First Report of Subclinical Uterine Rupture in Late Pregnancy After HIFU Ablation A Call for Enhanced Pregnancy Monitoring.docx

The application of high-intensity focused ultrasound (HIFU) for the treatment of uterine fibroids has gained traction due to its noninvasive nature and shorter pre-conception interval when compared to laparoscopic myomectomy. Current research indicates that attempting a vaginal delivery after HIFU ablation is generally safe. To date, only three instances of uterine rupture following HIFU have been reported worldwide: two cases involved adenomyosis, and one pertained to fibroids, all requiring emergency cesarean sections due to indications of fetal distress.This case report outlines a novel instance of chronic uterine rupture resulting from HIFU ablation for uterine fibroids, which contrasts with the previously documented cases that were characterized by acute ruptures occurring in the third trimester, accompanied by abdominal pain and non-reassuring fetal heart rate patterns. Our patient, who had undergone HIFU treatment two years prior to her current pregnancy, presented at 37 weeks and 2 days of gestation with an asymptomatic course, maintained fetal well-being, and showed no classical signs of rupture. During surgery, we identified a uterine defect encircled by organized necrotic tissue, indicative of a chronic rupture with an indeterminate onset during the course of the pregnancy. This case serves as the first documentation of subclinical uterine wall compromise post-HIFU, underscoring the necessity for long-term monitoring protocols in fertility-preserving ultrasound ablation. Current guidelines fail to provide a consensus on the management of pregnancies following HIFU treatment. This report emphasizes the urgent need for enhanced imaging protocols in pregnancies after HIFU ablation for uterine fibroids.