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CroniconO P E N A C C E S S EC CLINICAL AND MEDICAL CASE REPORTS
Case Report
Spontaneous Expulsion of Uterine Fibroid Two Weeks after Spontaneous Abortion: Case Report
H Nachchat1, M Chigri1, Nadir Sahli3*, M Khmou2, F Elhassouni1, S Amrani1, N Lamalmy2, M Youssfi1 and S Bargach1
1Department of Gynecology and Obstetrics, Maternity Souissi, University Mohammed V, Rabat, Morrocco.2Department of Pathology, Maternity Souissi, University Mohammed V, Rabat, Morrocco.3Department of Radiation Oncology, National Institute of Oncology, University Mohammed V, Rabat, Morrocco.
*Corresponding Author: Nadir Sahli, National Institute of Oncology, University Mohamed V, Morocco.
Citation: Nadir Sahli., et al. “Spontaneous Expulsion of Uterine Fibroid Two Weeks after Spontaneous Abortion: Case Report”. EC Clinical And Medical Case Reports 1.1 (2018): 35-39.
Received: September 19, 2018; Published: October 30, 2018
Abstract
Keywords: Spontaneous Expulsion; Fibroid; Abortion; Complications
Introduction
We are reporting an interesting and rare case of a large submucosal fibroid which was spontaneously expelled per vaginally.
Background: Uterine fibroids or leiomyomas are the commonest benign tumors amongst women. Their presence has been linked to
Case Presentation: This case report case involved a 42-year-old G5P4, She had 20 weeks gestation, presented to our department two weeks after spontaneous abortion, with abdominal pain, offensive vaginal discharge, and fevers. An abdominal ultrasound and computed tomography showed an 170 × 123 × 72 mm cm fibroid, two days later she expulsed spontaneously a large mass (necrotic fibroid) per vagina.Conclusion: This case demonstrates an unusual evolution with spontaneous fibroid expulsion without any intervention. It also dem-onstrated the increased risk of spontaneous abortion, justifying the importance of surveillance in these pregnancies.
Purpose: This paper aims to identify the pattern of child sexual abuse in Khartoum, Sudan and to study the offender associative factors.
Uterine myomas are the commonest benign solid tumours in female and are found in more than 70% of women by age 50 years [1].
Abbreviation
UAE: Uterine Artery Embolisation
Depending on their location within the uterus, myomas can be stratified into submucosal, intramural and subserosal.
During pregnancy, there is evidence to suggest that growth of the tumor is accelerated by the hormones progesterone and oestrogen [2,3] and uterine fibroids may be difficult to differentiate of physiological myometrium thickening [4].
Citation: Nadir Sahli., et al. “Spontaneous Expulsion of Uterine Fibroid Two Weeks after Spontaneous Abortion: Case Report”. EC Clinical And Medical Case Reports 1.1 (2018): 35-39.
Spontaneous Expulsion of Uterine Fibroid Two Weeks after Spontaneous Abortion: Case Report
Case Report
Their presence has been linked to many complications as spontaneous abortion, dystocia, preterm labor, fetopelvic disproportion, malposition of the fetus, retention of the placenta, postpartum hemorrhage and uterine inertia [8].
A 42 years old female G5P4 presented to our department with complaints of pain abdomen since last 10 - 12 hours. She had 20 weeks gestation and reported spontaneous abortion at home two weeks ago.
Biologically, Hemoglobin was 10.0 g/dL, White cell count; 13000/L, Neutrophils; 9000/L and C-Reactive Protein; 10.0 mg/L.
The computed tomography showed submucosal fibroma measuring 170 × 123 × 72 mm (Figure 1).
In fact, a study have shown that 68.4% of fibroids during pregnancy do not significantly change volume [5].
Spontaneous vaginal expulsion of fibroids in the post-partum or after uterine artery embolization has been reported, but as in our case, spontaneous expulsion of large submucosal fibroid is very rare.
On examination, she was febrile t° 39, her pulse: 114/min, BP: 110/70 mmhg without any significant finding on general physical ex-amination.
On per speculum; os open with blood mixed discharge without particular smell, on per vaginum, the cervix was soft, 50 percent effaced and 1 to 2 cm dilated.
Abdominal palpation found a soft abdomen without guarding, uterus was 20 week size.
Vaginal and abdominal ultrasound diagnosed a large intra uterine mass measuring 17 × 12 × 7 cm (fibroma? retained product of con-ception?).
Figure 1: Sagittal view of computed tomography showing submucosal fibroma measuring 170 × 123 × 72 mm.
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Citation: Nadir Sahli., et al. “Spontaneous Expulsion of Uterine Fibroid Two Weeks after Spontaneous Abortion: Case Report”. EC Clinical And Medical Case Reports 1.1 (2018): 35-39.
Spontaneous Expulsion of Uterine Fibroid Two Weeks after Spontaneous Abortion: Case Report
The patients was hospitalized and was given antibiotics for a suspected infection.
Two days later, the patient presented severe lower abdominal pain and excessive bleeding per vaginum. Vaginal examination found a large mass protruding from the cervix and then the patient expelled a large 19 x 14 cm friable mass, soft in consistency.
After expulsion, follow up ultrasound revealed a normal uterus and endometrial cavity without any uterine mass.
Histopathological examination confirmed a myoma measuring 190 x 140 x 45 mm, weighing 560g (Figures 2).
Figure 2: Macroscopic fibroid weighing 560g, measuring 190 x 140 x 45 mm.
Figure 3 and 4: Microscopic examination of uterine fibroid consistent with a leiomyoma.
Microscopic examinations confirmed the diagnosis of infarcted leiomyoma (Figure 3 and 4).
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Citation: Nadir Sahli., et al. “Spontaneous Expulsion of Uterine Fibroid Two Weeks after Spontaneous Abortion: Case Report”. EC Clinical And Medical Case Reports 1.1 (2018): 35-39.
Spontaneous Expulsion of Uterine Fibroid Two Weeks after Spontaneous Abortion: Case Report
Their pathogenesis is not clearly known, there is considerable evidence that estrogens and progestogens proliferate tumor growth [3] as the fibroids rarely appear before menarche and regress after menopause. In fact, they are present in 20% - 25% of women at reproduc-tive age and half of all women have fibroids by age 50.
Actually, uterine artery embolization (UAE) is a recent method of treating fibroids which can allow fertility-preserving [11,12]. A re-cently published Cochrane review [13] has found that there was no significant difference in satisfaction rates between UAE versus other medical or surgical interventions for symptomatic uterine fibroids, however a higher rate of post-procedural complications and further re-interventions in the UAE arm of the study was observed.
In this case, we report spontaneous vaginal expulsion of fibroids after miscarriage without any intervention, to our knowledge, there are a very few cases of spontaneous expulsion of fibroids reported in the literature [14-16] either in post-partum of after cesarean. It may be explained by rapid hormonal change and mechanical effects leading to the tearing of the tumor pedicle, in fact, the gravity of tumor and uterine contractions rise to ischemia and necrosis of pedicle and then the mass may be expulsed vaginally.
This case also demonstrated the increased risk of spontaneous abortion, justifying the importance of careful surveillance in these pregnancies.
Uterine leiomyomas are the commonest benign solid tumours in female [1].
They arise from smooth muscle cells of the uterus.
Discussion
Ultrasound studies of fibroid size during pregnancy has shown that uterine fibroids can increase size in 22 - 32%, or decrease size in 8 - 27% and 49 - 60% of uterine fibroids have a minimum volume change (< 10%) [5,7].
In most cases, myomas are asymptomatic during pregnancy. However, many complications are reported, including miscarriage, mal-presentation, fetal anomalies preterm labor, premature rupture of membranes, placenta abruption and placenta abruption [8].
Medical therapy such as progestogens, anti-fibrolytics, anti-progesterone, danazol, GnRH agonist and antagonists should be tried as a first line of treatment for symptomatic myomas [6], while surgical treatment should be reserved only for appropriate indications. Either hysterectomy or myomectomy, can be performed [10]. However, myomectomy is preferred when subsequent childbearing is a consider-ation.
In some cases, women may have severe abdominal pain [9].
Symptomatic uterine myomas can be treated with medical therapy, conventional surgical, or recently, less invasive approaches.
Uterine fibroid is commonest benign solid tumour in female mostly asymptomatic.
Conclusion
Symptomatic fibroid are managed with either medical therapy or surgical method UAE and hysteroscopic resection are gaining popu-larity with good results.
This case demonstrates the rare occurrence of spontaneous expulsion without any intervention after a spontaneous abortion.
The surveillance of women with fibroids should be started early during pregnancy to avoid such complications.
Competing Interests
The authors declare that they have no competing interests. Consent for publication Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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Citation: Nadir Sahli., et al. “Spontaneous Expulsion of Uterine Fibroid Two Weeks after Spontaneous Abortion: Case Report”. EC Clinical And Medical Case Reports 1.1 (2018): 35-39.
Spontaneous Expulsion of Uterine Fibroid Two Weeks after Spontaneous Abortion: Case Report
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15. Natalie De Cure., et al. “Spontaneous expulsion of large submucosal uterine fibroid without embolisation - a case study”. Australasian Journal of Ultrasound in Medicine 16.1 (2013): 37-40.
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Volume 1 Issue 1 November 2018©All rights reserved by Nadir Sahli., et al.
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