The American Surgeon | 2019
Traumatic Avulsion of a Uterine Fibroid after a Motor Vehicle Collision
Abstract
Uterine fibroids result from the benign proliferation of myometrial cells and are common in women of reproductive age.1, 2 Although they occur in 20–30 per cent of women aged 30 years and older, fibroids rarely cause acute complications in trauma and, therefore, much of our knowledge comes from case reports.1, 3 Known sequelae of uterine fibroids include thromboembolism, acute torsion of subserosal pedunculated leiomyomata, and acute hemorrhage due to degeneration of the myoma.4 Factors thought to predispose patients to hemorrhage from fibroids have all been associated with increased intra-abdominal pressure.1, 4 Here, we present the case of a patient with a known history of fibroids who presented with hemoperitoneum after a motor vehicle collision. Our patient is a 47-year-old woman with a past medical history of uterine fibroids who was brought to our Level I trauma center after being the restrained driver in a motor vehicle collision. On arrival to our trauma bay, her airway was intact with bilateral breath sounds. She was found to have a Glasgow Coma Scale score of 13 because of confusion. She was tachycardic with a heart rate of 140 beats/minute and hypotensive with a blood pressure of 95/35 mmHg. The focused assessment with sonography in trauma (FAST) examination was positive in the left upper quadrant. A secondary survey revealed a soft abdomen that was diffusely tender to palpation, and there were ecchymoses to her lower abdomen from her seat belt. Given her hemodynamic instability and positive FAST, she was taken to the operating room emergently for an exploratory laparotomy. A midline laparotomy incision was made, and entry into the peritoneal cavity revealed significant hemoperitoneum. All four quadrants of the abdomen were packed with laparotomy pads in the standard fashion. The abdomen including the liver, spleen, small bowel, and colon was inspected and found to have no injuries or sources of bleeding. A massive fibroid extending beyond the umbilicus was noted and found to be completely avulsed from the uterus. It was freely mobile and easily removed from the abdominal cavity. The fibroid measured 15 · 6.5 · 9 cm3 and weighed 1613 g (Fig. 1). Several punctate areas of arterial bleeding along the dome of the uterus were clamped for hemostasis, and her hemodynamic status rapidly improved. The uterus was noted to be enlarged, broad, and irregular with multiple intramural and subserosal fibroids as well as two additional pedunculated fibroids near the fundus. The obstetrics and gynecology team was consulted, given these findings, the extent of uterine trauma, and her perimenopausal age. They assessed the uterus and repaired a 6 · 2-cm serosal defect along the fundus where the fibroid had avulsed with 2–0 Vicryl sutures. After ensuring hemostasis throughout the remainder of the abdomen as well as performing copious saline lavage, the abdomen was closed in the standard fashion. The patient lost 1.5 L of blood from her uterine injury and was resuscitated with crystalloid and five