The uterine leiomyoma is a benign neoplasm. A variety of approaches are used to treat a uterine leiomyoma, such as observation; medical treatment; surgical myomectomy; and, in rare cases, hysterectomy [
5]. Intraperitoneal hemorrhage is a rare complication due to bleeding from uterine leiomyoma [
6] and is a life-threatening condition [
7]. The causes of hemoperitoneum in connection with leiomyoma include a ruptured leiomyoma [
8] rupture of a subserosal vein overlying a uterine myoma [
9], bleeding from a subserosal artery [
10], a lacerated leiomyoma [
11], or an avulsed pedunculated leiomyoma [
12]. In most cases, bleeding from a uterine leiomyoma has been associated with trauma or torsion of the tumor, but spontaneous rupture of the superficial vessels is extremely rare [
13,
14]. The source is mainly venous [
8]. Increased abdominal pressure due to hard work, defecation, sports, violent coitus, pregnancy, and menstruation are predisposing factors for rupture of the superficial veins on uterine leiomyoma [
9,
15]. Rupture of a blood vessel on a uterine pseudotumor leading to an isolated hemoperitoneum in the immediate postpartum period has also been reported [
16,
17].
A specific preoperative diagnosis can rarely be established in these cases. In one study, the correct diagnosis was made preoperatively in a mere 7.8% of cases [
18]. Computed tomography and ultrasound are able to show the hemoperitoneum but usually do not reveal the source of the bleeding [
19]. The preoperative diagnosis is commonly an acute abdomen or a hemoperitoneum of unknown origin [
8]. In these cases, timely diagnosis and emergent surgery, extending from ligation of the bleeding vessel to myomectomy or hysterectomy, can prevent catastrophic consequences [
15]. The decision depends on the patient’s age and her desire to preserve fertility [
20]. Previously reported cases of hemorrhage associated with uterine leiomyoma were successfully managed with emergency laparotomy, which proved to be a lifesaving measure [
15,
20]. In our patient’s case, laparoscopy was performed for the diagnosis of the source of the bleeding, the uterus was preserved during laparotomy, and the uterine leiomyoma was treated by surgical excision.
Despite its rarity, a bleeding leiomyomatous vessel should be included in the differential diagnosis of a hemoperitoneum of ambiguous origin. Rapid diagnosis and management are essential in this potentially life-threatening condition. Surgeons should consider the possibility of this complication in women with acute abdominal pain and a history of uterine leiomyoma in order to prevent severe morbidity or even mortality. When a patient undergoes conservative management of large asymptomatic subserosal fibromas, she should be informed of this rare complication.