Vaginal delivery of a giant submucous fibroid: A case report

Zainab D Ahmed; Suleiman A Gaya; Natalia Adamou; Ali B Umar

doi:10.4103/njbcs.njbcs_17_18

CASE REPORT

Year : 2020 | Volume : 17 | Issue : 1 | Page : 64-67

Vaginal delivery of a giant submucous fibroid: A case report

Zainab D Ahmed¹, Suleiman A Gaya¹, Natalia Adamou¹, Ali B Umar²
¹ Department of Obstetrics and Gynaecology, Faculty of Clinical Sciences, of Health Sciences, Bayero University, Kano/Aminu Kano Teaching Hospital, Kano, Kano State, Nigeria
² Department of Pathology, Faculty of Clinical Sciences, of Health Sciences, Bayero University, Kano/Aminu Kano Teaching Hospital, Kano, Kano State, Nigeria

Date of Submission	27-Apr-2018
Date of Acceptance	17-May-2018
Date of Web Publication	30-May-2020

Correspondence Address:
Dr. Ali B Umar
Department of Pathology, Faculty of Clinical Sciences, College of Health Sciences, Bayero University, Kano/Aminu Kano Teaching Hospital, Kano, Kano State
Nigeria

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/njbcs.njbcs_17_18

Abstract

Uterine fibroid is a benign neoplasm that arises from uterine smooth muscles and is the most common tumor of the female reproductive tract. They could be intramural, subserous, or submucous depending on the location in the uterus. The main definitive form of management is surgical, which is myomectomy, hysterectomy, or hysteroscopic excision of small subserous nodules. Rarely, submucous fibroids could extrude through the cervical os, which can make vaginal hysterectomy possible. We present the case of a 40-year-old multipara who presented with menorrhagia, vaginal discharge, and a large mass protruding through the vagina. She had vaginal myomectomy of a mass measuring 25 cm in diameter and weighing 2.3 kg. She did well postoperatively. Vaginal hysterectomy for huge pedunculated submucous fibroid is safe, short, simple, definitive, and rarely associated with discomfort or complication to patients.

Keywords: Fibroid, hysterectomy, leiomyoma, submucous, tumor

How to cite this article:
Ahmed ZD, Gaya SA, Adamou N, Umar AB. Vaginal delivery of a giant submucous fibroid: A case report. Niger J Basic Clin Sci 2020;17:64-7

How to cite this URL:
Ahmed ZD, Gaya SA, Adamou N, Umar AB. Vaginal delivery of a giant submucous fibroid: A case report. Niger J Basic Clin Sci [serial online] 2020 [cited 2021 Jan 27];17:64-7. Available from: https://www.njbcs.net/text.asp?2020/17/1/64/285463

Introduction

Uterine fibroids are the most common benign tumors of the uterus which develop in about 20%–40% of women of reproductive age group, especially nulliparous.^[1] The incidence of these tumors is much higher in black women than white, and clinically apparent lesions are less common in parous than nulliparous and postmenopausal women.^[2],[3] The normal myometrium of leiomyoma-containing uteri expresses higher levels of estrogen receptors, a fact that may be related to their pathogenesis.^[4] Most leiomyomas have normal karyotype, but approximately 40% have a simple chromosomal abnormality, the most consistent being rearrangement of 6p (involving HMGA1 gene), del(7q), and t(12, 14) (involving HMGA2 gene).^[5] They are classified as subserosal, intramural, and submucosal on the basis of their location in the uterus. Submucous fibroids are the most common structural cause of excessive menstrual bleeding in women of reproductive age and are also associated with dysmenorrhea, severe pelvic pain, and adverse reproductive outcomes.^[6] Some women, however, may generally have no symptoms. The main options of management depend on the size, location, and need for future fertility in the patient. The traditional management is surgery, however, uterine artery embolization or hormonal therapy using a gonadotropin-releasing hormone agonist or a selective estrogen receptor modulator is the preferred medical approach. Surgical management can be performed through laparoscopy or laparotomy; however, the use of laparoscopic myomectomy is being debated for patients with huge myomas. Small subserous fibroids can be removed by hysteroscopic excision.^[7],[8]

Submucous myomas grow in the inner aspect of myometrium and project into the uterine cavity. If pedunculated, they may finally protrude through the gradually dilating cervical canal and prolapse into the vagina (myoma nascens). The main complications of this condition are degenerative changes and infection.^[9],[10] The subgroup of prolapsed pedunculated submucous myomas, also known as nascent myomas, represents a separate entity regarding their treatment. They can be removed vaginally because they are easily accessible, produce little bleeding, and do not require additional dilatation of the cervix.^[11] Large broad-based nascent myomas may bleed heavily and pose a risk for uterine inversion during their removal, and hence may even require a hysterectomy. We present a case of a giant submucous uterine fibroid in a woman who had spontaneous vaginal delivery of the fibroid.

Case Report

We present the case of a 40-year-old P6+0, 4 alive whose last child birth was 7 years ago, and last menstrual period 2 weeks before presentation. She was referred to our gynecological clinic with complaint of abdominal swelling of 3 years and a sudden protrusion of a mass per vaginum. She also had menorrhagia, offensive vaginal discharge, and back pain. She was counseled for operation on two occasions elsewhere, but she declined. She has been taking analgesics and hematinics occasionally. Examination revealed a well-preserved woman, moderately pale, with no pedal edema. Abdominal examination revealed a firm pelvic mass of 22 weeks size. Vaginal examination revealed a large mass protruding through the cervix, bright pink in color, but no contact bleeding. An abdominal ultrasound scan showed features suggestive of large submucous uterine fibroid. She was counseled on her condition and planned for myomectomy the following week.

The following day, she presented to gynecological emergency unit with complaint of vaginal bleeding and a protruding mass in the introitus. On examination, reddish, firm to touch mass with a thick stalk was found protruding out of a prolapsed cervix [Figure 1]. She was immediately prepared and transferred to the theater where vaginal myomectomy was done. The mass weighed 2.3 kg and had a diameter of 25 cm [Figure 2]. She was transfused with two pints of blood. Patient did well postoperatively and was discharged home after 3 days. She was seen 3 weeks after discharge in a stable condition with normal vital signs and packed cell volume of 42%.

Figure 1: Huge nodular mass protruding through the vagina

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Figure 2: Myomectomy specimen with nodular surfaces

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Histologic gross report revealed a huge nodular mass with ulcerated surface measuring 25 × 25 × 20 cm and weighing 2.5 kg. Transection showed thick capsule surrounding grayish white whorled surfaces. Dark areas with cystic formations were also noted.

Microscopy showed encapsulated mass composed of interlacing fascicles of benign smooth muscle cells. Areas of hyaline and cystic degenerative changes were also present [Figure 3] and [Figure 4]. A diagnosis of a leiomyoma was made.

Figure 3: Encapsulated tumour composed of interlacing fascicles of benign smooth muscle cells. (x40)

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Figure 4: Spindle benign smooth muscle cells disposed as fascicles. (x400)

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Discussion

Uterine fibroids (myomas or leiomyomas) are the most common benign, monoclonal, smooth muscle tumors of the human uterus. Their etiology is multifactorial, and the incidence ranges from 20% to 40% in women of reproductive age.^[1]

The majority of women with uterine fibroids are asymptomatic and fibroid tumors therefore often remain undiagnosed. Symptomatic women typically complain of heavy and prolonged bleeding, especially if the myoma is located intramurally or submucosally.^[3] In addition, women with uterine fibroids may suffer more often from dyspareunia, dysmenorrhea, or non-cyclic pelvic pain and heaviness in the pelvic region with compression of neighboring organs such as the bladder or rectum.^[7] Our patient had few of these symptoms as she presented with only abdominal mass, protrusion per vaginum, and menorrhagia. The few symptoms and fear of surgical interventions might have contributed to her late presentation.

The diagnosis of prolapsed pedunculated myoma is easy once the myoma has protruded through the cervical canal. However, a broad-based endometrial polyp may sometimes be difficult to distinguish from a prolapsed pedunculated submucosal myoma. Moreover, both conditions present with similar symptoms (irregular uterine bleeding).^[9] Although preoperative ultrasonographic examination can be used to assess the position and size of the fibroid to select the best operative procedure, the overall predictive value of ultrasound is unsatisfactory because findings may be confused with those typical of other endometrial tumors (malignant tumors, molar tissue, etc.), especially when the myoma has undergone degenerative changes.^[8],[9] A recently described new ultrasound marker, referred to as “the bright edge of the polyp,” may be of diagnostic assistance in distinguishing between myomas and polyps.^[10] Some believe magnetic resonance imaging (MRI) is the best diagnostic method to determine an intracavitary pathology when precise mapping of tissue is needed.^[6],[9] In the case of our patient, clinical findings and ultrasound scan of the abdomen were used to make diagnosis as she could not afford MRI.

There are many management options for uterine fibroid, but the gold standard is surgery. In the case of submucous fibroids that are 4 cm in diameter or less, hysteroscopic resection is the preferred technique.^[6] However, for larger lesions, hysteroscopy may be difficult, especially for submucous myomas with a considerable intramural component. In the case reported, hysterectomy could not be possible because of the size of the mass.

Vaginal myomectomy for symptomatic prolapsed pedunculated submucous myoma is generally a very successful, quick, and safe procedure with reduced operating time. Therefore, this approach is recommended as the initial treatment of choice for prolapsed pedunculated submucosal myoma.^[10] For large pedunculated submucous myomas which cannot be extracted in one piece or for which vaginal hysterectomy cannot be performed, some authors have suggested transcervical resection or clamping of the pedicle before surgery to reduce tumor size.^[12] As a result, most huge myomas can be safely extracted vaginally without the need for hysterectomy. The average size of myomas successfully removed vaginally was 50 mm.^[13] However, we have shown here that vaginal extraction of an even larger myoma with a diameter of 25 cm and weighing 2.3 kg can be done effectively.

After successful vaginal myomectomy, most patients are asymptomatic and menstruate normally.^[9] The presented case once again demonstrates that the postoperative course of an adequately performed vaginal myomectomy can be uneventful with a quick recovery time, even if the myoma is very large. The patient was lost to follow-up, so the pattern of her menstrual cycle could not be ascertained.

Conclusion

Vaginal myomectomy is a treatment option for prolapsed pedunculated submucous fibroid, and even an extremely large uterine myoma can be successfully removed vaginally. The vaginal approach for myomas is safe, short, simple, definitive, and rarely cause discomfort to patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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