---
title: "Spontaneous uterine fibroid rupture causing hemoperitoneum in pregnancy mimicking appendicitis"
id: "cmaj-1-spontaneous-fibroid-rupture-and-hemoperitoneum-mimicking-appendicitis-in"
canonical_url: "https://medichelpline.com/clinical-feed/cmaj-1-spontaneous-fibroid-rupture-and-hemoperitoneum-mimicking-appendicitis-in"
content_type: "clinical_feed_article"
specialty: "General"
source_name: "CMAJ"
source_url: "http://www.cmaj.ca/cgi/content/short/198/28/E1110?rss=1"
published_at: "2026-08-10T04:05:21.000Z"
evidence_level: "Journal Feed"
license: "CC-BY-NC-4.0 / Informational Use"
---
# Spontaneous uterine fibroid rupture causing hemoperitoneum in pregnancy mimicking appendicitis
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/cmaj-1-spontaneous-fibroid-rupture-and-hemoperitoneum-mimicking-appendicitis-in
- **Specialty:** [General](https://medichelpline.com/clinical-feed/general.md)
- **Primary Source:** CMAJ
- **Source URL:** [Original Journal Publication](http://www.cmaj.ca/cgi/content/short/198/28/E1110?rss=1)
- **Published At:** 2026-08-10T04:05:21.000Z
- **Evidence Rating:** Journal Feed
## Executive GIST (TL;DR)
- A 36-year-old primigravida at 19 weeks presented with acute right lower quadrant pain and nausea; she was afebrile and hemodynamically stable on arrival. - Laboratory values on presentation: hemoglobin 129 g/L and leukocytes 9.7 × 10^9/L; physiologic pregnancy changes that can obscure labs are noted in the discussion. - History included multiple uterine fibroids, largest 5.1 cm on early ultrasound; pregnancy was conceived spontaneously. - Emergency ultrasonography identified a 6.5 × 7.3 × 5.7 cm exophytic fibroid at the point of maximal tenderness; the appendix was not visualized. - MRI was considered but not performed; within 24 hours the patient developed peritonitis signs and underwent diagnostic laparoscopy and planned appendectomy. - Laparoscopy (supraumbilical open Hasson entry) revealed ~200 mL hemoperitoneum and a 7-cm subserosal fibroid with capsular rupture and serosal bleeding; no active bleeding source was identified. - Management was expectant: evacuation of blood, application of absorbable hemostatic powder to serosal edges, and appendectomy despite a grossly normal appendix. - Postoperative course: pain improved, hemoglobin declined to 117 g/L then 108 g/L at discharge on postoperative day 3; appendix pathology showed lymphoid hyperplasia without acute appendicitis. - Serial ultrasound showed progressive fibroid growth to 7 cm at 20 weeks, 9 cm at 25 weeks, and 11 cm at 32 and 36 weeks; patient remained clinically well without analgesia. - Delivery: elective cesarean at 38+4 weeks for maternal request; healthy male infant, 3.4 kg, vertex presentation. - Key teaching points: acute abdominal pain in pregnancy is diagnostically challenging; **ultrasonography** is first-line imaging, **MRI** is an adjunct if stable, and CT is reserved if essential. - Acute **hemoperitoneum** from spontaneous fibroid rupture in pregnancy is extremely rare (~100 reported cases since 1902); prompt diagnosis and tailored surgical planning are critical. - Most fibroid complications in pregnancy are degeneration or torsion; risk factors include fibroids >5 cm and first-trimester growth, but rupture can occur later and mimic other acute abdominal pathologies such as **appendicitis**. - Surgical principles in pregnancy include low insufflation pressures, open (Hasson) entry, minimizing uterine manipulation and thermal injury, and multidisciplinary involvement to guide decision-making and limit maternal and fetal morbidity.
## Clinical Analysis & Structured Key Points
Spontaneous fibroid rupture and hemoperitoneum mimicking appendicitis in pregnancy | CMAJ Skip to main content Log in Toggle navigation menu Open settings menu Open search Advanced Search Advanced Search Log in --> Spontaneous fibroid rupture and hemoperitoneum mimicking appendicitis in pregnancy Alice Pham Alice Pham Department of Obstetrics and Gynecology (Pham, Deane), and Division of General Surgery (Zhang), North York General Hospital, University of Toronto, Toronto, Ont. MD MSc Find this author on Google Scholar Find this author on PubMed Search for this author on this site Natalya Zhang Natalya Zhang Department of Obstetrics and Gynecology (Pham, Deane), and Division of General Surgery (Zhang), North York General Hospital, University of Toronto, Toronto, Ont. MD Find this author on Google Scholar Find this author on PubMed Search for this author on this site and Angela Deane Angela Deane Department of Obstetrics and Gynecology (Pham, Deane), and Division of General Surgery (Zhang), North York General Hospital, University of Toronto, Toronto, Ont. MD MSc Find this author on Google Scholar Find this author on PubMed Search for this author on this site CMAJ August 10, 2026 198 (28) E1110-E1112; DOI: https://doi.org/10.1503/cmaj.251938 PDF Help Article Figures & Tables Responses Metrics PDF Key points Uterine fibroids in pregnancy are mostly asymptomatic, but as many as 20% will develop complications such as degeneration, torsion of a pedunculated fibroid, or spontaneous rupture. Appendicitis is the most common indication for nonobstetric surgery in pregnancy; delays in diagnosis increase risk of perforation, preterm labour, and pregnancy loss. Ultrasonography is the first line imaging modality for pregnant patients with acute abdominal pain; magnetic resonance imaging can be used as adjunct in stable patients. Acute hemoperitoneum secondary to spontaneous rupture of a fibroid in pregnancy is extremely uncommon, and timely diagnosis and tailored surgical planning are critical to prevent severe maternal and neonatal morbidity and mortality. A 36-year-old primigravida woman presented to the emergency department at 19 weeks and 1 day’s gestation with a 1-day history of worsening acute right lower quadrant pain that woke her from sleep. The pain was associated with nausea, but no emesis. She was afebrile and hemodynamically stable. Her hemoglobin level was 129 (reference 120 to 150) g/L with a leukocyte count of 9.7 (reference 4 to 11) × 10 9 /L. She was known to have a multi-fibroid uterus, with the largest fibroid measuring 5.1 cm on dating ultrasonography performed at 8 weeks and 2 days’ gestation. The pregnancy was conceived spontaneously. Her medical history included eczema, asthma (seasonal triggers), fatty liver, anxiety, and hysteroscopic polypectomy the year before. She was not on any medications. Ultrasonography arranged during the emergency department visit showed a 6.5 × 7.3 × 5.7 cm exophytic fibroid at the point of maximal tenderness ( Figure 1 ); the appendix was not visualized. Approximate myometrial thickness and distance from the fibroid to the gestational sac ranged from 5 to 12 mm. We admitted her for observation and pain management with a working diagnosis of possible appendicitis. Download figure Open in new tab Download PowerPoint Figure 1: Ultrasound of a 36-year-old primigravida woman with an exophytic fibroid (arrow) at point of maximal tenderness. Approximate myometrial thickness and distance from fibroid to gestational sac (arrowhead) ranged from 5 mm to 12 mm (double arrow). We considered magnetic resonance imaging (MRI) for diagnostic clarity but, within 24 hours, the patient had developed signs of peritonitis, including pain at McBurney point. We arranged for diagnostic laparoscopy and planned appendectomy in the operating room. Using a supraumbilical open Hasson laparoscopic technique, we found moderate hemoperitoneum and evacuated approximately 200 mL of blood. The uterus was at 20-week size with a 7-cm subserosal fibroid that had ruptured through its capsule at the right fundal region, and we noted blood at the serosal edges ( Figure 2 ). Because we did not observe active bleeding, we opted for expectant management and applied an absorbable hemostatic powder to the serosal edges of the fibroid. Although the appendix had a grossly normal appearance, we performed an appendectomy. Download figure Open in new tab Download PowerPoint Figure 2: Spontaneous fibroid rupture with capsular bleeding (blue arrow) in a patient at 19 weeks of pregnancy. Appendiceal stump noted in the right lower quadrant (white arrow). Postoperatively, the patient’s pain improved; repeat hemoglobin level was 117 g/L. She was able to ambulate and void with normal bowel movements, and tolerated a normal diet. We observed her in hospital for 3 days to ensure clinical stability, with a plan for laparoscopic myomectomy should her clinical status deteriorate. We discharged her home on postoperative day 3 with a hemoglobin level of 108 g/L and a leukocyte count of 7 × 10 9 /L. We prescribed acetaminophen and hydromorphone as needed for pain relief. Pathologic examination of the appendix showed lymphoid hyperplasia, negative for acute appendicitis and periappendicitis. We arranged serial ultrasonography monitoring, which showed progressive enlargement of the fibroid, measuring 7 cm at 20 weeks’, 9 cm at 25 weeks’, and 11 cm at both 32 and 36 weeks’ gestation. Despite the increasing size of the fibroid, the patient remained well and did not require any analgesia. She delivered a healthy male infant, in vertex presentation, at 38 weeks and 4 days’ gestation, weighing 3.4 kg, by elective cesarean delivery (maternal request). Discussion Acute abdominal pain in pregnancy presents a diagnostic challenge owing to anatomic and physiologic changes of pregnancy and additional concerns about fetal well-being. Maintaining a high index of suspicion for serious, nonbenign pathology is imperative, as uterine enlargement and abdominal wall laxity can mask peritoneal signs and make localization of pain challenging on physical examination. The differential diagnoses are broad and include appendicitis, biliary disease, bowel obstruction, nephrolithiasis, ovarian pathology (including cyst rupture and torsion), and complications of uterine fibroids such as degeneration or torsion. The latter are the most common, with the remaining diagnoses complicating fewer than 1% of pregnancies. 1 Acute hemoperitoneum secondary to spontaneous rupture of a fibroid in pregnancy is extremely rare, with just more than 100 cases reported in the English-language literature since 1902. 2 , 3 Associated symptoms such as nausea, vomiting, and fever can overlap with both obstetric and nonobstetric conditions, underscoring the importance of careful history taking and serial physical examination in making the diagnosis. Importantly, peritoneal signs such as rebound and guarding are not normal in pregnancy and should prompt expedient evaluation. Interpretation of laboratory results may be challenging. Physiologic leukocytosis is common in pregnancy, with “normal” leukocyte counts increasing to an upper limit of 15 × 10 9 /L. 4 Increases in plasma and red cell volume cause physiologic anemia of pregnancy, in which hemoglobin of less than 110 g/L is present in the absence of pathology. These normal adaptations can obscure classic laboratory signs of infection or hemorrhage. Abdominal and pelvic ultrasonography is the first-line diagnostic imaging modality in pregnant patients, with MRI as a useful adjunct when findings are inconclusive and the patient is stable. Uterine fibroids are the most common benign growths in females, affecting 70% to 80% over their lifetime. 5 During pregnancy, most people with fibroids remain asymptomatic. However, 10% to 20% will present with complications, most commonly with pain secondary to either degeneration or torsion of a pedunculated fibroid. Risk factors for complications include fibroids greater than 5 cm in diameter and the patient being in the first trimester of pregnancy, when fibroid size is thought to increase most significantly. 6 Degeneration occurs when a fibroid’s pace of growth outstrips its blood supply, leading to necrosis and inflammation that causes pain, leukocytosis, and fever. 7 Magnetic resonance imaging has the highest sensitivity and specificity in differentiating between torsion and degeneration of a fibroid. Uncomplicated fibroids are generally seen as T 1 and T 2 hypointense lesions with variable enhancement patterns. Torsion of a pedunculated fibroid is seen as a heterogeneously hyperintense signal on T 2 -weighted images, with peripheral enhancement (due to edema and obstructed venous flow) and a central nonenhancing necrotic area within the fibroid. Often, on ultrasound, a vascular pedicle is identified with patchy arterial flow and absent venous flow, suggesting torsion. The presence of the twisted pedicle, on both MRI and ultrasonography, helps to differentiate heterogeneity in a torted fibroid from that of heterogeneity due to fibroid degeneration. 8 Management of degenerating fibroids is primarily conservative, as surgery carries risk of miscarriage and preterm labour, in the range of 5% to 10% depending on gestational age. 6 Surgical intervention is reserved for hemodynamic instability secondary to intracapsular bleeding (from red or hemorrhagic degeneration) or refractory pain. The source of hemorrhage is usually due to rupture of a superficial venous vessel overlying the fibroid. However, in our patient, bleeding arose from the ruptured capsule rather than from a specific vessel. Rarely, emergency hysterectomy is needed as a last resort, usually in the case of uncontrolled bleeding at the myomectomy site secondary to the hypervascular gravid uterus. Conservative treatment principles focus on supportive measures with intravenous hydration, analgesia, and antiemetics. Symptoms usually resolve within 7 to 10 days. 8 Appendicitis remains the most common indication for nonobstetric surgery in pregnancy, with an incidence ranging from 1 in 500 to 1 in 1500 pregnancies. A delay in diagnosis can lead to a higher risk of perforation, which is associated with rates of fetal loss higher than 40%. 4 Ultrasonography is the optimal imaging modality for pelvic organs and in pregnancy, but findings can be inconclusive. The appendix is often not visualized owing to changes in body habitus, presence of the gravid uterus, and displacement of the appendix into an abdominal location around the iliac crest. Magnetic resonance imaging, although valuable for diagnostic purposes, is associated with increased scanning time and cost, and consideration must be given to after-hours availability. The confined space and breath control required can also be impediments for certain pregnant patients. Computed tomography (CT) with intravenous contrast dye remains the best diagnostic tool for appendicitis. 4 However, it comes with both a radiation risk (although a low-exposure technique can be used to reduce radiation exposure to 2.5 mGy) and theoretical concerns that iodinated contrast media crossing the placenta could result in goitre formation and thyroid dysfunction in the neonate. Consequently, CT is still recommended only if absolutely required to obtain additional diagnostic information (e.g., source of bleeding) that will guide decision-making regarding conservative versus surgical management. 9 Definitive management in cases of acute abdomen secondary to intra-abdominal hemorrhage is surgical. Timely diagnosis and prompt multidisciplinary surgical planning are essential to prevent severe morbidity or mortality in the gestational parent and fetus. Although laparotomy was once standard, laparoscopy is now considered equally safe in appropriately selected patients, when performed by an experienced surgical team and with consideration given to factors such as gestational uterine size. Goals of surgery include identifying and controlling the source of bleeding while minimizing uterine trauma, acknowledging the need for myomectomy or hysterectomy if uncontrollable bleeding is encountered. Principles of surgery include maintaining low intra-abdominal pressures to reduce maternal hypercapnia; open (Hasson) entry technique to better control entry site and minimize uterine injury, as compared with a blind Veress technique; and choosing a hemostatic technique that will minimize operating time and reduce uterine manipulation as well as thermal damage to uterine tissues. 10 A multidisciplinary team approach involving both gynecology and general surgery allows for vigilance with regard to other potential causes of bleeding and pain — particularly during diagnostic surgery, when the presence of uterine fibroids can act as a “red herring.” The section Cases presents brief case reports that convey clear, practical lessons. Preference is given to common presentations of important rare conditions, and important unusual presentations of common problems. Articles start with a case presentation (500 words maximum), and a discussion of the underlying condition follows (1000 words maximum). Visual elements (e.g., tables of the differential diagnosis, clinical features or diagnostic approach) are encouraged. Consent from patients for publication of their story is a necessity. See information for authors at www.cmaj.ca . Footnotes Competing interests: Angela Deane reports serving as a member of the Governance Committee of the Society of Obstetricians and Gynaecologists of Canada (unpaid). No other competing interests were declared. This article has been peer reviewed. The authors have obtained patient consent. Contributors: All of the authors contributed to the conception and design of the work, drafted the manuscript, revised it critically for important intellectual content, gave final approval of the version to be published and agreed to be accountable for all aspects of the work. This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e., research or educational use), and no modifications or adaptations are made. See: https://creativecommons.org/licenses/by-nc-nd/4.0/ References 1 ↵ Choi JH Liu HJ Heo SM . Hemoperitoneum caused by spontaneous ruptured of uterine leiomyoma in a perimenopausal woman . J Menopausal Med 2021 ; 27 : 42 – 5 . Google Scholar OpenURL PubMed 2 ↵ Lim WH Cohen SC Lamaro VP . Intra-abdominal haemorrhage from uterine fibroids: a systematic review of the literature . BMC Surg 2020 ; 20 : 70 . Google Scholar OpenURL PubMed 3 ↵ Swarray-Deen A Mensah-Brown SA Coleman J . Rare complication of fibroids in pregnancy: spontaneous fibroid rupture . J Obstet Gynaecol Res 2017 ; 43 : 1485 – 8 . Google Scholar OpenURL PubMed 4 ↵ Kim Y Hwang I . Acute appendicitis in pregnancy mimicking leiomyoma pain . BMJ Case Rep 2021 ; 14 : e238476 . Google Scholar OpenURL PubMed 5 ↵ Ye M Huang W Chen F . Dynamic volume variation of uterine leiomyomas during pregnancy . Int J Gynaecol Obstet 2023 ; 161 : 417 – 22 . Google Scholar OpenURL PubMed 6 ↵ Edney R Yap C Childs S . Second trimester semi-elective abdominal myomectomy to manage severe systemic inflammatory response syndrome secondary to fibroid degeneration . BMJ Case Rep 2025 ; 18 : e266076 . Google Scholar OpenURL PubMed 7 ↵ Cerdeira AS Tome M Lim L . The value of MRI in management of uterine fibroids in pregnancy . Eur J Obstet Gynecol Reprod Biol 2021 ; 256 : 522 – 3 . Google Scholar OpenURL PubMed 8 ↵ Dunphy L Gee M Ford J . Red degeneration of fibroid presenting with abdominal pain in pregnancy . BMJ Case Rep 2025 ; 18 : e263747 . Google Scholar OpenURL PubMed 9 ↵ Committee Opinion No. 723: Guidelines for diagnostic imaging during pregnancy and lactation [published erratum in Obstet Gynecol 2018;132:786] . Obstet Gynecol 2017 ; 132 : e210 – 6 . Google Scholar OpenURL 10 ↵ Magni F Ferrari FA Minasola M . Laparoscopic management of symptomatic uterine myoma in pregnancy: a case report and critical analysis of literature . J Obstet Gynaecol Res 2025 ; 51 : e70067 . Google Scholar OpenURL PubMed PDF Previous Next Back to top In This Issue CMAJ Vol. 198, Issue 28 10 Aug 2026 Table of Contents Index by author Article tools Respond to this article Print Download PDF Article Alerts Alerts for this Article User Name * Password * To sign up for email alerts or to access your current email alerts, enter your email address below: Email * Email Article Email This Article Thank you for your interest in spreading the word on CMAJ. 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Your Personal Message CAPTCHA Please verify that you are a real person Close Citation Tools Citation Tools Spontaneous fibroid rupture and hemoperitoneum mimicking appendicitis in pregnancy Alice Pham Alice Pham Natalya Zhang Natalya Zhang and Angela Deane Angela Deane CMAJ Aug 2026, 198 (28) E1110-E1112; DOI: 10.1503/cmaj.251938 Citation Manager Formats BibTeX Bookends EasyBib EndNote (tagged) EndNote 8 (xml) Medlars Mendeley Papers RefWorks Tagged Ref Manager RIS Zotero Request Permissions Share Share This Article Spontaneous fibroid rupture and hemoperitoneum mimicking appendicitis in pregnancy Alice Pham Alice Pham Natalya Zhang Natalya Zhang and Angela Deane Angela Deane CMAJ Aug 2026, 198 (28) E1110-E1112; DOI: 10.1503/cmaj.251938 Share This Article: Copy Post Like 0 Jump To Section Discussion Footnotes References PDF Related Articles No related articles found. Google Scholar PubMed Cited By... No citing articles found. 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