Antenatal myomectomy for acute abdomen caused by red degeneration of a large pedunculated leiomyoma: a case report

Uterine fibroids are one of the the most common benign tumors in women of reproductive age. During antepartum, intrapartum, and postpartum periods, hormonal changes can lead to fibroid enlargement and a range of pregnancy related complications. The most common complication of fibroids in pregnancy is acute abdominal pain, usually caused by red degeneration or torsion of a pedunculated subserosal fibroid. Abdominal pain during pregnancy caused by red degeneration of leiomyoma creates a diagnostic and therapeutic dilemma because of its peculiar and acute presentation. We present the case of a 35 years old, African primigravida, presenting with acute onset right-sided abdominal pain at 19 weeks of gestation. Magnetic resonance imaging revealed a live fetus along with a large degenerating subserosal myoma, abutting the uterine fundus and extending up to liver. In view of persistent abdominal pain not responding to conservative management, emergency exploratory laparotomy was performed. A large 21×15.5×12 cm fibroid was removed, weighing 1.850 kg. The postoperative course was uneventful. Histopathology confirmed infarct type degeneration with extensive hemorrhage and necrosis. At 38 weeks of gestation, she had an uncomplicated vaginal delivery of a healthy baby. Myomectomy is preferably avoided in gravid uterus, however, it may be individualized and performed for selected symptomatic cases following appropriate counselling.