Pregnancy After Laparoscopic Radiofrequency Ablation: A Case Report

A 29-year-old G0 patient presented to our clinic in November 2023 for AUB and inability to conceive. The patient’s medical history and surgical history were noncontributory. A workup for AUB revealed a fundal intramural leiomyoma (leiomyoma 1) and a subserosal pedunculated leiomyoma (leiomyoma 2), both in the anterior wall of the uterus, measuring 1.18×1.33 cm and 2.16×1.7 cm, respectively; a vascular echogenic structure within the endometrium resembling a polyp was also noted. On discussion of possible causes of AUB, the absence of alternative identifiable causes, and management options, the patient selected surgical uterine-sparing treatment. Myomectomy was considered for leiomyoma 1, but its intramural location meant myometrial incision, and closure would carry a recognized risk of scar dehiscence or rupture in future pregnancy; laparoscopic RFA was therefore selected to avoid a formal hysterotomy. In December 2023, laparoscopic RFA was performed on leiomyoma 1 after its location (anterior superior fundus) and dimensions (2 cm transverse, 2 cm anterior–posterior, and 2 cm sagittal) were mapped through laparoscopic ultrasound. With ultrasound guidance, the tip of the handpiece was inserted with minimal pressure using rotational back-and-forth movement, penetrating the leiomyoma in a controlled fashion. The entry to the leiomyoma was limited to 1–2 cm, and its correct position was confirmed by ultrasound from all three planes. The retractable array of seven needle electrodes was then deployed from the handpiece tip into the surrounding leiomyoma tissue, delivering two treatments of 1.5 minutes of radiofrequency after tip ramp-up. Temperatures at the 7 needle electrodes were monitored continuously and averaged 100°C. The return pad temperature remained below 40°C. The electrodes were retracted; the system was switched to 8-W coagulation; and the probe was withdrawn. Laparoscopic excision was performed for leiomyoma 2 with monopolar electrosurgery on its base. Of note, the ablation treatment volume (2 cm in all planes) exceeded the dimensions of the leiomyoma itself (1.18×1.33 cm), consistent with standard RFA technique. Endometrium and ovarian implants were sampled. Procedure time was 1.5 hours; hemostasis was confirmed; and no complications were noted. Final pathology revealed benign proliferative endometrium (no discrete polyp), hemosiderin-laden macrophages within the ovary, endometriosis of the cul-de-sac, and leiomyoma, consistent with leiomyoma 2. In December 2025 the patient presented to our office for pregnancy confirmation after conceiving spontaneously at 5 5/7 weeks of gestation. At this time, pelvic ultrasound revealed no leiomyomas. At 17 5/7 weeks of gestation, the patient presented to the emergency room with acute abdomen and hypotension. On arrival, the patient underwent fluid resuscitation, fetal monitoring, and intravenous access placement. An obstetric ultrasound was limited but revealed a healthy fetus. Right upper quadrant ultrasound revealed hemoperitoneum with septations, prompting a pelvic magnetic resonance imaging (MRI), which showed possible uterine rupture. The patient underwent emergent laparotomy, confirming a 4- to 5-cm defect in the mid anterior fundal wall. Hemoperitoneum 600 cm 3 was evacuated; amnioreduction was performed (120 cm 3 ) to reduce the bulging amniotic bag, followed by myometrium closure with one running layer of 0 vicryl, followed by a second layer of 0 vicryl to imbricate the first layer. Anatomy scan at 19 weeks of gestation revealed 3.5-cm myometrial thickness over the area of hysterorrhaphy. The patient was discharged on postoperative day 4 with instructions for strict bed rest, followed by biweekly outpatient ultrasounds and visits to monitor uterine wall thickness and fetal well-being. The remainder of the pregnancy was uneventful aside from diet-controlled gestational diabetes and a short cervix (2.0 cm) managed with vaginal progesterone. Given the paucity of data on recurrent uterine rupture risk and decision–analytic modeling proposing delivery between 34 and 36 weeks in women with prior uterine rupture, a multidisciplinary team scheduled cesarean delivery at 35 weeks. 17 The patient received steroids at 34 weeks and delivered a live-born 2,390-g boy, with Apgar scores of 9 at 1 and 9 at 5 minutes, at 35 weeks by scheduled cesarean. There were no postpartum complications. Pelvic MRI at 6 months postpartum (26 months after ablation) revealed no myometrial lesions and no persistent myometrial defect, with susceptibility artifact noted at the anterior fundus in keeping with prior intervention.

The precise mechanism responsible for rupture in this case cannot be established with certainty, although several hypotheses can be considered. Although laparoscopic RFA is generally believed to preserve uterine integrity, it is conceivable that alterations in targeted myometrial architecture could predispose susceptible patients to rupture during pregnancy. Of note, the ablation volume in this case exceeded the dimensions of the leiomyoma and thus necessarily included a margin of adjacent normal myometrium, offering a more concrete anatomic basis for this hypothesis. That the rupture occurred in the anterior fundal region, the location of the treated leiomyoma, suggests a possible relationship between prior ablation and subsequent uterine wall failure. The 2-year interval between intervention and rupture suggests that any alterations on myometrial integrity may persist beyond the immediate postoperative period. However, several limitations should be acknowledged. Histopathologic evaluation of the rupture site was not available, precluding direct assessment of tissue changes attributable to prior ablation. Imaging obtained before laparoscopic RFA documented uterine and leiomyoma dimensions but did not include a measurement of myometrial thickness at the site of leiomyoma 1, so no baseline value is available for comparison. Similarly, the pregnancy confirmation ultrasound did not document gestational sac implantation relative to the ablation site, limiting assessment of whether implantation proximity to the treated myometrium contributed to the rupture. Postpartum pelvic MRI demonstrated no myometrial lesions or persistent myometrial defect but did not report a specific myometrial thickness measurement at the site of repair, limiting assessment of long-term structural integrity at this site. Furthermore, causality cannot be established from a single case. The original clinical trials excluded women who desired future fertility, so no pregnancy outcome data existed at the time of approval by the U.S. Food and Drug Administration. 12 , 13 However, six subjects unexpectedly conceived; five had full-term deliveries, and one had a first-trimester miscarriage. 14 A retrospective review of 40 pregnancies after laparoscopic RFA procedure showed no cases of uterine rupture, invasive placenta, abruption, or fetal growth restriction, although one placenta previa and one postpartum hemorrhage occurred. 8 , 15 A prospective cohort study (ULTRA [Uterine Leiomyoma Treatment With Radiofrequency Ablation] Study) described 22 pregnancies after laparoscopic RFA, 10 of which ended in first-trimester miscarriage, with one intrauterine fetal demise, and 11 live births. 16 Of note, one of the miscarriages was complicated by a uterine rupture during misoprostol treatment at 10 weeks. 16 In our review, we could not find any reports of uterine rupture in an ongoing pregnancy after laparoscopic RFA. Although the existing data on uterine rupture after laparoscopic RFA are reassuring, this should not be extended to reproductive outcomes overall. Aggregated data from the reviewed studies show a miscarriage rate of approximately 24% (16 of 68), which is not negligible, and highlight that the absence of reported rupture should not be conflated with an absence of reproductive risk more broadly. Cases like this challenge the notion that laparoscopic RFA is uniformly benign for future pregnancies, although limited by its nature as a single report. Clinicians should nonetheless recognize uterine rupture as a rare but potentially fatal complication after laparoscopic RFA, warranting inclusion in patient counseling and underscoring the need for further research.