IJCRR - 14(21), November, 2022
Date of Publication: 10-Nov-2022
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A Case of Mucoid Degeneration of Uterine Fibroid with Hydrosalphinx and Ovarian Cyst
Author: Saurabh Suvidha
Abstract:Introduction: Uterine fibroids are the most common benign pelvic tumors in women of reproductive age. Most of them are asymptomatic but they are also a major source of clinical morbidity. Aim: We present this case due to its uniqueness and the diagnostic difficulties it posed. Case Report: A 40-year-old female presented to the OPD with complaints of pain abdomen on and off and heavy menstrual bleeding. Physical examination revealed a lump of 14-week size.USG and CT scan revealed intramural fibroid with cystic/mucoid degeneration. The patient had an elective total abdominal hysterectomy with bilateral scalping-oophorectomy. Intraoperatively uterus was enlarged with hydrosalpinx on the right side. Histopathological examination showed mucoid degeneration of fibroid with chronic cervicitis. Discussion: Degenerating changes in fibroids are considered to result from excessive growth that outmatches the blood supply or mechanical compression of feeder arteries. Conclusion: This case illustrates that degeneration of uterine leiomyoma should be considered as one of the differential diagnoses for all women presenting with abdominal pain and a large fibroid mass regardless of hormonal status or age.
Keywords: TAH BSO, Degeneration, Uterine tumours, Fibroid, Blood supply
Uterine fibroids are the most common benign uterine tumours. Fibroids are seen in at least 40 -50% of women of 35 years or older. Degeneration of fibroid usually occurs because of loss of blood supply caused by its rapid growth during pregnancy or with oral contraceptive use and so the diagnosis of degenerating uterine fibroid in a non-pregnant woman is often difficult. This case is remarkable as degeneration of fibroid is extremely uncommon in a peri-menopausal woman who is not on hormone therapy and degeneration of fibroid should always be considered in a large fibroid mass as its rapid growth can ultimately lead to decreased blood supply leading to its degeneration.
A 40-year-old female presented to OPD with pain abdomen on and off and heavy menstrual bleeding for 4 to 5months. Her last menstrual period was on 8th Jan 22. She was P4L4 all by vaginal delivery at term.
On examination the patient was febrile and all other vital signs were within normal limits. Abdominal examination showed a lump of size 14 weeks, firm, irregular and non-tender. On bimanual examination, the mass was enlarged more towards the right and was about 14-week size. Right fornix was full.
Routine investigations, as well as special investigations, were done which showed Hb 10.9g/dl, TLC 6000/ul, Platelets 1.05 lac/mm3, ESR 40, CA 125 6.6U/ml, SGPT 46 U /ml, CEA 2.15 ng/ml, S Bil 0.52 mg/dl, PT 15.4, INR 1.3.
USG showed a uterus 12x5x9 cm. A large heterogeneous well-circumscribed lesion occupying the whole of the fundus and anterior myometrium with disfigurement of the uterine cavity, 7x8x8 cm suggestive of fibroid. Simple cyst in the right ovary of size 5x6 cm. CT scan shows a bulky uterus with heterogeneously enhancing well-defined lesion in the uterine myometrium of the anterior wall of the fundus and body causing
compression of the endometrial cavity posterior suggestive of intramural fibroid with likely cystic /mucous degeneration. Right simple Adnexal cyst and elongated hypodense tubular structure in right adnexa likely hydrosalpinx.
A peri menopausal woman presenting with a large fibroid mass raised the concern of leiomyosarcoma. Together with abdominal pain, differential diagnosis includes torsion of pedunculated fibroid, infarction or degeneration as well as a ruptured fibroid.
TAH BSO was done under combined spinal epidural anaesthesia.14-week size enlarged uterus with hydrosalpinx on the right side was noted. The specimen was sent for HPE which revealed mucoid degeneration of fibroid with chronic cervicitis. The postoperative period was uneventful. She was discharged on the 8th post-operative day.
Degeneration of uterine leiomyoma so occurs when they enlarge in size and outgrow their blood supply. This is commonly seen in pregnant women or women who are taking oral contraceptive pills.1 Hyaline degeneration is the commonest degeneration but can also co exist with
other degeneration.2 The diagnosis of degenerating uterine leiomyoma in non-pregnant women is often difficult. The inflammation in case of degeneration can cause abdominal tenderness, localised rebound tenderness on palpating, the elevation of temperature and leucocytosis. All these signs and symptoms are non-specific and all possible causes of an acute abdomen should be considered. On rare occasions, a degenerating leiomyoma can rupture and result in intra-abdominal bleeding.3-5 Pre-operative diagnosis of degenerative leiomyoma is often difficult and they can be commonly misinterpreted as complex adnexal cysts of ovarian origin. 6 This is especially true with CT scans reporting when degenerative fibroids are frequently indistinguishable from cystic ovarian masses.7 When women present with abdominal pain suspected to be of gynaecological origin, ultrasound is highly sensitive and often regarded as the investigation of choice.
Therefore we conclude that in a woman with a large fibroid mass presenting with acute pain, degeneration of fibroid should be a differential diagnosis irrespective of her age or hormone status. The majority of leiomyomas are symptomless when they are small, there appears no relationship between presenting symptoms and type of degeneration. Symptomatology and severity depend on the size of the leiomyoma rather than degenerative changes.8
Staff members of the department of Obstetrics and Gynaecology of ESIC Medical College and Hospital BIHTA, Patna
Conflict of interest None
Source of funding NIL
Competing interest – None
Patient consent – Obtained
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