AbstractFibroid in pregnancy is common in clinical obstetricpractice. There are conflicting reports in the literature onmany so-called fibroid complications in pregnancy, andthere are inadequate data on the optimum managementstrategy. We present a case of a pregnancy with largefibroid which was uneventful till delivery but ended inimmediate postpartum complication of fibroiddegenerating and prolapsing into vagina dealt withmyomectomy at day 30 postnatal. Initially managedconservatively with intrauterine balloon tamponade andanaemia correction and discharged home. Later onmyomectomy was performed on day 40 postop due torecurrent complaint of foul smelling vaginal dischargeand fibroid protruding in vagina. This case illustrates avery rare complication of pregnancy with fibroid and thedifficulties that are encountered in managing such cases.

Keywords: Uterine Fibroid, Pregnancy.

IntroductionThe prevalence of uterine fibroids in pregnancy variesbetween 1.6 and 10.7 percent, depending upon thetrimester of assessment and the size threshold.1-5 There isa plethora of publications in the medical literature andtextbook chapters on the gynaecological aspects offibroid outside of pregnancy, but the literature is scantyand conflicting on the fibroid features and managementduring pregnancy and labour. The most important factorsin determining morbidities in pregnancy include fibroidnumber, size, location, and relation to placentalimplantation (retroplacental). Submucous fibroids havethe strongest association with lower ongoing pregnancyrate (OR 0.5, 95% CI 0.3 to 0.8), mainly due to defectiveimplantation.6 However, there is no evidence thatsubserous or intramural fibroids adversely affectpregnancy outcome.7 Large submucous or multiplefibroids may distort the uterine cavity leading toabnormal lie and presentation (risk of breech 13%(fibroids) vs. 8% (without fibroids)), pre-labour prematurerupture of the membranes (PPROM), pre-term labour(PTL) (19% (fibroids) vs. 13% (without fibroids)) and risk of

CS (49% (fibroids) vs. 21% (without fibroids).8 Cervical orlow anterior fibroids may obstruct labour and render CStechnically difficult. Retroplacental fibroids have beenshown to be associated with a higher incidence ofmiscarriage, PTL, placental abruption, and postpartumhaemorrhage (PPH) (8% (fibroids) vs. 3% (withoutfibroids).8,9

Case ReportA 31 year old woman, primigravida, married since one anda half years was booked at12 weeks at our hospital. Herroutine sonography at 11 weeks of gestational agedemonstrated an incidental finding of a fibroid arisingfrom posterior wall of uterus 4.5 x 3.8 cm at 11 weekswhich increased in size till18weeks gestational age to 6.8x 5.2cm. Thereafter the size of fibroid remained static andpregnancy went uneventful. She was delivered byelective caesarean section at 37 weeks on 1 November2016 at Agha Khan Hospital for Women Garden, Karachibecause of oblique lie and recurrent complaint ofabdominal pain. Patient's haemoglobin preoperativelywas 10.4gm/dl. Intraoperatively a large sub-mucosalfibroid in posterior wall of uterus compressed by baby'shead of about 7x8 cm was noticed (Figure-1). An alivefemale baby of 3.0 kg was delivered followed by placentaand membranes. Haemostasis was secured, andestimated blood loss was 600 to 700ml. Pateint was kepton Syntocinon infusion for 12 hours postoperativelyanticipating risk of Postpartum haemorrhage.

After 10 hours of surgery, the patient complained ofvaginal bleeding. On examination, there was old brown

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CASE REPORT

Prolapsed degenerating postpartum uterine fibroid: A case reportErum Saleem Khan, Reeta Chander Parkash

Agha Khan Hospital For Women, Garden, Karachi.Correspondence: Erum Saleem Khan. Email: erum959@hotmail.com Figure-1: Uterus with large submucosal fibroid.

coloured 250ml of clot which was removed from vaginabut there was no active bleeding. Patient was kept understrict observation with half hourly monitoring of vitals,intake output and blood loss vaginally. Patient suddenlybecome hypotensive about 20 hours after surgery. Herblood pressure dropped to 70/40 mmhg, pulse 90 b/min,patient was drowsy but arousable and startedcomplaining of severe pain in sacral area. Immediately callfor help was given. Patient was resuscitated with fluidreplacement and blood sent for crossmatch and completeblood count. Her urgent Hb showed a drop to 6.4gm/dl. Itwas then planned to examine the patient underanaesthesia. On examination under anaesthesia, cervicalos was open with lower segment ballooned up andfibroid felt protruding from cervical os. Upper segmentwas well contracted with mild pervaginal bleeding.Intrauterine balloon tamponade with vaginal packing wasdone. Patient remained stable vitally during theprocedure.

Post EUA and tamponade, blood transfusion wascommenced but patient persistently complained ofsevere pain in sacral area despite opioid infusion andbecame tachycardic (pulse 130 to 140b/m), so onsuspicion of degenerating fibroid and need of tertiary

care and imaging patient was shifted to tertiary carecentre.

MRI was done (Figure-2) which showed a soft tissue lesionarising from the posterior wall of uterus and hanging intothe endometrial cavity. It measured approximately 50 x68 x 133 mm in AP x T x CC dimensions respectively,having low signal intensity on T1, heterogenous lesionhyperintense signal on T2 and heterogenouspostcontrast enhancement with central areas ofnonenhancement. These signals suggested acutehaemorrhage and necrosis within the soft tissue. Thelower end of this soft tissue was in contact withtamponade balloon. Overall appearances represented alarge degenerating fibroid arising from posterior wall ofthe uterus.

Patient was managed conservatively with bloodtransfusion, broad spectrum IV antibiotics and balloontamponade was retained for 48 hours. Patient remainedstable and tamponade was removed and patientdischarged on day 4 postoperatively.

On day 30 postoperatively patient presented in clinic withcomplaint of Increased foul smelling vaginal discharge , and

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Figure-2: Sagittal MRI of degenerating Uterine Fibroid. Figure-3: Sagittal MRI of Degenerating Uterine fibroid prolapsing with balloontamponade insitu through cervix.

fever spikes on and off for one week. She was examined andfound to have fibroid occupying half of upper vagina withfoul smelling discharge. Her Repeat MRI was done whichshowed a broad based fibroid originating from uterus andprotruding through cervix now comparatively reduced insize to 6*8*8cm. It was planned to resort for abdominalmyomectomy which was successfully performed on 10December 2016. Patient remained stable.

DiscussionTo the best of our knowledge this is the first report inliterature of a prolapsed degenerating uterine fibroidpostpartum. It also highlights the dearth of evidencebased information in management of these rarecomplications of fibroids associated with pregnancy.

Leiomyoma's are the most common pelvic tumour inwomen with a 1% incidence in pregnancy. Ultrasoundstudies have shown that about 20% of fibroids increase insize and similar percentage decrease during pregnancy.The greatest increase in volume occur before the 10thgestational week.1 Fibroids are associated with anincreased risk of threatened miscarriage, threatenedpreterm delivery, abruption, pelvic pain, which is oftendue to degeneration of the fibroid, and usually managedconservatively during pregnancy. There is high incidenceof caesarean section in women with leiomyomata, with alarge proportion being directly related to the fibroid.2Myomectomy at the time of caesarean section is knownto be hazardous because of uncontrollable haemorrhage.Most obstetricians advise against myomectomy at thetime of caesarean section, unless the myoma ispedunculated.2,3 Three cases have been described wheremyomectomy was performed to achieve delivery.4,5 Mostuterine fibroid either stopped growing or decrease in sizepostpartum. One study on 32 patients with leiomyomasshowed that the size at 6 weeks postpartum did not differsignificantly from size during pregnancy6 but another of34 women who underwent ultrasound scan four weeksafter delivery showed that myomas become smaller,shrinking back to their initial size at the commencementof pregnancy.1 In our case uterine fibroid increased morethan four fold in volume during first post-operative day.Such rapid growth of uterine leiomyoma in earlypostpartum period has never been reported in theliterature, only one case reported by Manyonda et al.7 Arapidly growing uterine fibroid postpartum, was done. Asleiomyoma enlarge they may outgrow their blood supply

resulting in various types of degeneration. This drasticallyalters the appearance of the tumour and creates difficultyin establishing diagnosis; the differential diagnosis ofleiomyoma includes adenomyosis, adnexal mass anduterine leiomyosarcoma. MRI is the most accurateimaging technique for detection and localization ofleiomyoma. Degenerated leiomyoma can have varyingappearances. Rapid growth of degenerative fibroid ismainly due to necrosis, infarction and cystic changes. Inour case MRI findings were suggestive of degeneratedfibroid. This is the second case report describing a largebenign degenerated leiomyoma that grew postpartumand was managed conservatively with balloontamponade. It also demonstrates the possibility ofconfusion in diagnosis arising with such findings.

Acknowledgement: Dr. Aysha Basharat isackniowledged with thanks for proof reading the article.

Disclaimer: None to declare.

Conflict of Interest: None to declare.

Funding Disclosure: None to declare.

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