Acute complications of fibroids

Spontaneous rupture of a uterine leiomyoma accompanied by a hematoma appearing as a cystic lesion on imaging: A case report

The rupture of a uterine leiomyoma is a rare complication. We report a case of ruptured leiomyoma that formed a hematoma that was initially suggestive of an ovarian origin. Magnetic resonance imaging revealed intact ovaries and a cystic lesion adjacent to leiomyomas. During surgery, the cystic lesion was found to be a hematoma caused by a rupture of the leiomyoma.

Case report: A case of perineal prolapse of giant uterine fibroids complicated by multiple pulmonary embolisms and deep venous thrombosis

A 43-year-old woman with a history of uterine fibroids, anemia, and deep vein thrombosis presented with a chief symptom of prolapse of tumor from the perineum, complicated by infection. The case was further complicated by bilateral pulmonary multiple embolism, deep vein thrombosis, acute cardiac insufficiency, acute renal insufficiency, and shock. The patient was treated with preoperative placement of an inferior vena cava filter, open hysterectomy, and perioperative anticoagulation with low-molecular-weight heparin. She smoothly navigated the perioperative period and recovered completely.

Management of Uterine Fibroids and Sarcomas: The Palermo Position Paper

BACKGROUND

Uterine fibroids are benign monoclonal tumors originating from the smooth muscle cells of the myometrium, constituting the most prevalent pathology within the female genital tract. Uterine sarcomas, although rare, still represent a diagnostic challenge and should be managed in centers with adequate expertise in gynecological oncology.

OBJECTIVES

This article is aimed to summarize and discuss cutting-edge elements about the diagnosis and management of uterine fibroids and sarcomas.

METHODS

This paper is a report of the lectures presented in an expert meeting about uterine fibroids and sarcomas held in Palermo in February 2023.

OUTCOME

Overall, the combination of novel molecular pathways may help combine biomarkers and expert ultrasound for the differential diagnosis of uterine fibroids and sarcomas. On the one hand, molecular and cellular maps of uterine fibroids and matched myometrium may enhance our understanding of tumor development compared to histologic analysis and whole tissue transcriptomics, and support the development of minimally invasive treatment strategies; on the other hand, ultrasound imaging allows in most of the cases a proper mapping the fibroids and to differentiate between benign and malignant lesions, which need appropriate management.

CONCLUSIONS AND OUTLOOK

The choice of uterine fibroid management, including pharmacological approaches, surgical treatment, or other strategies, such as high-intensity focused ultrasound (HIFU), should be carefully considered, taking into account the characteristics of the patient and reproductive prognosis.

An unusual cause of small bowel obstruction: Case report of spontaneous uteroenteric fistula

Uteroenteric fistulae in the setting of degenerating leiomyomas may present with small bowel obstruction and require multidisciplinary surgical management to perform fertility‐sparing myomectomy.

Imaging findings of fibroid torsion in pregnancy: A case report

When our patient presented emergently to labor and delivery at 18 weeks pregnant with severe right abdominal pain, the common diagnoses (such as appendicitis, cholecystitis, etc.) were on the top of the differential. However, US and MRI revealed a rarer cause of her pain, a pedunculated fibroid. The most important question then became whether this fibroid had torsed, which would require surgical intervention to prevent life-threatening sequelae. Unfortunately, presurgical imaging diagnosis of fibroid torsion in pregnancy is difficult. We offer a description of our patient's imaging findings, which align with other radiologic descriptions of fibroid torsion in pregnancy in the literature, to contribute to the radiologist's diagnostic confidence in this patient population.

Large Submucosal Uterine Leiomyoma Prolapse Into the Vagina After Complicating a Pregnancy: A Case Report

Uterine leiomyomas are the most common pelvic neoplasm in females. They are non-cancerous monoclonal tumors that develop from the fibroblasts and smooth muscle cells of the myometrium. They can develop in females of reproductive age and post-menopausal as well. When symptomatic, they frequently manifest as abnormal uterine bleeding and/or pelvic pain or pressure. Reproductive effects are also possible in fibroids such as infertility and poor pregnancy outcomes. In this report, we present a case of a 39-year-old woman, G9P4A4, GA 16 weeks who came to the ER with an incomplete abortion at home after which she had large multiple uterine submucosal fibroids prolapsing into the vagina. On ultrasound, the placenta was still inside, and a large submucosal anterior uterine fibroid and a posterior uterine fibroid were found with sizes 10x10 cm and 2x3, respectively. Evacuation and curettage (E&C) could not be completed because fibroids were obstructing and limiting the access. The patient was managed medically and then discharged, after which she came back with prolapsing uterine fibroids and part of the placenta. In the end, she was managed by hysteroscopic myomectomy.

Acute abdomen caused by internodular bleeding from a multiple myoma pseudocapsule in a postmenopausal woman

A woman in her 50s presented with lower abdominal pain. She had a diagnosis of multiple uterine myomas 3 years earlier, followed by menopause. CT showed a pelvic mass of 19.5×9.4×10.2 cm in size, containing a haemorrhagic component. It was assumed that the tumour was the previously diagnosed myoma, and that it had increased to 150% of the size noted 3 years ago. An emergent hysterectomy was performed, and the pathological diagnosis was a uterine leiomyoma, with no components suggestive of sarcoma or degeneration. We witnessed a rare case of acute abdomen caused by internodular bleeding of multiple myomas. We assumed that the source of bleeding was the vessels of the myoma pseudocapsule. These cases may be more likely to occur in patients with multiple myomas presenting around the commencement of menopause. For symptomatic relief, emergent hysterectomy is considered to be the best treatment.

A subserosal uterine leiomyoma complicated with intra-abdominal haemorrhage: A case report

Uterine leiomyomas, or fibroids, are the most common benign tumours of the female genital tract. Although uterine fibroids are commonly associated with menorrhagia, dysmenorrhea, symptomatic anaemia, urinary or bowel symptoms and infertility, intra-abdominal haemorrhage is an exceedingly rare complication. Often, the diagnosis is poorly recognizable based on the patient's clinical presentation and alternative diagnoses such as ruptured ectopic pregnancy, ruptured ovarian cyst or perforated viscus are frequently considered. Herein, we describe a case of a 50-year-old perimenopausal woman who presented with acute, lower abdominal pain, evolving anaemia, hypovolaemic shock and haemoperitoneum with no discernable source. Emergency exploratory laparotomy confirmed the source of massive haemoperitoneum arising from a ruptured blood vessel supplying a large subserosal uterine leiomyoma and the patient subsequently underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy. Given the paucity of publications on this clinical entity, the aim of this report is to highlight a rare complication of uterine leiomyomas, its pathophysiological spectrum and its relevance to emergency physicians, general surgeons and gynaecologists.

Acute lower limb ischaemia secondary to aortic compression from uterine fibroid

A woman in her early 50s with uncontrolled diabetes mellitus and a huge uterine fibroid presented to the emergency department with diabetic ketoacidosis and bilateral acute lower limb ischaemia. Vascular and advanced imaging studies confirmed distal aortic compression by a huge uterine fibroid, resulting in extensive lower limb arterial thrombosis. After resuscitation, the patient underwent emergency hysterectomy, thromboembolectomy and amputation of the right leg. She remained critically ill and died of fulminant sepsis and multiorgan failure 10 days later. This case reports the effects of external vascular compression by a large pelvic mass.

Torsion of a huge subserosal uterine leiomyoma: A challenging case of acute abdomen

Torsion of a uterine leiomyoma is an extremely rare, albeit life-threatening surgical emergency. A 28-year-old woman presented with acute abdominal pain. Imaging revealed a torsed subserosal uterine leiomyoma which was managed surgically and the diagnosis confirmed intraoperatively as well as on histopathology.

Contribution

While intraoperative findings remain the primary means of diagnosis, radiologists should be familiar with the potential imaging findings of leiomyoma torsion as timely intervention can greatly improve patient outcome.

Pregnancy With Uterine Fibroids: Obstetric Outcome at a Tertiary Care Hospital of Central India

BACKGROUND

Uterine fibroids are the most frequent benign tumor of the female reproductive system, with a significantly lower frequency in pregnancy. This could be due to the fact that uterine fibroids are linked to infertility and low implantation rates following in vitro fertilization (IVF). The goal of this study was to look at the obstetrics outcomes of uterine fibroids and their consequences in a tertiary hospital.

MATERIALS AND METHODS

The current study was a observational cohort study that evaluated the cases of pregnancy with fibroid. Study was undertaken at the Department of Obstetrics and Gynecology (OBGY) at a medical college in central India and it was conducted over a period of nine months from 1st November 2021 to 31st July 2022. All pregnant women who had an ultrasonography (USG)-documented uterine fibroid diagnosed prenatally or antenatally were enrolled. All demographic information, laboratory and USG results were noted and their mode of delivery, obstetric complications, if any, and neonatal outcomes were evaluated.

RESULTS

A total of 110 cases were enrolled as per inclusion and exclusion criteria. The majority of patients (42.73%) were in the 26- to 30-year-old age group. In this study, the majority of cases were carried to term (80.9%). The most prevalent mode of delivery was caesarean section (61.82%). Major complications during pregnancy were threatened preterm labor (21.82%), and blood transfusion (20.00%), whereas postpartum hemorrhage (PPH) occurred in 9.09% cases, and 47 patients (42.72%) were asymptomatic throughout pregnancy. Major neonatal outcomes in our study were neonatal intensive care unit (NICU) hospitalization (20%), required neonatal resuscitation (14.55%), and neonatal mortality occurring in 1.82% cases. Gestational age at termination of pregnancy, when compared with different characteristics of fibroid, like type (p value 0.663), location (p value 0.552) and number of fibroid (p value 0.112), did not show any significant association. Similarly, maternal complications also did not show significant association (p value >0.05) with different characters of fibroid.  Conclusion: Pregnancies with fibroid are high-risk pregnancies that are linked to difficulties throughout the antepartum, intrapartum, and postpartum periods, as well as increased chances of cesarean delivery and PPH.

Ruptured ectopic molar pregnancy and ruptured uterine fibroid: a challenging rare diagnosis

Although rare and unusual occurrences, a ruptured ectopic molar pregnancy (MP) and a ruptured uterine fibroid can lead to significant maternal morbidity and mortality. We present a unique case of these complications developing concurrently-resulting in the haemodynamic compromise of an otherwise healthy young female patient. The patient underwent a diagnostic laparoscopy which converted into a laparotomy, salpingectomy and myomectomy. Comprehensive histopathology confirmed the diagnosis of a ruptured ectopic complete MP and ruptured uterine fibroid. The patient recovered quickly within days. Prompt definitive management, conclusive histopathology and adequate follow-up were the hallmarks of this singular case. These key factors lead to the rare diagnosis of ruptured ectopic MP and uterine fibroid, prevention of adverse outcomes and provision of comprehensive patient care.

Differential Diagnosis of Uterine Leiomyoma Torsion Mimicking Ovarian Torsion in a Second Trimester of Pregnancy: A Case Report

In patients with acute abdomen, especially during pregnancy, it is difficult to suspect myoma torsion initially due to its rarity. However, when these patients have a solid mass in the pelvis, torsion of uterine fibroids or adnexa and large infarct inside leiomyoma are the main diagnoses that must be differentiated. We report a case of uterine myoma torsion mimicking ovarian torsion in the second trimester of pregnancy that was successfully managed by laparoscopic myomectomy. A 31-year-old pregnant woman with severe right lower abdominal pain at 21 + 2 weeks of gestation was transferred. On ultrasonography, the appendix appeared normal but a solid mass (7.0×4.0 cm) containing a cystic portion was observed on the right side of the uterus. The mass had no blood flow and tenderness appeared on the transducer pressure. Pelvic magnetic resonance imaging revealed a 7 cm edematous mass with low signal intensity on T2-weighted image, instead of a normal-looking right ovary. These findings led to suspicion of right ovarian torsion. One day after admission, the patient's symptoms worsened with acute elevation in C-reactive protein (CRP) (4.55 mg/dL) and neutrophile-to-lymphocyte ratio (NLR) (10.1), despite the use of analgesics and tocolytics, and uterine contractions were not controlled. Emergency surgery was performed, and the final diagnosis was a uterine leiomyoma torsion. Laparoscopic myomectomy was successfully performed, and symptoms were relieved after operation. She had full term vaginal delivery without complication. The differential diagnosis between myoma torsion and ovarian torsion is challenging in patients with acute abdomen during pregnancy. To exclude ovarian torsion, a comparison with an asymptomatic contralateral normal ovary will be very helpful. When fibroids are found in mothers with an acute abdomen, follow-up of NLR and CRP is related to preterm labor and can be a reference point for considering surgery.

Symptomatic uterine leiomyomatosis with intracaval and intracardiac invasion: Video case report

Background

Fibroid is the most prevalent benign tumor of the female genital tract. Intravenous and intracardiac leiomyomatosis (IVL and ICLM, respectively) are rare complications that present with symptoms of pulmonary thromboembolism and heart failure and whose etiology, despite controversial, is a direct vascular invasion by a primary uterine leiomyoma.

Case presentation

We present the case of a 31-year-old female patient with a previous history of pelvic pain and dysmenorrhea, whose ultrasound showed an enlarged and heterogeneous uterus. Complete hysterectomy was performed, and the anatomopathological examination showed leiomyomas without evidence of malignancy. One month later, the patient manifested dyspnea and chest pain. A neoplastic thrombus was identified, extending from the inferior vena cava to the right atrium, for which we proceeded with cavo-atrial thrombectomy under Normothermic Cardiopulmonary Bypass (CPB) with Warm Blood Cardioplegia (WBC). A metastatic lung injury of non-malignant histology was also detected.

Discussion

Uterine leiomyoma is a very common benign tumor of the female genital tract. IVL with ICLM are rare and difficult-to-treat complications, whose etiology is a direct vascular invasion by a primary uterine leiomyoma, although it is still controversial. The incidence of ICLM is 10 to 30% of IVL cases. The main symptoms of ICLM are dyspnea, syncope, edema of the lower extremities and palpitations. Treatment is based on complete surgical removal of the tumor thrombus. Studies demonstrated that the one-stage procedure is safer from the patient's perspective and that CPB with WBC reduced intraoperative blood loss and total operative time, ensuring a less traumatic postoperative.

Conclusions

Most patients with uterine leiomyoma are asymptomatic and acute complications are rare. In ICLM clinical manifestations are related to heart failure and flow obstruction. Because of the severity of the condition and the curative potential of treatment, surgery is morbid but highly recommended. The use of CPB with WBC improved the postoperative period and increased the patient's quality of life.

Vaginal prolapse of a large uterine cervical leiomyoma complicated with cervical inversion: A case report of an extremely rare entity with review of the literature

Cervical leiomyoma is a relatively uncommon type of uterine leiomyoma. Prolapse of a cervical leiomyoma with inversion of the cervix is an extremely rare phenomenon, especially in a non-puerperal woman. Only a handful of cases are reported in the English literature. The case discussed here is of a vaginal prolapse of a submucous cervical fibroid complicated by cervical inversion in a South Asian perimenopausal woman with multiple comorbidities who had defaulted medical follow-up during the second wave of the COVID-19 pandemic. Being one of the largest reported cervical fibroids to date is another particularity of this case. Emphasis is given to the clinical diagnostic, anaesthetic, and surgical challenges encountered with a brief note on the impact of COVID-19 on outpatient clinic follow-up.

Uterine fibroid: a socially malignant illness in Haiti

This qualitative study documented the effects of uterine fibroids on the suffering of women in Haiti. It makes a unique contribution by re-socializing this disease, by making visible the social inequalities and what is at stake for the women, for their families, and for healthcare delivery. Uterine fibroid is a benign tumor of the uterus, common in gynecology, but profoundly malignant in how it affects women's lives. Little has been reported on their lived experiences. Haiti has historical, social, and economic factors that hinder the search for treatment. The study explores how and why patients seek surgical care for uterine fibroids at Mirebalais University Hospital. Seventeen in-depth interviews with patients and seven accompanying family members were conducted and recorded in Creole and translated into English, along with participant observations in two patients' homes. Content and narrative analysis were done iteratively, and the processual ethnographic method was used to relate our findings to Haitian history, to the context of the study, and to future implications. The women's experience of accompaniment, their suffering in their pèlerinage (care-seeking journey), and the troubling social impact of uterine fibroids make it a socially malignant illness. The study shows that it is critical to address the suffering of women afflicted with uterine fibroids by strengthening the Haitian health system, improving economic advantages, and establishing ways for them to gain access to social goods and participate in community activities.

Vena cava balloon occlusion for pulmonary embolism prevention during resection of giant uterus fibroids

We report the case of a single 46-year-old woman presenting with huge uterine fibroids growing for the last 12 years, resulting in a recent common iliac vein thrombosis. Due to the high risk for pulmonary embolism, an occluding balloon was inserted through the right jugular vein before the abdominal incision and occluded the vena cava just inferior to the renal veins. The tumor was easily mobilized, and the vena cava bifurcation was exposed and controlled until the uterus with the masses was resected. We recommend this method for oncovascular surgeries involving deep vein thrombosis and vein thromboembolism.

Guizhi Fuling Capsule inhibits uterine fibroids growth by modulating Med12-mediated Wnt/β-Catenin signaling pathway

ETHNOPHARMACOLOGICAL RELEVANCE

Guizhi Fuling Capsule (GFC) is a famous traditional Chinese medicine (TCM) formula recorded in Synopsis of the Golden Chamber, which has achieved obvious effects in the treatment of uterine fibroids (UFs).

AIM OF STUDY

Mediator complex subunit 12 (Med12) mutations were closely related to UFs in 85% of fibroid cases. The Wnt/β-Catenin signaling pathway plays an important role in the occurrence and development of UFs. This study aims to explore the pharmacological mechanism of GFC against UFs in which the Med12-mediated Wnt/β-Catenin pathway is involved.

MATERIALS AND METHODS

Med12 was silenced in uterine fibroid cells (UFCs) using a lentivirus-based Med12 gene-specific RNA interference (RNAi) strategy. Cell proliferation was performed by CCK-8 assay, cell apoptosis and cell cycle were measured by flow cytometry. The rat model of UFs was established by injecting estradiol benzoate and progesterone. Forty-eight rats were divided into six groups, the low-dose GFC (L-GFC) group, the medium-dose GFC (M-GFC) group and the high-dose GFC (H-GFC) group were intragastrically treated with GFC solution at 0.25 g/kg, 0.50 g/kg and 1.00 g/kg per day for 8 weeks, the positive control (PC) group was administrated with mifepristone (2.70 mg/kg/day), the normal control (NC) group and the model control (MC) group were given equal volume of normal saline once a day for 8 weeks. The histopathological changes of uterine tissues were evaluated by H&E staining. The expression of Med12 in uterine tissues were detected by immunohistochemistry. The protein and mRNA levels of associated genes were evaluated by western bolt and real time-PCR, respectively. Related indicators involved in Wnt/β-Catenin pathway, such as Wnt1, β-Catenin, Cyclin D1, TCF1/TCF7 and C-myc, were compared among different groups.

RESULTS

The Wnt/β-Catenin signaling pathway was inhibited after Med12 gene was knocked out in UFCs. GFC-containing serum could induce cell apoptosis, make the cell cycle stagnated in G0/G1 phase to inhibiting the proliferation and reduce the expression of Wnt1, β-Catenin, Cyclin D1, TCF1/TCF7, and C-myc in control-shRNA cells, while had no significant effect on Med12-shRNA cells. Compared with the MC group, the weight, endometrial thickness, and pathological structure of the uterus in the GFC treated groups were significantly improved. The expression of Med12, Wnt1, β-Catenin, Cyclin D1, TCF1/TCF7, and C-myc that related to Wnt/β-Catenin pathway in the GFC treated groups were decreased with the increase of dosage administration.

CONCLUSIONS

GFC inhibited UFs growth, which was directly associated with Med12 modulated Wnt/β-Catenin signaling pathway. This study provided new perspective to understand the therapeutic mechanism of UFs.

A giant metastatic low-grade endometrial sarcoma requiring surgical management

Introduction and importance

Low-grade endometrial stromal sarcomas are relatively rare tumors. We here report a case of a woman presenting with a giant metastatic low-grade endometrial stromal sarcoma with thromboembolic complications requiring urgent surgical management.

Case presentation

A 58-year-old obese female was admitted, with a voluminous abdominopelvic mass, due to complications related to its size and extent. The tumor derived from the uterus and invaded the ureters, bladder and rectum. It compressed the right iliac vessels causing both deep vein thrombosis and pulmonary embolism. She developed a painful irreducible umbilical. We proceeded with a debulking surgery (hysterectomy with bilateral salpingo-oophorectomy). Histological findings were consistent with a low-grade endometrial stromal sarcoma.

Clinical discussion

Low-grade endometrial stromal sarcomas are generally low-grade malignant neoplasms with an indolent clinical course. Surgery is the cornerstone of treatment. In low-income countries, malignancies are more often diagnosed at a late stage, which limits therapeutic options. Cytoreduction is recommended in advanced tumors with extrauterine manifestation, depending on symptoms and with palliative intent.

Conclusion

Low-grade endometrial stromal sarcomas are indolent uterine malignancies with metastatic potential. Even in advanced cases, cytoreduction must be considered.

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Endometrial stromal sarcomas (ESS) are relatively rare tumors.

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They are classified into three categories: low-grade, high-grade, and undifferentiated.

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Staging is the most important prognostic factor.

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Cytoreduction surgery is recommended even in advanced tumors.

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Late presentation of cancers is commonplace in most low-income countries.

Pelvic Pain in Reproductive Age: US Findings

Pelvic pain in reproductive age often represents a diagnostic challenge due to the variety of potential causes characterized by overlapping clinical symptoms, including gynecological and other disorders (e.g., entero-colic or urological). It is also necessary to determine if there is a possibility of pregnancy to rule out any related complications, such as ectopic pregnancy. Although ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI) are strongly integrated, the choice of which is the ideal diagnostic tool should be guided both by clinical suspicion (gynecological vs. non-gynecological cause) and by the risk ratio–benefit (ionizing radiation and instrumental costs), too. The didactic objective proposed by this review consists in the diagnosis of the cause and differential of pelvic pain in reproductive age by describing and critically analyzing the US diagnostic clues of the most frequent adnexal, uterine, and vascular causes.

Assessment of Maternal and Fetal Outcomes in Pregnancy Complicated by Fibroid Uterus

Background

The study aims to assess maternal and fetal outcomes in pregnancy complicated by a fibroid uterus.

Materials and methods

Sixty-four adult women patients with fibroids in age range of 25-45 years were selected. Fetal and maternal outcomes were recorded.

Results

Thirty-four patients were in the age group of 25-35 years, and 50 were aged 35-45 years of age. Primigravida was seen in 52 and multigravida in 32. The common types were intramural in 40, submucosal in 16, pedunculated in seven, and subserosal in 21 cases. Size >5 cm was seen in 38 and 2 cm-5 cm in 46 patients. Common symptoms were preterm labor pain in 50, abdominal pain in 12, and urinary tract infection (UTI) in 22 cases. The common sites were the anterior wall fibroid in 42, posterior wall in 22, and lateral wall in 20 cases. Complications reported in our study were premature rupture of membranes (PROMs) in 12, threatened preterm in 11, associated infertility in five, intrauterine growth retardation (IUGR) in two, malpresentation in seven, postpartum hemorrhage (PPH) in four, preterm labor in six, and abruption in eight cases. The difference was observed to be significant (P<0.05). 

Conclusion

Common complications were PROM, threatened preterm, associated infertility, IUGR, malpresentation, PPH, preterm labor, and abruption.

Intra-Abdominal Hemorrhagic Catastrophe due to Large Subserous Myomatous Capsular Venous Rupture

Uterine leiomyoma is a common benign uterine tumor of women in the reproductive age group. Although the common symptoms of leiomyoma are menorrhagia and dysmenorrhoea, this patient presenting as a near collapse is a rare finding. The patient presented with abdominal pain and worsening anemia within a span of hours and hypotension, tachycardia, and tachypnoea needing urgent surgical intervention and blood transfusion and intensive care support is relatively rare. Though every effort to know the exact cause of intraperitoneal hemorrhage in this patient was taken, the rarer diagnosis of capsular venous rupture was not identified prior to surgical intervention. Initially, laparoscopy was introduced first to identify the cause of massive hemorrhage; the approach was changed to open myomectomy keeping in mind the general condition of the patient. Hence, for any patient with a prior diagnosis of myoma with hemodynamic instability, the rarer diagnosis of leiomyomatous capsular venous erosion should be a differential diagnosis to aid in the appropriate management of the women. The team of interdisciplinary expertise will definitely improve the outcomes in such cases.

Successful Embolization of Collaterals from the Round Ligament Artery during Uterine Artery Embolization for Traumatic Uterine Leiomyoma Rupture: A Case Report

We describe the case of a 48-year-old woman who presented with traumatic rupture of a giant leiomyoma and massive hemoperitoneum caused by slipping and falling in the bathroom. She was in shock on arrival, and resuscitation was performed. Contrast-enhanced computed tomography showed massive intra-abdominal hematoma and extravasation from the subserous leiomyoma. Uterine artery embolization was performed, but she went into shock again after 6 h. The second contrast-enhanced computed tomography revealed persistence of extravasation. During 2^nd UAE, an angiogram revealed extravasation originating from left round ligament artery. After the embolization of the left round ligament and bilateral uterine arteries, the patient recovered from shock. Total abdominal hysterectomy was performed on day 2 of admission to prevent re-bleeding and infection, then she discharged on day 19 of admission.

Painless spontaneous haemoperitoneum secondary to a uterine leiomyoma/fibroid: unusual presentation of a life-threatening differential

This is a case of a 47-year-old woman with a spontaneous haemoperitoneum secondary to uterine leiomyomas (fibroids), an important differential diagnosis in patients with uterine fibroids and hypovolaemic shock. Uterine fibroids are very common in women of reproductive age, yet little is taught about their potential to cause hypovolaemic shock. Although it is a rare complication, given the prevalence of fibroids, it is important to bear this life-threatening differential in mind to optimise the care for these women. Presentation typically involves abdominal pain, syncope, haemodynamic instability and an intra-abdominal mass. CT of the abdomen and pelvis can be helpful in identifying the source of the haemoperitoneum, but should not delay surgery, which is the definitive management.

Ruptured Degenerating Fibroid Causing Preterm Labour and Systemic Inflammatory Response Syndrome

BACKGROUND

Fibroids are present in at least 10% of pregnancies and are recognized to cause a variety of complications. A few case reports have described fibroids as an etiological factor in uterine rupture, sometimes with life-threatening hemorrhage.

CASE

A 28-year-old G1, P0 woman at 20 weeks gestation developed systemic inflammatory response syndrome with acute renal failure and massive ascites secondary to a ruptured degenerated fibroid. This resulted in preterm delivery and neonatal death. At 6 weeks postpartum, she successfully underwent an abdominal myomectomy.

CONCLUSION

This is a rare case of uterine fibroid rupture causing preterm labour and systemic inflammatory response syndrome. This report discusses the diagnosis of uterine rupture related to the fibroid with imaging and subsequent management, which included fertility-preserving surgery.

Hypovolaemic shock due to intra-abdominal haemorrhage from multiple uterine fibroids

Intra-abdominal bleeding due to uterine fibroids is extremely rare, and preoperative diagnosis is difficult. Herein, we report a case of preoperatively diagnosed hypovolaemic shock due to intra-abdominal haemorrhage, in which fatal sequelae were prevented. A 46-year-old non-pregnant woman was brought to the hospital with a sudden-onset lower abdominal pain. On admission, she was in shock, and abdominal CT showed severe intra-abdominal haemorrhage. Since bleeding from uterine fibroids was suspected, an emergency simple total hysterectomy was performed, and her condition became stable after the operation. Intra-abdominal haemorrhage with hypovolaemic shock requires prompt surgical intervention. Although it occurs very rarely due to bleeding from uterine fibroids, imaging shows large fibroids; if the patient is not pregnant, bleeding from the fibroids should be considered.

Hemoperitoneum Caused by Spontaneous Rupture of Uterine Leiomyoma in a Perimenopausal Woman

Uterine fibroid, or leiomyoma, is a common benign neoplasm in women, but serious complications are rarely reported. We present the case of a 48-year-old woman with acute onset of abdominal pain. She was hemodynamically unstable, and computed tomography revealed abundant fluid collection in the peritoneal cavity, suggesting hemoperitoneum. During emergency exploratory laparotomy, the subserosal vein overlying a uterine fibroid was identified as the source of bleeding. Hemostasis was accomplished with fibroid excision. Spontaneous hemorrhage originating from a uterine fibroid is extremely rare, but may lead to life-threatening conditions. Therefore, in female patients with acute abdominal pain and hemoperitoneum, uterine fibroid may be a potential etiology and emergency exploratory laparotomy should be considered.

A rare case of acute abdomen: spontaneous rupture of degenerated fibroid

A 29-year-old nulliparous woman presented with an acute abdomen. She had a large uterus with multiple fibroids and was on the waiting list for elective surgery. An urgent CT scan demonstrated an extensive intraperitoneal fluid collection suspicious for fibroid rupture. She required an emergency laparotomy which identified a rupture of the largest degenerative fibroid. There was 2 Litres of pus in the peritoneal cavity. This case was a rare presentation of spontaneous fibroid rupture due to degeneration and necrosis, and acute abdomen from peritoneal irritation. Imaging was vital in making the diagnosis, and urgent surgical intervention was essential to reduce morbidity and mortality.

Torsion of a parasitic leiomyoma: a rare but important differential in women presenting with lower abdominal pain

A 39-year-old multiparous Afro-Caribbean woman attended the emergency department with sudden-onset severe right iliac fossa pain. Her inflammatory markers were mildly elevated. Computerised tomography of the abdomen demonstrated features of fat stranding in the right iliac fossa suspicious of acute appendicitis. The scan also noted uterine leiomyomas. The patient was taken to theatre for an emergency diagnostic laparoscopy where her appendix was found to be macroscopically normal. A necrotic heavily calcified parasitic leiomyoma was seen in the right adnexa, free of the uterus and adherent to the greater omentum on a long torted pedicle. The parasitic leiomyoma was successfully removed piecemeal laparoscopically. Complications of leiomyomas, namely, torsion and necrosis, are important differentials in women presenting with sudden-onset lower abdominal pain. A history of sudden-onset severe lower abdominal pain with a background of known leiomyoma should prompt the clerking surgeon to consider a complication of leiomyoma as part of the differential diagnoses.

Assessing burden, risk factors, and perceived impact of uterine fibroids on women's lives in rural Haiti: implications for advancing a health equity agenda, a mixed methods study

BACKGROUND

Uterine fibroids, the most common cause of gynecologic surgery, have a reported cumulative incidence of 59% among Black women in the U.S. Uterine fibroids negatively impact the quality of women's lives. No study has been found in the literature about fibroids in Haiti. We conducted a mixed methods study to assess the burden and risk factors of uterine fibroids, as well as their effects on women's quality of life.

METHODS

A convergent mixed methods study was conducted between October 1, 2019 and January 31, 2020 at MUH's (Mirebalais University Hospital) OB-GYN outpatient department. Quantitatively, in a cross-sectional study 211 women completed consecutively a structured questionnaire. In-depth interviews with 17 women with fibroids and 7 family members were implemented for the qualitative component. Descriptive statistics were calculated for clinical and social demographic variables. Logistic regression was performed to examine associations between fibroids and related risk factors. An inductive thematic process was used to analyze the qualitative data. A joint display technique was used to integrate the results.

RESULTS

Of 193 women analyzed 116 had fibroids (60.1%). The mean age was 41.3. Anemia was the most frequent complication- 61 (52.6%). Compared to women without uterine fibroids, factors associated with uterine fibroids included income decline (AOR = 4.7, 95% CI: 2.1-10.9, p = < 0.001), excessive expenses for transport (AOR = 4.4, 95% CI: 1.6-12.4, p = 0.005), and family history with uterine fibroids (AOR = 4.6, 95% CI: 1.6-13.6, p = 0.005). In contrast, higher level of education and micro polycystic ovarian syndrome were associated with lower prevalence (AOR = 0.3, 95% CI: 0.1-0.9, p = 0.021) and (AOR = 0.2, 95% CI: 0.1-0.97, p = 0.044), respectively. The qualitative findings delineate how contextual factors such as health system failures, long wait times, gender inequality and poverty negatively affect the quality of women's lives. The poverty cycle of uterine fibroids emerged.

CONCLUSIONS

A vicious cycle of poverty negatively impacts access to care for uterine fibroids in Haiti. Health insurance, social support, and income generating activities may be keys to promote social justice through access to adequate care for women with uterine fibroids in Haiti.

MRI Findings and Differential Diagnosis of Benign and Malignant Tumors of the Uterine Corpus

자궁은 크게 자궁체부와 자궁경부로 나뉜다. 이 중 자궁내막과 자궁근층으로 이루어진 자궁체부에는 양성에서 악성 종양까지 다양한 질환이 발생한다. 비침습적인 일차적 평가로 초음파와 컴퓨터단층촬영이 있으나 비특이적인 영상 소견으로 감별이 어려운 경우가 있다. 반면높은 해상도와 병리학적 특성 파악이 가능한 자기공명영상은 병변의 위치 확인뿐만 아니라 조직학적 특징, 그 리고 악성 종양의 병기 설정에도 도움을 준다. 이 종설에서는 영상의학과의사들이 알아야 할 자궁체부에서 볼 수 있는 다양한 양성과 악성 종양들의 특징적인 자기공명영상 소견들과 이들의 감별점에 대해 정리했다.

Hemoperitoneum due to bleeding from a vein overlying a subserous uterine myoma: a case report

Background

Fibroids are the most common pelvic tumors in women; serious complications are rare but can be life-threatening.

Case presentation

We present a case report of a 38-year-old Persian woman with acute abdominal pain and a history of uterine fibroids. The patient refused to undergo a laparoscopic myomectomy. Her ultrasound examination revealed free fluid in the abdominal cavity, and her vital signs were indicative of vasogenic shock. A diagnostic laparoscopy was performed to identify and control the source of bleeding: 400 ml of blood and blood clots were removed. Active bleeding was seen from a vein overlying a subserosal myoma. A laparotomic myomectomy was performed, and the patient was discharged 3 days after surgery with no complications.

Conclusion

Surgeons should consider the possibility of this complication in women with acute abdominal pain and a history of uterine leiomyoma.

Intra-abdominal haemorrhage from uterine fibroids: a systematic review of the literature

Background

Uterine leiomyomas are common benign tumours found in women of reproductive age that are rarely associated with intra-abdominal haemorrhage. The aetiology behind this relationship is poorly understood and the aforementioned association poorly recognized from a patient’s clinical presentation. Available information in the literature is limited to case reports. The aim of this systematic review is to document and highlight the occurrence of intra-abdominal haemorrhage from uterine fibroids, and determine associated morbidity and mortality.

Methods

A systematic review of Medline, EMBASE, Web of Science, Scopus, and The Cochrane Library – CENTRAL was performed from the databases inception through to December 2018 for case report and series of patients who experienced intra-abdominal haemorrhage from uterine fibroids. Findings were presented according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines.

Results

We identified 115 publications reporting on 125 original case reports. The documented intra-abdominal haemorrhage were commonly due to the rupture of superficial blood vessels over the surface of a fibroid, followed by rupture and avulsion of the fibroid involved. A clinical picture of sudden and profound hypovolemic shock with severe abdominal pain was often the presenting complaint, with a correct pre-operative diagnosis only made in 7 cases on computed tomography imaging. Hysterectomy and myomectomy were the most common surgery performed. Mortality was reported in 4 cases which were directly related to complications of uterine fibroids.

Conclusion

Intra-abdominal haemorrhage secondary to uterine fibroids remained a rare phenomenon which is poorly recognized among clinicians. While this association is not representative of the population of interest, it highlights the pathophysiological spectrum of uterine fibroids and its relevance to emergency physicians, surgeons and gynaecologists during clinical practice.

Successful management of preoperatively diagnosed torsion of a subserosal uterine fibroid by pneumoperitoneum laparoscopic single-port surgery

OBJECTIVE

Preoperative diagnosis and successful management of acute torsion of a subserosal fibroid by using appropriate imaging modalities and single-port laparoscopic surgery.

CASE REPORT

A 44-year-old nulliparous woman presented with lower abdominal pain. Computed tomography and magnetic resonance imaging with contrast enhancement revealed a tumor in the pouch of Douglas with a low contrast at the center and thin-rim enhancement. Torsion of a uterine subserosal fibroid was diagnosed preoperatively. Laparoscopic single-port surgery by pneumoperitoneum was performed. Torsion of the pedicle attached to the uterine wall was excised by bipolar coagulation and cut with scissors. The extirpated fibroid was extracted from the umbilical wound. The pneumoperitoneum single-port laparoscopic surgery was completed as a gynecologic emergency operation.

CONCLUSION

Torsional uterine fibroids are difficult to diagnose preoperatively as symptoms are nonspecific and need emergent surgical management as an acute abdomen. Preoperative diagnosis using appropriate imaging modalities is important to perform single-port laparoscopic surgery.

Management of acute abdomen in pregnancy: current perspectives

Acute abdomen in pregnancy represents a unique diagnostic and therapeutic challenge. Acute abdominal pain in pregnancy can occur due to obstetric factors as well for reasons that are unrelated to pregnancy. The diagnostic approach of acute abdomen during pregnancy can be tricky owing to the altered clinical presentations brought about by the anatomical and physiological changes of gestation along with the reluctance to use certain radiological investigations for fear of harming the fetus. Delay in diagnosis and treatment can lead to adverse outcomes for both the mother and fetus. In this article, we attempt to review and discuss the various etiologies, the current concepts of diagnosis, and treatment, with a view to developing a strategy for timely diagnosis and management of pregnant women presenting with acute abdominal pain.

Diagnostic ambiguity of aseptic necrobiosis of a uterine fibroid in a term pregnancy: a case report

Background

Uterine fibroids are the most common uterine tumours in females of reproductive age. During pregnancy, uterine fibroids may be complicated by aseptic necrobiosis. We herein report an ambiguous clinical presentation of uterine fibroids in pregnancy and discuss the diagnostic challenges encountered in our resource-constraint setting.

Case presentation

A term pregnant Cameroonian woman was admitted to our maternity unit with clinical findings suggestive of a strangulated umbilical hernia. She underwent an emergency caesarean section which fortuitously revealed aseptic necrobiosis of a uterine fibroid, managed within the same surgical intervention by myomectomy. Her post-operative course was uneventful.

Conclusion

The authors highlight the need for a high index of suspicion by healthcare providers, as well as the need for a multidisciplinary approach for a favourable maternal and foetal outcome.

European Society of Urogenital Radiology (ESUR) Guidelines: MR Imaging of Leiomyomas

OBJECTIVE

The aim of the Female Pelvic Imaging Working Group of the European Society of Urogenital Radiology (ESUR) was to develop imaging guidelines for MR work-up in patients with known or suspected uterine leiomyomas.

METHODS

Guidelines for imaging uterine leiomyomas were defined based on a survey distributed to all members of the working group, an expert consensus meeting at European Congress of Radiology (ECR) 2017 and a critical review of the literature.

RESULTS

The 25 returned questionnaires as well as the expert consensus meeting have shown reasonable homogeneity of practice among institutions. Expert consensus and literature review lead to an optimized MRI protocol to image uterine leiomyomas. Recommendations include indications for imaging, patient preparation, MR protocols and reporting criteria. The incremental value of functional imaging (DWI, DCE) is highlighted and the role of MR angiography discussed.

CONCLUSIONS

MRI offers an outstanding and reproducible map of the size, site and distribution of leiomyomas. A standardised imaging protocol and method of reporting ensures that the salient features are recognised. These imaging guidelines are based on the current practice among expert radiologists in the field of female pelvic imaging and also incorporate essentials of the current published MR literature of uterine leiomyomas.

KEY POINTS

• MRI allows comprehensive mapping of size and distribution of leiomyomas. • Basic MRI comprise T2W and T1W sequences centered to the uterus. • Standardized reporting ensures pivotal information on leiomyomas, the uterus and differential diagnosis. • MRI aids in differentiation of leiomyomas from other benign and malignant entities, including leiomyosarcoma.

Uncommon obstetric and gynecologic emergencies associated with pregnancy: ultrasound diagnosis

INTRODUCTION

Many uncommon obstetric and gynecologic problems associated with pregnancy and the early postpartum period can lead to severe abdominal pain and be life-threatening. The patient will be in urgent need of a quick and accurate decision. The means of management will depend on the ability to differentiate between these problems to achieve an optimal diagnosis.

MATERIALS AND METHODS

30 pregnant females attended a private obstetric ultrasound clinic with clinical picture of acute abdomen with pregnancy. All were subjected to an ultrasound exam, the results were recorded, and the final diagnosis was reached based on the postoperative results.

RESULTS

Patients were classified according to their duration of pregnancy into cases with acute abdomen that occurred during the first trimester, during the second trimester, during the third trimester, and in the early postpartum period.

CONCLUSION

Ultrasonography is a valuable tool for detecting the etiology and guiding the management in cases of emergency situations faced by the obstetrician and gynecologist during pregnancy and the early postpartum period.

Management considerations for patients with uterine fibroids and concurrent venous thromboembolism

PURPOSE OF REVIEW

The purpose is to provide an update on management strategies for uterine fibroids in the setting of venous thromboembolism (VTE).

RECENT FINDINGS

Uterine fibroids and VTE are independently associated with morbidity and increasing healthcare costs. Women with large uterine fibroids have a higher likelihood of VTE. Current strategies for stratifying patients with VTE take into account the nature of the VTE (i.e., truly provoked or unprovoked) and many patients may only require short-term anticoagulation. In those patients with risk factors for recurrent VTE, longer term anticoagulation may be required.

SUMMARY

In women with large uterine fibroids, the likelihood of concurrent VTE increases. Peri and postoperative management should be determined based on patient-specific risk stratification, with the majority of patients requiring short-term anticoagulation. Further risk stratification may be required for patients with essentially an unprovoked VTE, and consultation with a thrombosis specialist is recommended.

Deep Venous Thrombosis Caused by a Huge Uterine Myoma

Cases of deep venous thrombosis (DVT) and pulmonary thromboembolism (PTE) related to the isolated risk factor of uterine myoma are very rare. In a setting of emergency department (ED), it is unlikely that uterine myoma would be suspected as the primary cause of symptoms in a patient with thromboembolism. We presented a 44-year-old woman who visited the ED for DVT presenting with right lower leg swelling with an underlying cause of a huge uterine myoma. Various aetiologies, including obstetric and gynaecological causes (especially uterine myoma), should be considered in female patients visiting the ED with suspected DVT or PTE.

Myomectomies for massive hemoperitoneum from spontaneous bleeding of a uterine myoma

Massive hemoperitoneum from spontaneous bleeding of uterine myoma is an extremely rare condition, that needs urgent surgical exploration. We report a 40-year-old woman, admitted for acute onset of abdominal pain. Physical examination revealed hypovolemic shock. The hemoglobin level was of 5 g/dL. Ultrasonography revealed hemoperitoneum. Emergency surgical exploration was planned. There was hemoperitoneum of 3 L, uterine myomas with multiple subserous myomas, bleeding from superficial ruptured varice overlying the most largest subserous myoma, which measured 15 cm. Glove adapted as a tourniquet, was applied at the base of the uterus, and myomectomies were performed with removal of around twenty myomas. The postoperative course was uneventful. Myomectomies can be safely and effectively performed by using a tourniquet, for massive hemoperitoneum with precarious hemodynamic status due to subserous myoma bleeding, despite the number and the size of myomas.

Spontaneous Rupture of a Leiomyoma Causing Life-Threatening Intra-Abdominal Hemorrhage

Background. Uterine fibroids are common benign tumors in women. Clinical manifestations are well known. Acute complications necessitating emergent surgical intervention are rare. Case. We report a case of a 53-year-old woman with a history of uterine fibroids presenting with acute-onset severe abdominal pain. Imaging indicated massive free fluid and a large partially solid uterine mass. Vitals were consistent with hypovolemic shock. Examination revealed a surgical abdomen. She underwent an emergent laparotomy and total hysterectomy. Surgery revealed 4.5 L of hemoperitoneum and a 15 cm degenerated uterine fibroid with active bleeding. Pathology was consistent with intraoperative findings. She required transfusion of numerous blood products perioperatively. Her postoperative course was uncomplicated. Conclusion. It is rare for a uterine fibroid to spontaneously rupture. However, prompt recognition of this severe complication is critical for expeditious, life-saving surgical management.

Should Prophylactic Anticoagulation Be Considered with Large Uterine Leiomyoma? A Case Series and Literature Review

Introduction. Uterine leiomyomas, also called uterine fibroids or myomas, are the most common pelvic tumors in women. They are very rarely the cause of acute complications. However, when complications occur they cause significant morbidity and mortality. Thromboembolic disease has been described as a rare complication of uterine leiomyomas. DVT is a serious illness, sometimes causing death due to acute PE. Cases. We report a case series of 3 patients with thromboembolic disease associated with uterine leiomyoma at Hurley Medical Center, Flint, Michigan, during 2015 and conduct a literature review on the topic. A literature search was conducted using Medline, PubMed, and PMC databases from 1966 to 2015. Conclusion. The uterine leiomyoma is a very rare cause of PE and only few cases have been reported. DVT secondary to uterine leiomyoma should be considered in a female presenting with abdominal mass and pelvic pressure, if there is no clear common cause for her symptoms. Thromboembolic disease secondary to large uterine leiomyoma should be treated with acute stabilization and then hysterectomy. Prophylactic anticoagulation would be beneficial for lowering the risk of VTE in patients with large uterine leiomyoma.