128 599 deliveries (incidence of uterine rupture was 0.052 1%) [28]. Cesarean scar rupture were found in 59 cases, two cases of assisted delivery operation trauma, two cases of malformed uterus, three cases of unknown causes (all with artificial abortion history) and one myomectomy scar case. There was no maternal death, ten patients out 67 underwent hemostatic hysterectomy and 12 perinatal fetal deaths were reported [28].

Hesselman et al. analysed 7683 women attempting vaginal birth after previous cesarean section [10]. They reported uterine rupture during labor in 109 patients (incidence of uterine rupture was 1,3%). Maternal factors associated with uterine rupture were: age ≥35 years and height ≤160 cm. Factors from the first delivery associated with uterine rupture in a subsequent delivery were: infection and giving birth to an infant large for gestational age. Risk factors from the second delivery were induction of labour, use of epidural analgesia, and a birthweight of ≥4500 g.

Using electronic searches of PubMed and Google Scholar, hand searches of references, and e-mail queries of unpublished cases, Parker et al. identified mineteen cases of uterine rupture after laparoscopic myomectomy [19]. There were no instances of maternal deaths; however, three fetuses died, at 17,

28, and 33 weeks’ gestation, respectively. They conclude, that deviation from standard technique as described for abdominal myomectomy, seems to bet he main risk factor for uterine rupture [20]. In three cases, the uterine defect was not repaired; in 3 cases it was repaired with a single suture; in 4 cases it was repaired in only one layer; and in one case, only the serosa was closed. In 16 cases, monopolar or bipolar energy was used for hemostasis. The second largest series reporting ten cases of uterine rupture after laparoscopic myomectomy published Wu et al. in 2018 [27]. Maternal outcomes were relatively favorable, with all uterine tissue preserved. Among all ten patients, fetal death occurred in four, nad perinatal asphyxia occurred in one case. Similarly as in the report of Parker et al., excessive use of energy equipment and the lack of multilayer suturing were identified as the most common risk factors of uterine rupture after laparoscopic myomectomy [27].

Endometriosis affects approximately 10% of premenopausal women [6]. Among them, as many as 50% may have ovarian endometriotic cysts, some 10% bowel endometriosis, and 1% ureteral or vesical endometriosis [14]. Although endometriotic lesions usually regress during pregnancy owing to the favorable hormonal milieu, complications of preexisting endometriotic foci may rarely occur [18]. Intrapartal uterine rupture has been observed in four women who had undergone surgery for rectovaginal endometriosis before pregnancy [4, 9, 23, 26]. In the first patient, laparoscopic excision of a 3 cm nodule in the rectovaginal septum extending into the right uterosacral ligament was performed using laparoscopy and CO₂ laser beam.

Six years after surgery, uterine rupture approxi­mately 9 cm long and located in the lower uterine segment about 0,5 cm above the posterior fornix, was found during labor at 37 weeks‘ gestation and repaired in the same way as for layered closure of a caesarean incision. No signs of fetal distress occurred [23]. In the case of Villa et al., the patient had severe abdominal pain, and signs and symptoms of hemorrhagic shock six hours after normal vaginal delivery [26]. Transabdominal ultrasonographic scanning revealed the presence of a hemoperitoneum. At laparotomy, a 6 cm transverse, complete uterine rupture was found on the posterior lower uterine segment about 0,5 cm above the posterior fornix to the left side. Hemostatic hysterectomy was, performed because of severe atony. Nine months before delivery the patient underwent laparoscopic removal of a 3 cm endometriotic nodule located deep in the rectovaginal septum, involving the posterior vaginal wall. Excision of rectovaginal septum endometriosis was carried out with the “en bloc resection” technique and was started vaginally [26]. One month after the procedure the patient bas diagnosed with a spontaneous pregnancy that had an uneventful course until term.

In the third woman, thick adhesions between the rectosigmoid and the posterior wall of the uterus had been excised while taking care not to create damage to the intestinal loop by cutting closer to the uterine wall. Five years later, at 32 weeks‘ gestation, an emergency cesarean section was performed and a hemoperitoneum of four liters was evacuated. A loss of integrity involving two-thirds of myometrium was observed in the posterior wall of the uterus, at the level of the lower segment [9].

Delepine et al. reported the fourth patient with posterior 5 cm transverse uterine rupture after labor induction for postterm pregnancy. Delivery was terminated by vacuumextraction for perinatal asphyxia. Two and half a year before delivery the patient underwent laparoscopic resection of rectovaginal endometriosis with bilateral ureterolysis [4]. Fetal outcome was excellent in three cases and not reported in one case [9].

Laparoscopic resection of uterosacral ligaments or rectovaginal septum infiltrated with endometriosis has been demonstrated to be an effective method for pain relief. The major problem with excision of deeply invasive endometriosis is lack of a capsule and therefore, as in uterine adenomyosis, there is a risk that the excision is either excessive or incomplete. In these cases where a cleavage plane is lacking, the attempt of a complete lesion excision may result in damage to the cervix or the uterine isthmus, possibly predisposing to uterine rupture owing to the stretching of weakened myometrium during pregnancy [25].

In summary, we herein report the first case of repeated uterine rupture at two vaginal deliveries as a delayed consequence of laparoscopic resection of rectovaginal and bladder endometriosis.

CONCLUSION

Pregnant women presenting with abdominal pain and a history of laparoscopic resection of rectovaginal endometriosis should be evaluated for uterine rupture. Surgeons should ensure strict training of laparoscopic suture skills, limit the use of energy equipment, and ensure effective hemostasis by suturing.

MUDr. Jan Vystavěl

Gynekologicko-porodnické oddělení

Nemocnice Prostějov

Středomoravská nemocniční a.s.

Mathonova 291/1

796 04 Prostějov

e-mail: Vystavel.J@seznam.cz