{"paper_id":"6842959e-114e-41ee-9b8e-4c3373def568","body_text":"C A S E R E P O R T Open Access\nAn intramural uterine fibroid became\nsubmucosal in the puerperium – proposed\nprobable mechanism: a case report\nElie Nkwabong\nAbstract\nBackground: Vaginal prolapse of a large uterine fibroid is a rare phenomenon in a woman who delivered vaginally\nrecently, given that this fibroid might have obstructed labor. The author presents a case report of a vaginally prolapsed\nlarge pedunculated submucosal uterine myoma in a woman with a recent uncomplicated vaginal delivery.\nCase presentation: A 25-year-old black African woman had four intramural uterine fibroids of diameters 62 to 94 mm\ndiagnosed in April 2013 with standard ultrasound scan. She got pregnant in July 2014. An ultrasound scan done on 31\nAugust 2014 at 10 weeks ’ gestation identified four intramural uterine fibroids, with sizes varying from 70 to 150 mm.\nHer pregnancy was well followed up, without any complications. She had an uneventful vaginal delivery on 10 April\n2015. During uterine exploration, indicated for retention of parts of fetal membranes, no pedunculated submucosal\nfibroid was found. On 15 May 2015, she consulted for difficult micturition and partial urinary retention that occurred 2\ndays ago. A vaginally prolapsed 10 cm uterine fibroid was diagnosed. Forty-eight hours after administration of\nintravenously administered broad spectrum antibiotics, the myoma was successfully twisted off by means of\nvaginal route under general anesthesia, which relieved her symptoms.\nConclusions: To the best of our knowledge, this is the first case of vaginally prolapsed large submucosal uterine fibroid\nin a woman who delivered vaginally recently. The author recommends that women with known large low situated\nuterine fibroid should be well observed during the postpartum period to diagnose a vaginally prolapsed uterine fibroid\nearly, so as to prevent fibroid superinfection and obstructive complications.\nKeywords: Puerperium, Large uterine fibroid, Vaginal prolapse, Urinary retention\nBackground\nVaginal prolapse of submucosal uterine fibroids is a rare\nphenomenon during pregnancy, delivery, or puerperium\n[1, 2]. The prolapse is preceded by strong uterine contrac-\ntions that are necessary to dilate the cervix before expel-\nling the fibroid. Low situated uterine fibroids measuring 5\ncm or more are usually responsible for previa obstacle,\nwith consequently an emergency cesarean section as the\nonly safe mode of delivery [ 3, 4]. Vaginal prolapse of ≥ 5\ncm low situated uterine fibroids during the puerperium in\nwomen with recent uncomplicated vaginal delivery might\nbe possible only with an initially intramural fibroid. Thus,\nlarge and low situated uterine fibroids may be complicated\nwith previa obstacle during delivery, if not, with delivered\nmyoma in the puerperium with potential obstructive\ncomplications. The author reports here on a case of\npuerperal vaginal prolapse of a large pedunculated\nsubmucosal uterine fibroid initially intramural in a woman\nwho delivered vaginally.\nCase presentation\nA 25-year-old black African woman, gravida 1 para 1,\npresented on 15 May 2015 with a 5-day history of\ncramp-like lower abdominal pain radiating to her lower\nback. This was associated with a foul-smelling hydro-\nrrhea, difficult micturition, and partial urinary retention\nthat occurred 2 days ago. She had a past history of\nmenorrhagia. She had four intramural uterine fibroids\nmeasuring 62, 64, 70, and 94 mm diagnosed with stand-\nard ultrasound scan in April 2013 during work-up for\nCorrespondence: enkwabong@yahoo.fr\nDepartment of Obstetrics & Gynecology, University Teaching Hospital/Faculty\nof Medicine and Biomedical Sciences, P.O. Box 1364, Yaoundé, Cameroon\n© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0\nInternational License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and\nreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to\nthe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver\n(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.\nNkwabong Journal of Medical Case Reports  (2018) 12:88 \nhttps://doi.org/10.1186/s13256-018-1624-0\n\nmenorrhagia. She got pregnant in July 2014. A standard\nultrasound scan done on 31 August 2014 at 10 weeks ’\ngestation identified four intramural uterine fibroids, in-\ncluding a left lateral intramural uterine fibroid of 150\nmm (biggest) and a posterior intramural uterine fibroid\nof 70 mm (smallest; Fig. 1). Her pregnancy was well\nfollowed up, without any complications. During preg-\nnancy, her uterus had always an irregular shape and a\nhigh symphysis-fundal height (20 cm at the 14th week of\ngestation, 30 cm at the 24th week, 34 cm at the 28th\nweek, and 40 cm at the 38th week). At the 38th week of\ngestation, two fibroids of 7 cm and 8 cm were palpated\non the uterine corpus (the first anteriorly at the right\nside of the uterine corpus and the second anteriorly on\nthe uterine fundus). At the left lateral side of her uterus,\nthere was also a low situated large fibroid that could not\nbe well palpated and measured. The presentation was\ncephalic with an unmovable fetal head. The fetal heart\ntones were normal. She delivered a baby girl, who\nweighed 3000 g, vaginally on 10 April 2015 at 41 weeks\n6 days in the same health facility. A placenta examin-\nation revealed retention of parts of fetal membranes.\nThey were removed manually during uterine explor-\nation. During this procedure, no pedunculated submuco-\nsal fibroid was found. There were neither maternal nor\nneonatal complications.\nOn physical examination at admission, her temperature\nwas 38.5 °C. There was hypogastric tenderness. She had a\nmyomatous uterus with a symphysis-fundal height of 16\ncm. There was a foul-smelling vaginal discharge. On\nspeculum and digital vaginal examinations, a mass of ap-\nproximately 10 cm in diameter was present in her vagina,\nrendering examination of the cervix difficult.\nThe diagnosis of an infected prolapsed pedunculated\nuterine fibroid associated with urinary retention was\nmade. An indwelling urinary catheter was set up, as well\nas an intravenous drip. Antibiotic therapy was started\nintravenously with ceftriaxone (1 g twice daily) and\nmetronidazole (500 mg thrice daily). Two days later,\nunder general anesthesia, the almost necrotic fibroid was\nheld with two big toothed forceps and easily twisted off\nper vaginal route, without any significant bleeding,\nwhich relieved her symptoms. On speculum and vaginal\nexaminations, her cervix was normal and 4 cm dilated\nwith the base of the fibroid ’s pedicle located in the\nposterior uterine wall at 3 cm from the external cervical\nos. The fibroid was sent for pathology, which later\nconfirmed uterine leiomyoma. Five days after fibroid\nremoval, she developed a urethrovaginal fistula due to\nprolonged urethral obstruction.\nDiscussion\nUterine fibroid is the most frequent benign tumor of the\nfemale genital tract. The locations can be subserosal,\ninterstitial, or submucosal. Submucosal fibroids, which\ncan be sessile or pedunculated, give more symptoms:\nmenorrhagia; pain due to prolapse process, to red\ndegeneration, or when the stalk of the pedunculated type\nis twisted; intermenstrual bleeding; and hydrorrhea [ 5].\nComplications of uterine fibroids include anemia (from\nmenorrhagia) and infertility.\nDuring delivery, fibroids may be responsible for\nplacental abruption, abnormal presentation, mechanical\ndystocia (previa mass) requiring cesarean delivery, and\npostpartum hemorrhage [ 6]. None of these complica-\ntions were observed in our patient.\nOther rare complications are vaginal prolapse with\ncompression of the bladder neck or the urethra with\nresulting urinary retention, as in our case. Urethrovagi-\nnal fistula is possible; our patient developed it later [ 7].\nFig. 1 Intramural uterine fibroids diagnosed at 10 weeks. a Left lateral intramural uterine fibroid of 15.0 cm diameter (arrow). b Posterior intramural\nuterine fibroid of 7 cm diameter (arrow). The other arrow is pointing to the fetus\nNkwabong Journal of Medical Case Reports  (2018) 12:88 Page 2 of 3\n\nVaginal prolapse of a fibroid can also occur following\nuterine artery embolization for uterine fibroids [ 8]. Uter-\nine fibroids may also induce uterine inversion during\nprolapse, especially the non-pedunculated submucosal\nfibroids [ 9]. Prolapsed pedunculated uterine fibroids are\nmost likely to be infected, especially when they are\nnecrotic, as in our case.\nA large submucosal uterine fibroid, low situated in the\nuterine cavity, is responsible for previa obstacle [ 4]. The\nabsence of obstacle in our case is explained by the fact\nthat the fibroids were all intramural (as diagnosed with\nultrasound scan, regularly palpated abdominally during\npregnancy with no pedunculated submucosal fibroid found\nduring uterine exploration),with no obstacle to delivery. In\nt h ep u e r p e r i u m ,o n ef i b r o i db e c a m ep e d u n c u l a t e ds u b -\nmucosal which then prolapsed easily; this phenomenon\nhas been described by some authors [ 10]. The probable\nmechanism proposed here is that during the uterine invo-\nlution process, the intramural fibroid was expelled through\nthe myometrium layer (probably thinner and therefore eas-\nily breakable) lining between the endometrium and the\nintramural fibroid and after through the endometrium.\nThis phenomenon might have been due to uterine contrac-\ntions, since our patient complained of pelvic pain that\nstarted 5 days prior to presentation.\nThe twisting off of a prolapsed pedunculated submuco-\nsal uterine fibroid by means of vaginal route is a simple\ntreatment option [ 11, 12], which can be done even in a\nlow resource setting. The surgery duration and hospital\nstay are shorter when compared to laparotomy [ 13].\nPatients should be put on broad spectrum antibiotics [ 14],\nas we did for our patient.\nConclusions\nThis case report shows that a low situated large intra-\nmural uterine fibroid might prolapse vaginally during\npuerperium. Consequently, women with such fibroids\nshould be well observed during puerperal period to diag-\nnose an eventual vaginal prolapse of the fibroid early, so\nas to prevent infectious or obstructive complications.\nAcknowledgements\nNot applicable.\nFunding\nNot applicable.\nAvailability of data and materials\nNot applicable.\nEthics approval and consent to participate\nNot applicable.\nConsent for publication\nWritten informed consent was obtained from the patient for publication of\nthis case report and any accompanying images. A copy of the written\nconsent is available for review by the Editor-in-Chief of this journal.\nCompeting interests\nThe author declares that he has no competing interests.\nPublisher’sN o t e\nSpringer Nature remains neutral with regard to jurisdictional claims in\npublished maps and institutional affiliations.\nReceived: 28 September 2017 Accepted: 19 February 2018\nReferences\n1. Straub HL, Chohan L, Kilpatrick CC. Cervical and prolapsed submucosal\nleiomyomas complicating pregnancy. Obstet Gynecol Surv. 2010;65(9):583–90.\n2. Demirci F, Somunkiran A, Safak AA, Ozdemir I, Demirci E. Vaginal removal of\nprolapsed pedunculated submucosal myoma during pregnancy. Adv Ther.\n2007;24(4):903–6.\n3. Vergani P, Locatelli A, Ghidini A, Andreani M, Sala F, Pezzullo JC. Large\nuterine leiomyomata and risk of cesarean delivery. Obstet Gynecol. 2007;\n109(2 Pt 1):410 –4.\n4. Brazet E, Ghassani A, Voglimacci M, Chalret Du Rieu M, Berlioux P, Parant O.\n[Previa uterine leiomyoma: a rare case of bowel obstruction during\npregnancy] [Article in French]. Gynecol Obstet Fertil. 2014;42(11):806 –9.\n5. Sulaiman S, Khaund A, McMillan N, Moss J, Lumsden MA. Uterine\nfibroids—do size and location determine menstrual blood loss? Eur J\nObstet Gynecol Reprod Biol. 2004;115(1):85 –9.\n6. Gupta S, Jose J, Manyonda I. Clinical presentation of fibroids. Best Pract Res\nClin Obstet Gynaecol. 2008;22(4):615 –26.\n7. Nkwabong E, Fomulu JN. Urethrovaginal fistula following vaginal prolapse of a\npedunculated uterine myoma: a case report. J Med Case Rep. 2017;11:292.\n8. Pollard RR, Goldberg JM. Prolapsed cervical myoma after uterine artery\nembolization. A case report. J Reprod Med. 2001;46(5):499 –500.\n9. Shabbir S, Ghayasuddin M, Younus SM, Baloch K. Chronic non-puerperal\nuterine inversion secondary to sub-mucosal fibroid. J Pak Med Assoc. 2014;\n64(5):586–8.\n10. Haskins RD Jr, Haskins CJ, Gilmore R, Borel MA, Mancuso P. Intramural\nleiomyoma during pregnancy becoming pedunculated postpartally. A case\nreport. J Reprod Med. 2001;46(3):253 –5.\n11. Obara M, Hatakeyama Y, Shimizu Y. Vaginal Myomectomy for Semi-\npedunculated Cervical Myoma during Pregnancy. AJP Rep. 2014;4(1):37 –40.\n12. Golan A, Zachalka N, Lurie S, Sagiv R, Glezerman M. Vaginal removal of\nprolapsed pedunculated submucous myoma: a short, simple, and definitive\nprocedure with minimal morbidity. Arch Gynecol Obstet. 2005;271(1):11 –3.\n13. Rolli R, Favilli A, Acanfora MM, Scuderi G, Di Renzo GC, Gerli S. Vaginal\nmyomectomy is a safe and feasible procedure: a retrospective study of 46\ncases. J Obstet Gynaecol Res. 2012;38(9):1201 –5.\n14. Stott D, Zakaria M. The transcervical expulsion of a large fibroid. BMJ Case\nRep. 2012;2012. doi: https://doi.org/10.1136/bcr.01.2012.5523.\n•  We accept pre-submission inquiries \n  Our selector tool helps you to find the most relevant journal\n  We provide round the clock customer support \n  Convenient online submission\n  Thorough peer review\n  Inclusion in PubMed and all major indexing services \n  Maximum visibility for your research\nSubmit your manuscript at\nwww.biomedcentral.com/submit\nSubmit your next manuscript to BioMed Central \nand we will help you at every step:\nNkwabong Journal of Medical Case Reports  (2018) 12:88 Page 3 of 3","source_license":"CC0","license_restricted":false}