Author
Information
Patel A*, Gupta AS**.
(*
Second Year Resident, ** Professor, Department of Obstetrics and Gynecology,
Seth GS Medical College
& KEM Hospital , Mumbai , India
Abstract
We report a case of torsion of a large pedunculated
fundal uterine leiomyoma. A 45 year old nulligravida presented to us with
abdominal pain. With preoperative diagnosis of leiomyoma of the uterus patient
was operated for total abdominal hysterectomy, but intra operatively a large
fundal subserosal peduculated leiomyoma with one and half turn twist in its
thick pedicle was seen. Mostly torsion of pedunculated leiomyoma presents with
acute abdomen and needs emergency intervention but in our case the torsion was
not suspected clinically. It was a chronic condition.
Introduction
Uterine leiomyomas or leiomyomas are smooth muscle
tumors with benign course. They are the most common gynecological tumors. In
25% women in the reproductive age group leiomyomas were diagnosed clinically
and in almost 80% patients they were detected in surgically excised uteri. [1]
Leiomyomas can be sub mucosal, intramural, and sub serosal.[2]
Sometimes subserosal myomas can become pedunculated and rarely can they undergo
torsion to give acute symptoms. A torsion may cause ischemia and rapid clinical
deterioration. [3] There are very few cases reported till now. We
report a case of pedunculated sub serosal uterine myoma that underwent torsion.
Case
Report
A 45 year old nulligravida, a treated case of hyperthyroidism
presented to us with complain of mild continuous abdominal discomfort. The
patient did not have any acute symptoms, menstrual complaints or any difficulty
in defecation or micturition. The pain was chronic dull aching in nature. On
abdominal examination there was a 24 weeks size, non tender, hypogastric mass
with side to side mobility. The mass was more towards right of the midline. On
vaginal examination the uterus was not felt separately from the mass.
Clinically a large single fundal leiomyoma was diagnosed. All hematological,
biochemical and serological investigations were performed. All were within
normal limits except that the peripheral blood smear showed target cells and
occasional sickle cells. A hemoglobin
electrophoresis was done which was negative for any hemoglobinopathies.
Fragility test for sickling was negative. The patient was posted for elective
total abdominal hysterectomy. Surgery was done under combined spinal and
epidural anesthesia. The abdomen was opened by a midline infra-umbilical
vertical incision which had to be extended 2 cm above the umbilicus. On
entering the abdomen there was a large subserosal leiomyoma around 12x15 cm in
size with a thick pedicle. The pedicle of the leiomyoma had twisted and the
leiomyoma was lying behind the uterus. On exteriorizing the leiomyoma the thick
pedicle showed a one and a half circle turn. The myoma was very vascular,
congested with large dilated veins on its surface. The uterus, ovaries and
fallopian tubes were normal. The leiomyoma weighed 1.2 kg. Hysterectomy was
done. Histopathology was suggestive of a benign leiomyoma. The peripheral blood
smear was repeated twice within the next 15 post operative days, but no
abnormal cells were seen.
Figure 1. Large fibroid with a thick pedicle.
Figure 2. Posterior surface of the uterus.
Figure 3. Anterior surface of the fibroid.
Discussion
Torsion of a subserosal uterine leiomyoma is very
rare. Torsion is mostly seen in ovarian tumors. Torsion first occludes venous
and then arterial supply and causes gangrene. The ischemia due to arterial
occlusion leads to acute abdominal pain. Small subserous leiomyomas with thin
pedicles may undergo torsion.[4] In our case the pedicle was thick
about 5 cm in width and hence the 1 and a 1/2 turn of the pedicle probably
could out occlude the arterial supply. This obstructed the venous drainage only
leading to congestion and a dull aching discomfort. The torsion was probably
triggered by the large weight of the leiomyoma and also by the fact that the
leiomyoma was broader than its height looking like a mushroom. The turning
movements of the patient in recumbent position could have triggered the
rotation of the pedicle. In leiomyomas with thin pedicles the torsion may be
severe enough to obstruct arterial blood supply leading to ischemic necrosis
and a surgical emergency. Hematological changes like anemia, polycythemia,
thrombosis, thrombocytosis, and coagulopathies have been reported. In our case
the the finding of target cells and few sickle cells were reported on peripheral
smear, the significance of which remained undetermined. After the surgery the
peripheral smear was again studied twice 15 days apart by the same laboratory
senior scientific officer but no trace of those target cells or sickle cells
could be found. We postulate that due to torsion and venous congestion the red
blood corpuscles were distorted in the twisted pedicle which were then released
in the circulation. No report regarding such cells could be found on Medscape,
Pubmed, or internet search. In majority of the reported cases the patients
presented mostly with acute pain and tenderness over abdomen needing urgent
surgical intervention. On redirect
questioning our patient gave history of intermittent episodes of moderate
intensity pain which could be due to sub-acute episodes of torsion. Torsion was
not detected on ultrasound Doppler signals as its blood supply was intact.
Conclusion
This case is interesting as a large leiomyoma
underwent torsion. Thick pedicle rather than a thin pedicle was twisted and
abnormal red blood cells were found preoperatively in the peripheral smear
which disappeared after the twisted leiomyoma was removed.
References
1.
Cramer SF, Patel A. The
frequency of uterine leiomyomas. Am J Clin Pathol.1990;94(4):435-8.
2.
Berek JS. Chapter 13: Benign
Disease of the Female Reproductive Tract. In: Novak’s Gynecology, 13th edition.
Philadelphia
3.
Grover S, Sharma Y, Mittal S.
Uterine torsion: a missed diagnosis in young girls? J Pediatr Adolesc Gynecol.
2009;22(1):e5-8.
4.
Shrestha E, Ngangbam HS, Yang
Y, Li X. Torsion of Pedunculated Subserous Myoma. Journal of Medical Cases.
2011;2(2), 62-3.
Citation
Patel A, Gupta AS.