About the Author

Dr. Neerja Varshney, Dr. Meenakshi Sharma, Dr. Vandana Jain

CMO, (NFSG), Incharge, Dept Obs & Gynae

Junior Specialist, Dept Obs & Gynae

Senior Resident, Dept Obs & Gynae

Dr. Hedgewar Arogya Sansthan, Govt NCT, New Delhi

Abstract

Acute red degeneration in a large prolapsed cervical haemorrhage can mimick uterine inversion and presents as emergency where an emergency hysterectomy can be life saving.

Introduction

Cervical leiomyoma are usually single, interstitial or subserous but rarely become sub mucous and can rarely present as prolapsed or inverted uterus. We present a case report of huge prolapsed cervical fibroid with acute red degeneration requiring emergency hysterectomy.

Case Report

Mrs X, 45-yrs, P3L3, presented in Gyne OPD with the complaints of a painless mass coming out per-vaginum for 2 months associated with offensive purulent discharge and menometrorrhagia, loss of weight and appetite. There was no history of bowel or bladder complaints or any history of significant medical or surgical illnesses in the past.

The patient was thin built (BMI 17.15 Kg/m2), pale and malnourished. The vitals and systemic examination were within normal limits. On abdominal examination pelvic mass 14 wks gravid uterus size was palpated in suprapubic region. Per speculum examination showed an oblong, 6 x 7 cm size, firm, non tender mass in vagina and a portion (3 x 4 cm) of it was lying outside the introitus. The mass was irreducible with areas of ulceration, hemorrhage, and offensive purulent discharge. On bimanual examination the mass was arising from right lip of cervix and posterior wall of uterus. The uterus was multiparous size separately from the mass and bilateral fornices were free.

Investigations showed Hb - 8.0 gm%, TLC-14,400/cm3, ESR - 70 mm with microcytic hypochromic anemia. TVS revealed enlarged uterus showing multiple hypoechoic lesions within the myometrium with submucosal component. Surgery was planned after controlling the local infection and blood transfusions.

One day after admission patient complained of sudden acute increase in the prolapsed mass outside the vagina with bleeding from the fibroid. On examination uterus was not palpable per abdominally and the prolapsed mass had increased in size upto 15x20 cm with active bleeding from the prolapsed mass. She was immediately taken up for emergency hysterectomy by a combined abdomino-perineal route in view of the active bleeding and suspicion of uterine inversion. Intraoperatively uterus was bulky and the contour of fundus maintained. Ligation of uterine vessels was tried but it was not approachable because of the prolapsed mass pulling down the uterus. Vaginal myomectomy was performed and the rest of the hysterectomy was completed abdominally. Cut section of the uterus revealed cervical fibroid polyp of 15 x 20 cm with red degeneration arising from the posterior wall of uterocervical junction weighing 1.1kg. The histopathology of the resected specimen showed leiomyoma of uterus with areas of hemorrhage and infarction. Postoperative period of patient was uneventful.

Discussion

Cervical leiomyoma may elongate, prolapse and present with emergency like acute retention of urine and haemorrhage. Prolapsed fibroid also has been reported after use of GnRH therapy1and uterine artery embolization2. In our case there was an acute increase in size of prolapse spontaneously with haemorrhage requiring emergency hysterectomy.

Vaginal myomectomy has been recommended as the initial treatment of choice for prolapsed pedunculated submucous myoma, except in those cases in which other indications necessitate an abdominal approach3. In patients requiring hysterectomy, vaginal route is preferable to abdominal route as the operating- time, cost, postoperative fever, and need for analgesia are reported to be less without any significant difference in blood loss or other complications4,. In our case, abdominoperineal approach was used due to acute haemorrhage and the confusion in diagnosis with suspicion of uterine inversion and inaccessibility of the pedicle of cervical myoma by a solitary vaginal route.

References

1. Kriplani A, Agarwal N, Parul D, Bhatla N, Saxena AK. Prolapsed leiomyoma with severe haemorrhage after GnRH analogue therapy. J Obstet Gynaecol. 2002 Jul;22(4):449-51.
2. Pollard RR, Goldberg JM. Prolapsed cervical myoma after uterine artery embolization. A case report. J Reprod Med 2001; 46: 499-500.
3. Ben-Baruch G, Schiff E, Menashe Y, Menczer J. Immediate and late outcome of vaginal myomectomy for prolapsed pedunculated submucous myoma. Obstet Gynecol 1988; 72: 858-861.
4. Benassi L, Rossi T, Kaihura CT, Ricci L, Bedocchi L, Galanti B, Vadora E. Abdominal or vaginal hysterectomy for enlarged uteri: a randomized clinical trial. Am J Obstet Gynecol 2002; 187: 1561-156.