INTRA#ABDOMINAL HEMORRHAGE DUE TO

SPONTANEOUS RUPTURE OF A VEIN ON A

FIBROID UTERUS

MAX SCHNEIDER, M.D. AND EDWARD E. JEMERIN, M.D. Associate Gynecologist and Obstetrician,

Sydenham Hospital

NEW YORK,

T HE rupture of a vein on a fibromyoma of the uterus with intra-abdominal hemorrhage, is a rare finding, and

only forty-eight similar cases have been reported.

CASE REPORT

L. B., colored, aged forty, was brought into the hospital by ambulance. Her chief com- pIaints were (I) sharp pains in the abdomen, (2) sweIIing of the abdomen and (3) weakness. The onset of the above was sudden and had occurred about twenty hours prior to admis- sion. The onIy relevant fact in the past history, was that one year ago, she had refused oper- ation for an abdominal tumor at a municipa1 hospita1. She had had norma menses until four months before admission; since then she had been amenorrheic. For the Iast few days there had been sIight vagina1 spotting. She had had no bowel movement for two days.

She was pare, had a cold cIammy skin and appeared very weak. Her pulse was thready, of poor quahty; the rate varied between 96 and 120. Her bIood pressure was 90/60. The temperature was IOI’F. The hemoglobin was 42 per cent; red bIood ceIIs 3,280,ooo; white bIood ce1I.s 4,200.

The abdomen was markedly distended and tender throughout. A nodular, stony-hard, tender mass fiIIed the entire abdominal cavity, reaching to the xiphoid. A fluid wave was aIso present.

The peIvic examination showed the cervix to be high, and the uterus merged into the abdomina1 mass. The fornices were cIear, and not tender. The aspiration of the fluid in the abdomina1 cavity revealed the presence of bIood. The preoperative diagnosis was a Iarge fibromyomatous uterus, associated with intra- abdomina1 hemorrhage from an undetermined source.

Adjunct Surgeon, Sydenham Hospital

NEW YORK

Preoperatively the patient received an intra- venous infusion of 3 per cent gIucose. The operation was started under local anesthesia. The Iatter, however, was unsatisfactory, and she was given a genera1 anesthesia of gas, oxygen and ether.

Upon opening the peritonea1 cavity, almost two Iiters of bIoody fluid escaped, in part old bIood. (This accounts for the low white count.) A huge fibroid uterus was seen and easily deIivered through the wound. (Fig. I.) On the posterior aspect of the proxima1 portion of the tumor, there was a defect in a superficia1 vein. CarefuI search faiIed to reveal any other source of bIeeding.

A supracervical hysterectomy and right saIpingo-oopherectomy were done, the stumps peritoneaIized, the remaining fluid evacuated by suction and the abdomina1 waI1 cIosed.

The infusion of 3 per cent gIucose which had been given throughout the operation was con- tinued and suppIemented by a transfusion of goo cc. of bIood.

Recovery was uneventfu1 except for a paracervica1 exudate. The wound heaIed by primary union and she was discharged on the twenty-seventh postoperative day.

The pathoIogica1 report, made by Dr. Arthur M. GinzIer, is as foIIows:

“Specimen is a supracervicaIIy amputated uterus weighing approximateIy 3200 Gm. It contains numerous subserous, intramural, and submucous fibromyomata varying in size from I cm. in diameter to a Iarge subserous fibroid measuring approximateIy 16 cm. in diameter. The serosal aspect of this Iarge fibromyoma exhibits irreguIar pIaque-like areas of grayish- white thickening. CIose by, the serosa presents a thin-walled channel with an irreguIar tear. (Fig. 2.) The fibromyomata on section shows degenerative changes and extensive areas of calcification.

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NEW SERVES VOL. LVIII, No. 2 Schneider, Jemerin-Hemorrhage American Journal of Surgery 295

“The endometrium is smooth, thin and paIe. “A tube and ovary, grossIy normaI, are

attached to the uterus.

“ Pathologica Diagnosis : MuItipIe fibro- myomata of uterus showing degenerative changes and hemorrhage.”

Frc. I. Gross specimen of uterus and f&o- myomas; weight 3,200 Gm.

“HistoIogicaI: Sections show multipIe fibro- myomata of typica structure. There are extensive degenerative changes and areas of calcification. One fibromyoma, as grossIy described, presents on its serosal aspect, a pIaque-Iike Iayer of hyaIine tibrosis containing many diIated, thin-waIIed vesseIs and foca1 areas of chronic inflammation. Some sections show extravasation of red blood cells about these vessels, and, in one section, there is what appears to be a tear tract, apparentIy pro- duced by tissue degeneration, containing blood and fibrin.

FIG. 2. Photograph of ruptured vein. Two straws have been inserted to indicate veins and Iocation of rupture.

The area of irregular pIaque-Iike thicken- ing described by Dr. Ginzler was on the posterior surface of the Iarge fibroid, in cIose contact with the spina coIumn. Be- cause of the presence of oId bIood in the abdomen, and the acute onset, twenty hours prior to admission, one may infer that there had been bIeeding from the ruptured vein.

. . The preclpltating factor

can not be accounted for in the history obtained.

REFERENCES

SHELFO, ANTHONY L. Am. J. Oh. @ Gynec., 37: 1049,

1939. TUREL. Internat. J. Med. CT Surg., 47: 240, 1934. RANSOHOFF, J. LOUIS and DREYFOOS, MAX. Surg.,

Gynec. ti Obst., 33: 296, ,921.