Atypical cerclage indication: a case report and review of the literature

PURPOSE:To report a rare case of a prolapsing fibroid in pregnancy requiring surgical removal and placement of cervical cerclage. METHODS: Case report.RESULTS: Symptomatic leiomyomas in pregnancy resulting in clinical complications are uncommon.Furthermore, the prevalence of cervical leiomyomas in general is less than 1%.Patients may present in the first trimester of pregnancy with abdominal pain, vaginal bleeding, abdominal heaviness, urinary retention, or may be asymptomatic.We present a 28 year old G3P0112 female with an intrauterine pregnancy at 6 weeks 3 days gestation who endorsed heavy vaginal bleeding with symptomatic anemia.Speculum exam revealed a 4 cm prolapsing, lobulated, and pedunculated mass in the vaginal vault appearing to originate from the cervix.Ultrasound examination revealed a viable intrauterine pregnancy and the mass was characterized as 4.5 cm x 3.6 cm with hyperemia.Her hemoglobin was 7.8 g/dL.The decision was made to take her to surgery that day.A vaginal approach was used to surgically excise the mass.After excision, the cervix remained dilated and continued bleeding was noted from the endocervical canal.Thus, the decision was made to place a McDonald cerclage, despite atypical indication.Postoperatively, the patient had continued symptomatic anemia, prompting transfusion of two units of packed red blood cells after her hemoglobin resulted at 5.1 g/dL.She was discharged home in stable condition.Her hemoglobin on day of discharge was 9.5 g/dL.At outpatient follow-up, she remained asymptomatic with continued pregnancy.Pathologic examination determined the mass to be a benign uterine/cervical leiomyoma.CONCLUSIONS: An English language PUBMED search for management of prolapsing cervical leiomyoma in pregnancy yielded only 10 case reports, none of which used placement of cerclage in the setting of cervical dilation.Complications from surgical removal of leiomyomas during pregnancy include hemorrhage, rupture of amniotic membranes, preterm labor, and in some cases hysterectomy.If left untreated, large obstructing leiomyomas increase the risks of cesarean section, shoulder dystocia, malpresentation of fetus, and postpartum hemorrhage.Obstetricians are faced with a difficult decision and ultimately must weigh the risks versus benefits of treatment when a patient presents with a prolapsed cervical leiomyoma in the first trimester of pregnancy.