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\title{Uterine Rupture at 35 Weeks Gestational Age after Laparoscopic Myomectomy-A Case Report}
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             \author[1]{Dr. Karthiga  Dhandapani}

             \author[2]{Dr. Valsa Diana  G}

             \author[3]{Dr. Shyamala  Madheswaran}

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\date{\small \em Received: 6 December 2018 Accepted: 3 January 2019 Published: 15 January 2019}

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\begin{abstract}
        


Laparoscopic myomectomy is a treatment option to preserve fertility and alleviate symptoms associated with fibroids. Although this procedure is reasonably expected to increase the risk of uterine rupture during pregnancy, reports on this issue are scarce. We are, hereby, reporting a case of second gravida who conceived within 2 months of laparoscopic myomectomy who presented with complaints of pain abdomen and decreased fetal movements at 35 weeks of gestational age. She was found to be in early shock with her abdomen tense and tender and was taken up for emergency cesarean section promptly. Every abdominal pain in pregnant women with scarred uterus should be carefully evaluated and properly examined to rule out rupture. Proper advice to the patients regarding the risks during pregnancy post myomectomy is a must.

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\let\tabcellsep& 	 	 		 
\section[{Introduction}]{Introduction}\par
terine rupture is one of the most dreaded complications of childbirth with potentially grave consequences to the mother and fetus .It is known fact that the rate of uterine rupture increases in patients with previous scarred uterus in the form of previous cesarean sections, myomectomy and abortion with instrumentation. We are in an era of rising trend of myomectomy being performed in patients facing infertility or to alleviate menstrual symptoms. Laparoscopic myomectomy is generally preferred by the patients in view of early recovery and less post operative discomfort. The effects of laparoscopic myomectomy in the subsequent pregnancy is less studied. Here we report a case of spontaneous rupture of uterus at 35 weeks of gestation following laparoscopic myomectomy. 
\section[{II.}]{II.} 
\section[{Case Report}]{Case Report}\par
A 30 years old, gravida 2 para 1 was referred to our hospital at 35 weeks of gestation with complaints of pain abdomen and loss of fetal movements for the past 6 hours. Patient had a previous vaginal delivery of a healthy male baby 4 years back. She had complaints of dysmennorhoea and heavy menstrual bleeding 3 years after the first childbirth. She underwent laparoscopic myomectomy at a private hospital for the same complaints and a fundal fibroid was removed. No mention was made as to whether the endometrium was opened or not and hence the scar was taken as an unknown scar. Patient was not aware of the fact that she was supposed to postpone her next pregnancy and became pregnant within 2 months of the surgery.\par
The antenatal period was uneventful till 35 weeks. She was admitted with complaints of pain abdomen and reduced fetal movements for the past 6 hours. There was no history of bleeding per vaginum. On examination, the patient was found to be in a state of early shock with tachycardia, pallor and cold extremities. The abdomen was found to be tense and tender. Fetal bradycardia was noted. Ultrasound revealed the absence of retro placental clots .Patient was taken up for emergency cesarean section suspecting uterine rupture.\par
On opening the abdominal cavity, massive hemoperitoneum of around 1.5 liters was found. A lower transverse uterine incision was made and an alive male baby of birth weight of 2.6kg was delivered with a 5 minute Apgar of 4. Fundal rupture of size 3*3 cm at the site of myomectomy was seen and placenta was found to be adherent around the scar site. There was active bleeding from the site of rupture. Leaving the placenta in situ hysterectomy was proceeded. The post operative period was uneventful.  
\section[{Discussion}]{Discussion}\par
This case has suggested two important issues namely: 1) Women with a history of previous laparoscopic myomectomy suffer from uterine rupture more than those who don't. 2) A short interval between myomectomy and pregnancy may affect the pregnancy outcome.\par
According to Centers of Disease Control and prevention \hyperref[b0]{1} , approximately 1 per cent of mortality is caused by uterine rupture. In a report from rural India, maternal mortality associated with uterine rupture was found to be around 30\% (Chatterjee 2007) \hyperref[b1]{2} . Uterine rupture can be broadly classified as primary or secondary rupture \hyperref[b2]{3} . Primary rupture occurs in an unscarred uterus while secondary rupture occurs in a scarred uterus. Recent studies suggest that the incidence of rupture in a previous lower segment incision is 0.2-1.5\% and in previous classical section is 4-9\%. A recent review by Morimatasu et al \hyperref[b3]{4} suggested that the rate of rupture after adenomyomectomy during pregnancy is 6.0\% which is way much higher. There are many proposed reasons for this high incidence of rupture. The most plausible cause is that during laparoscopic myomectomy it is difficult to delineate exactly the border of the lesion due to a lack of sense of touch and deep sensation. This leads to leaving behind a portion of myoma near the scar site which further weakens the scar.\par
Although we are in an era of increasing trend of laparoscopic myomectomy, only six case publications including our present study have been published about uterine rupture in a case of previous laparoscopic myomectomy. The table below shows the comparision among the publications. A short inter-pregnancy interval was associated with increased risk of uterine rupture in patient with previous cesarean section. The same may hold good for myomectomy also. Case reports by Wada et al \hyperref[b6]{7} and Morimatsu et al also has a short interval of 1 and 12 months respectively. Hence, it is wise to advise patients to plan pregnancy at least 18 months after myomectomy. To further support the previous studies, Bujold et al 8 demonstrated that inter delivery interval of more than 24 months decreased the rupture rates.\par
In the recent past, many studies are conducted to develop surgical procedures to conserve uterus for future pregnancy in patients with huge fibroids. Osada et al \hyperref[b8]{9} recommends triple flap method of closure and have reported zero uterine rupture in the subsequent pregnancies whereas Huang et al \hyperref[b9]{10} have described double flap method of closure after laparoscopic adenomyomectomy.\par
Recent advances in the management of fibroid including MR guided Focussed Ultrasound Surgery \hyperref[b10]{11,}\hyperref[b11]{12} offer promising results.\par
In spite of these enormous advances, there is a still a lack of enough studies highlighting the adverse pregnancy outcomes in patients with previous laparoscopic myomectomy. Further reports must be evaluated to develop safe operative techniques and to establish guidelines about management of pregnancy post myomectomy.\par
IV. 
\section[{Conclusion}]{Conclusion}\par
The present case study highlights that we should have a strong suspisicion of uterine rupture in patients with previous laparoscopic myomectomy. Patients should be explained the risks of short interval between surgery and pregnancy. Planning of conservative management of fibroid in reproductive age group should be done with caution. \begin{figure}[htbp]
\noindent\textbf{1}\includegraphics[]{image-2.png}
\caption{\label{fig_0}Figure 1 :}\end{figure}
  \begin{figure}[htbp]
\noindent\textbf{1} \par 
\begin{longtable}{P{0.426183844011142\textwidth}P{0.00947075208913649\textwidth}P{0.021309192200557103\textwidth}P{0.11601671309192199\textwidth}P{0.04261838440111421\textwidth}P{0.02722841225626741\textwidth}P{0.026044568245125348\textwidth}P{0.07931754874651811\textwidth}P{0.10181058495821727\textwidth}}
\multicolumn{2}{l}{Author et al (Year)}\tabcellsep Age\tabcellsep Operative Method\tabcellsep Obs. Score\tabcellsep GA in Weeks\tabcellsep Uterine Bleeding\tabcellsep Outcome\tabcellsep Delivery Method\\
\multicolumn{2}{l}{Suginami (2001)}\tabcellsep \tabcellsep Laparoscopic\tabcellsep \tabcellsep 32\tabcellsep +\tabcellsep Live birth\tabcellsep Emergency Cesarean\\
\multicolumn{2}{l}{Wada (2006)}\tabcellsep 33\tabcellsep Laparoscopic\tabcellsep G0P0\tabcellsep 30\tabcellsep -\tabcellsep Live birth\tabcellsep Emergency cesarean\\
\multicolumn{2}{l}{Morimatsu (2007)}\tabcellsep 35\tabcellsep Laparoscopic\tabcellsep G1P1\tabcellsep 28\tabcellsep -\tabcellsep Live birth\tabcellsep Emergency\\
\multicolumn{2}{l}{Onishi (2011)}\tabcellsep 40\tabcellsep Laparotomy\tabcellsep G3P1\tabcellsep 31\tabcellsep -\tabcellsep Live birth\tabcellsep Emergency\\
\multicolumn{2}{l}{Yukari (2014)}\tabcellsep 42\tabcellsep Laparoscopic\tabcellsep G2P0\tabcellsep 35\tabcellsep +\tabcellsep Live birth\tabcellsep Elective\\
\multicolumn{2}{l}{Our case (2018)}\tabcellsep 30\tabcellsep Laparoscopic\tabcellsep G2P1\tabcellsep 35\tabcellsep -\tabcellsep Live birth\tabcellsep Emergency\\
\multicolumn{5}{l}{A study by Kim et al 6 about the comparision of}\tabcellsep \tabcellsep \tabcellsep \\
obstetric\tabcellsep outcomes\tabcellsep after\tabcellsep laparoscopic\tabcellsep versus\tabcellsep \tabcellsep \tabcellsep \\
\multicolumn{5}{l}{laparotomic myomectomy in 2013 concluded that rate of}\tabcellsep \tabcellsep \tabcellsep \\
\multicolumn{5}{l}{dehiscence is 1.85-4.9\% after laparoscopic when}\tabcellsep \tabcellsep \tabcellsep \\
\multicolumn{5}{l}{compared to 0\% after laparotomic myomectomy.}\tabcellsep \tabcellsep \tabcellsep \\
\multicolumn{5}{l}{A similar study by Tian et al in 2015 concluded}\tabcellsep \tabcellsep \tabcellsep \\
the same.\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \end{longtable} \par
 
\caption{\label{tab_0}Table 1 5}\end{figure}
 			\footnote{© 2019 Global Journals Uterine Rupture at 35 Weeks Gestational Age after Laparoscopic Myomectomy-A Case Report} 		 		\backmatter  			  				\begin{bibitemlist}{1}
\bibitem[Chatterjee and Bhaduri (2007)]{b1}\label{b1} 	 		‘Clinical analysis of 40 cases of uterine rupture at Durgapur Subdivisional Hospital: an observational study’.  		 			S R Chatterjee 		,  		 			S Bhaduri 		.  	 	 		\textit{Journal of the Indian Medical Association}  		2007 Sep. 105  (9)  p. .  	 
\bibitem[Huang et al. (2015)]{b9}\label{b9} 	 		\textit{Efficacy of laparoscopic adenomyomectomy using double-flap method for diffuse uterine adenomyosis. BMC women's health},  		 			X Huang 		,  		 			Q Huang 		,  		 			S Chen 		,  		 			J Zhang 		,  		 			K Lin 		,  		 			X Zhang 		.  		2015 Dec. 15 p. 24.  	 
\bibitem[Bujold et al. (2002)]{b7}\label{b7} 	 		‘Interdelivery interval and uterine rupture’.  		 			E Bujold 		,  		 			S H Mehta 		,  		 			C Bujold 		,  		 			R J Gauthier 		.  	 	 		\textit{American Journal of Obstetrics \& Gynecology}  		2002 Nov 1. 187  (5)  p. .  	 
\bibitem[Tempany et al. (2003)]{b10}\label{b10} 	 		‘M R imaging-guided focused ultrasound surgery of uterine leiomyomas: a feasibility study’.  		 			C M Tempany 		,  		 			E A Stewart 		,  		 			N Mcdannold 		,  		 			B J Quade 		,  		 			F A Jolesz 		,  		 			K Hynynen 		.  	 	 		\textit{Radiology}  		2003 Mar. 226  (3)  p. .  	 
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\end{document}
