Conservative management of uterine rupture in gestational tr
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Gestational trophoblastic neoplasia (GTN) includes invasive mole, choriocarcinoma, and placental site trophoblastic tumors. Once GTN is diagnosed, patients are categorized by FIGO Stage and World Health Organization (WHO) risk score, and their stage and score dictate the initial treatment regimen to assure the best possible outcomes with the least morbidity Here reported a case of a patient with low risk disease in the setting of life-threatening hemorrhage from uterine rupture.

A 19-year-old female was diagnosed with a complete hydatidiform molar pregnancy after dilation and evacuation was performed for nonviable intrauterine pregnancy. The patient was followed with serial hCG and her level initially started down trending from the time of evacuation value of 268,400. However, approximately 4 weeks post-evacuation, her level rose to 120,748, resulting in referral to gynecologic oncology for persistent GTN.

Pertinent findings on a chest CT scan revealed multiple bilateral pulmonary nodules consistent with metastatic disease, and her abdomen/pelvis CT scan revealed a heterogeneous mass within the right uterine wall, extending slightly beyond the posterior uterine wall and measuring approximately 4.3 × 3.5 × 4.3 cm. Pelvic ultrasound was also performed for better characterization of this mass . This constellation of findings and a negative pre-treatment chest x-ray was consistent with invasive molar pregnancy and patient was diagnosed with low risk III:3 GTN. Single agent therapy with methotrexate was to be initiated however, 3 days prior to initiation of treatment, the patient presented to a local emergency department with severe abdominal pain and near syncopal episodes. Physical exam was remarkable for abdominal distension and diffuse tenderness with rebound.

Labs revealed severe anemia, Hgb 5.6, and CT scan imaging revealed large hemoperitoneum and uterine wall mass with uterine rupture . she was transferred to a tertiary care center and counseled on the management of uterine rupture in the setting of invasive molar pregnancy. The patient strongly maintained a desire to preserve her fertility; therefore a conservative management approach was employed. an angiogram revealed a large hypervascular mass within the right pelvis with extravasation of contrast, and she subsequently underwent bilateral uterine artery embolization using Gelfoam slurry to temporize bleeding. Immediately after the embolization, the patient was taken to the operating room and underwent an exploratory laparotomy where 3 L of hemoperitoneum was evacuated, and a 5 cm bulging mass was noted on the right posterior fundal aspect of the uterus at the level of the serosa.

Within the mass, a 1 cm serosal rupture was noted with extruding tumor and active bleeding. The site of bleeding was subsequently coated with thrombin spray and packed with Surgiflo and Gelfoam soaked in thrombin.

The site of bleeding was inspected and excellent hemostasis was noted. At the time of abdominal wall closure, a JP drain was placed in the pelvis to monitor any post-operative bleeding. Chemotherapy with induction low dose cisplatin and etoposide was initiated on post-operative day 1. Patient was subsequently transferred to her home where she received cycle 2 of induction low dose cisplatin and etoposide, and eventually completed 5 cycles of Etoposide 90 mg/m2/Methotrexate 300 mg/m2/Dactinomycin 450mcg (EMA) on a q14 day schedule. patient was without evidence of disease, and at her 20 month follow up visit she had a confirmed viable intrauterine pregnancy with suspected placenta accreta.

In summary this is a rare case of GTN complicated by uterine rupture. In addition, the patient strongly desired future fertility and every effort was made to respect her wishes and goals. UAE and a conservative surgical approach were utilized to control hemorrhage, while low-dose induction chemotherapy was administered to prevent potential complications including a higher risk of death that can occur from rapid tumor destruction associated with high-dose therapy.

Source: https://www.sciencedirect.com/science/article/pii/S2352578920300059
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