In the current case, we successfully managed to diagnose spontaneous hemorrhage from the rupture of the superficial vessels overlying a uterine fibroid and subsequently treated the uterine fibroid by laparoscopic enucleation to remove the origin of the hemorrhage.

In literature, intra-abdominal hemorrhage due to uterine fibroids is rare with approximately 125 cases reported so far [11, 12]. As per a recent review, women who develop this complication typically present with hypovolemic shock and abdominal pain without a definite preoperative diagnosis, and the mortality rate is approximately 3.2% [10]. In most cases, bleeding from a uterine fibroid has been associated with trauma or torsion of pedunculated fibroids, while spontaneous rupture of the superficial vessels is extremely rare [13, 14]. In cases associated with bleeding, the source was mainly venous in origin [15]. There have been several hypotheses regarding the cause of spontaneous vascular rupture associated with uterine fibroid. One hypothesis is that the rupture of superficial vessels overlying the fiborid can be due to passive venous congestion associated with increased abdominal pressure during menstruation or when straining to pass stool, lifting heavy weights, or exercising [15,16,17]. Another hypothesis is that uterine fibroids greater than 10 cm in diameter might be associated with stretching and tension of the overlying vessels resulting in rupture [18]. Third hypothesis is that micro-RNAs, especially miR-29b which is a pivotal role to promote fibroid formation and upregulated mRNAs for multiple collagens in uterine fibroids [19], is recently reported to lead to the pathogenesis of leiomyoma [20], and progesterone downregulated miR-29b and upregulated mRNAs for multiple collagens in fibroids may induce to inhibit the growth of uterine fibroids [19]. In the current case, we speculate that the extreme congestion of the superficial veins of uterine fibroids owing to the withdrawal of progesterone during the late menstrual period along with the size of the uterine fibroid, which had a diameter of > 10 cm, may have contributed to the venous rupture. In addition, the decrement of progesterone on late menstrual period may contribute to upregulate miR-29b and downregulate mRNAs as the epigenetic change. and resulted in the rupture of the superficial vessels overlying a uterine fibroid.

A precise preoperative diagnosis is extremely difficult due to the rarity of this entity [12, 21]. Imaging techniques, such as ultrasound and computed tomography, are commonly used for preoperative examination, but in most cases, the preoperative diagnosis is unexplained hemoperitoneum. Recently, Scioscia and colleague [22, 23] commented that vascularity with doppler ultrasound may improve the detection rate of endometrial cancer which is relevant cause of abdominal uterine bleeding in pre- or perimenopausal women since vascularity the myometrium is not altered in fibroids, whereas it is aberrant in infiltrating endometrial cancer. In addition, Stabile et al. recommended to consider Meigs syndrome as the differential diagnosis on recognizing unexplained hemoperitoneum because they misdiagnosed an ovarian cancer due to the presence of a pelvic tumor, elevated CA-125 and ascites, and the patient underwent a total abdominal hysterectomy, salpingoophorectomy, removal of the pelvic mass, pelvic lymphadenectomy and peritoneal biopsies. peritoneal biopsies, even though it was Meigs syndrome with ovarian fibroma [24]. In this case, we regrettably misdiagnosed it as hemoperitoneum associated with the torsion of subserosal fibroids. Therefore, clinical examination with ultrasound, especially doppler ultrasound, is sufficient for preoperative diagnosis since surgery should not be delayed, especially in a setting of profound hemodynamic instability [25].

While supportive and resuscitative measures play a crucial role in the management of patients with massive intra-abdominal bleeding, surgeries such as hysterectomy and myomectomy should be performed immediately. The preferred procedure is hysterectomy for women who are postmenopausal and myomectomy for women of child-bearing age, since preserving the uterus should be a priority. If bleeding cannot be controlled, a hysterectomy must be considered [26]. In the current case, we chose the laparoscopic surgical approach for determining the origin of hemorrhage and subsequently performed hemostasis of the bleeding site and myomectomy with the repair of the uterine defect.

To our knowledge, this is the first report of a case in which a hemoperitoneum of ambiguous origin was laparoscopically diagnosed and treated by laparoscopic myomectomy for the removal of the origin of hemorrhage. However, a previous report has described the use of laparoscopy to diagnose the source of the bleeding and excision of the uterine fibroid by laparotomy [27].

In conclusion, although acute complications of uterine fibroids that require surgical intervention are exceptionally rare, hemorrhage from the rupture of the superficial vessels overlying a uterine fibroid should be included in the differential diagnosis of an unexplained hemoperitoneum. Surgeons should rapidly diagnose and manage women with acute abdominal pain and a history of uterine fibroids to prevent severe morbidity or even mortality. Based on our experience with this case, we recommend laparoscopic surgery in patients with stable hemodynamics.

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