INTRODUCTION

Leiomyomas are common, but rarely are they associated with severe complications in pregnancy.

We present the case of a successful abdominal myomectomy in a patient who developed a severe systemic inflammatory response reaction and subacute small bowel obstruction secondary to red degeneration of multiple leiomyoma in the second trimester of pregnancy. This case highlights the complex decision making and multi-disciplinary management involved.

CASE SUMMARY

The patient was 29 years old with no significant past medical history other than uterine leiomyomas, the largest of which measured 8cm.

The patient presented to her local early pregnancy unit on multiple occasions between 5-16 weeks’ gestation due to abdominal pain. At 16 weeks’ gestation, she was admitted to hospital with symptoms of worsening pain, bilious vomiting, constipation and feeling unwell. Her inflammatory markers were elevated. Imaging performed showed a large multi-fibroid uterus, with a 20cm left para-central leiomyoma and a 14cm pedunculated leiomyoma. The initial impression was a paralytic ileus secondary to fibroid degeneration, and small bowel obstruction secondary to large leiomyomas and a gravid uterus.

She was managed with IV antibiotics, IV fluids and analgesia, however her clinical condition worsened, and she was referred to our tertiary unit for ongoing care.

Despite conservative management, her clinical condition deteriorated, and she developed a severe systemic inflammatory response reaction to fibroid degeneration at 16+4 weeks’ gestation.

A multi-disciplinary team (MDT) meeting was organised to discuss ongoing care, including professionals from Gynaecology, Obstetrics, the Pregnancy Advisory service, Radiology and Anaesthetics. The risks and benefits of ongoing conservative care, surgical termination of pregnancy or abdominal myomectomy were presented to the patient. The patient opted for surgical management, and, following careful pre-operative planning, underwent a successful abdominal myomectomy at 17+4 weeks gestation. She was discharged a week later, to continue her antenatal care locally. She underwent an elective caesarean at 39 weeks gestation. The baby weighed 3.9kg.

Figure 1 - from Left- Right: (i) initial MRI examination in sagittal view, demonstrating a large fundal subserosal fibroid and singleton gravid uterus, (ii) second MRI examination in coronal view, demonstrating two large leiomyomas with features of red degeneration. 

SPECIMENS

DISCUSSION

There are few published studies advising on the optimal management of symptomatic leiomyomas in pregnancy which are refractory to conservative measures, especially relating to myomectomy during pregnancy. There is no consensus on the management of such cases.

Clinicians may discuss the option of antenatal myomectomy in such cases, however, must bear in mind limited evidence available on its safety and efficacy. Risks include miscarriage,  haemorrhage and hysterectomy.

A profound systemic inflammatory response syndrome secondary to complications relating to leiomyomas in pregnancy, as seen in the case described, is rare. Further comprehensive research is required to better understand the pathophysiology of fibroid complications in pregnancy.

CONCLUSION

This case highlights the importance of multi-disciplinary teamwork when making complex clinical decisions in the context of limited published data advising on optimal treatment. Involving the patient in the decision-making process is key.  Careful peri-operative planning is necessary for a successful outcome.