Positive Seatbelt Sign with Avulsed Leiomyoma following Motor Vehicle Accident Leading to Hemoperitoneum

Abstract

A positive seatbelt sign following a motor vehicle accident is associated with an increased risk of intra-abdominal injury and hemoperitoneum. Injury to the uterus in reproductive-age women can also occur. In this report, we describe a 29-year-old nulligravida female who presented to the emergency room following a motor vehicle accident at freeway speeds. A positive seatbelt sign was noted, and a focused assessment with sonography for trauma revealed hemoperitoneum with an incidental finding of uterine leiomyomata. Upon exploratory laparotomy, a free-floating intraperitoneal mass was identified as an avulsed uterine leiomyoma. A uterine laceration containing a subserosal leiomyoma was also identified. The gynecological team was consulted, and a myomectomy of the subserosal leiomyoma followed by a closure of the uterine laceration was performed. The patient was transfused with a total of three units of packed red blood cells and two units of fresh frozen plasma. The postoperative course was without major complication. A positive seatbelt sign and hemoperitoneum in a reproductive-age woman with leiomyomata should increase the clinical suspicion for uterine injury and decrease the threshold for obtaining a gynecological consultation.

A case of severe hemorrhagic shock caused by traumatic avulsion of uterine fibroid

“…The “submarine effect” refers to the sinking of the patient's body in the forward direction due to the impact of collision even if the seatbelt is properly attached to the ilium, causing the seatbelt to deviate upward and directly compress the abdominal organs ( Fig. 3 ) [5] , [6] . The abdominal wall and gastrointestinal tract have been reported to be injured because of the submarine effect owing to their position with respect to the seat belt, but in women, the risk of injury to the uterus must also be considered.…”

Traumatic Avulsion of a Uterine Fibroid after a Motor Vehicle Collision

“…3,6 There are few case reports of traumatic avulsions of fibroids that result in a free-floating mass in the peritoneum. [7][8][9] It is thought that the mechanism of avulsion involves sheer stress from the uterus and fibroid moving at relatively different rates. 8 Manoukian et al 7 theorized that fibroids extending superior to the pubic rami are at a greater risk for trauma.…”

“…[7][8][9] It is thought that the mechanism of avulsion involves sheer stress from the uterus and fibroid moving at relatively different rates. 8 Manoukian et al 7 theorized that fibroids extending superior to the pubic rami are at a greater risk for trauma. This theory is further supported by the association of a pelvic fracture with traumatic avulsion of a uterine fibroid reported by Venables et al 8 Although it has been reported that a fibroid larger than 10 cm is a risk factor for spontaneous rupture of superficial vessels leading to hemorrhage, there are not sufficient reports of traumatic avulsion to definitively classify size as a risk factor.…”

“…Furthermore, patients with abdominal pain and an abdominal seatbelt sign should expeditiously be evaluated with a FAST for intraperitoneal hemorrhage. 7 Although rare, hemorrhage from a fibroid should remain on the differential, especially in the case of patients with a known fibroid history or irregularly enlarged uterus on examination.…”