Giant Uterine Fibroid with Vascular Pseudocyst and Intrauterine Rupture: A Rare Life- Threatening Emergency

Giant Uterine Fibroid with Vascular Pseudocyst and Intrauterine Rupture: A Rare Life- Threatening Emergency | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Giant Uterine Fibroid with Vascular Pseudocyst and Intrauterine Rupture: A Rare Life- Threatening Emergency juntao feng, xiaomei Qin, guirong Qin This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8572984/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background Uterine fibroids are common benign tumors, yet their potential for life-threatening vascular complications is exceedingly rare. This report details an exceptional case of hemorrhagic shock caused by a ruptured vascular pseudocyst (pseudoaneurysm) arising from the stalk of a giant pedunculated uterine fibroid. Case Presentation A 45-year-old premenopausal woman presented with painless vaginal bleeding culminating in hemorrhagic shock (hemoglobin 57 g/L). Pelvic imaging revealed a 25 cm pedunculated fibroid originating from the lower uterine segment. Computed tomography angiography (CTA) identified a critical finding: a 2.0 × 1.5 cm vascular pseudocyst at the stalk base, supplied by aberrant hypertrophied uterine arteries and showing evidence of rupture. Emergency hysterectomy confirmed a bleeding pseudoaneurysm at the fibroid's peduncle. Histopathology confirmed a benign, degenerated leiomyoma and a pseudoaneurysmal cavity devoid of endothelial lining, consistent with a vascular pseudocyst. Conclusion This case illustrates that large pedunculated uterine fibroids, while typically benign, can rarely develop stalk-based vascular pseudocysts (pseudoaneurysms) leading to catastrophic hemorrhage. In patients presenting with a pedunculated pelvic mass and acute symptoms, prompt CTA evaluation for vascular anomalies is crucial. Early recognition and immediate surgical or interventional radiological management are vital to prevent life-threatening outcomes. Uterine fibroid Vascular pseudocyst Hemorrhagic shock Emergency surgery Rare complication Figures Figure 1 Introduction Uterine fibroids are the most common benign tumors in women of reproductive age, with the vast majority remaining clinically stable and asymptomatic[1]. However, in extremely rare cases, they can lead to catastrophic complications requiring urgent intervention. Here, we report a life-threatening case of a giant fibroid with vascular pseudocyst formation and intrauterine rupture, highlighting the importance of recognizing such atypical presentations. A 45-year-old premenopausal woman presented with 10 days of recurrent painless vaginal bleeding, which culminated in hemorrhagic shock (hemoglobin [HGB] 57 g/L) at admission. Pelvic MRI (Fig 1A-B) revealed a 25 cm pelvic-abdominal pedunculated mass arising from the anterior wall of the lower uterine segment, accompanied by cystic degeneration and a vascularized stalk (Doppler resistive index [RI] = 0.47) communicating with the cervical canal. Further pelvic CTA (Fig 1C-D) delineated a 2.0 × 1.5 cm vascular pseudocyst/pseudoaneurysm at the stalk base, with supply from aberrant hypertrophied uterine arteries and evidence of rupture into the uterine cavity. Emergency hysterectomy was performed, and intraoperative findings (Fig 1E-H) confirmed the imaging observations: the pseudocyst was localized to the fibroid’s peduncle base, with active arterial bleeding from the aberrant vasculature. Histopathological examinations were performed separately on the tumor and stalk tissues: Fig 1I (H&E staining) confirmed a degenerated uterine leiomyoma, with no nuclear atypia, increased mitotic activity, or other malignant features; Fig 1J (H&E staining) demonstrated pseudoaneurysm formation at the stalk, characterized by a cavity filled with abundant blood and lacking intact endothelial cell coverage. This case, along with our previous report of a postmenopausal woman with a torsioned and ruptured subserosal fibroid[2], demonstrates that uterine fibroids—despite their typically benign nature—can rarely lead to life-threatening complications in both pre- and postmenopausal women. Discussion Uterine leiomyomas are the most common benign gynecologic tumors, affecting 20%–40% of reproductive-aged women, but pedunculated leiomyomas with stalk pseudoaneurysm rupture are extremely rare[3, 4] . Our case highlights a life-threatening complication of a large pedunculated uterine leiomyoma: pseudoaneurysm formation at the stalk base, leading to hemorrhagic shock—a presentation reported in fewer than 50 cases globally[5, 6]. 1. Pathological Mechanism of Stalk Pseudoaneurysm The vascular pseudoaneurysm identified at the fibroid stalk in this case is proposed to originate through a sequential pathophysiological process, integrating structural, vascular, and molecular drivers. First, hemorrhagic degeneration of the giant leiomyoma laid the foundational lesion: rapid tumor growth (25 cm in maximum diameter) outpaced the capacity of its pedunculated vascular supply, leading to central ischemia, necrosis, and liquefaction. This degenerative pattern is well-documented in large uterine fibroids, occurring in approximately 15% of lesions exceeding 10 cm[7] , and creates a potential space for subsequent vascular abnormality formation. Second, aberrant high-flow vasculature exacerbated the lesion’s progression. Doppler ultrasound revealed a low resistive index (RI = 0.47)—a hallmark of increased vascular perfusion and neovascularization—while CTA confirmed hypertrophied uterine arteries supplying the fibroid stalk. This vascular dysregulation is likely mediated by vascular endothelial growth factor (VEGF) overexpression, a key molecular driver of fibroid angiogenesis. Boldu-Fernández et al[8] demonstrated that uterine fibroids exhibit robust upregulation of VEGF signaling pathways, particularly in specialized endothelial cell subpopulations; these VEGF-enriched endothelial cells display enhanced angiogenic activity and are tightly correlated with tumor growth and vascular density. Notably, this dysregulated neovascularization may compromise vessel wall integrity, predisposing to structural breakdown. Finally, pseudoaneurysm formation and rupture ensued. Histopathological examination (Fig. J, H&E staining) confirmed the lesion lacked intact endothelial coverage — a defining feature of pseudoaneurysms, distinguishing them from true aneurysms with intact tunica intima. Consistent with prior reports, this pseudoaneurysm arose from disruption of the arterial tunica media and adventitia, with blood pooling within a fibrous capsule formed by surrounding connective tissue[9]. The inherently weak wall structure of such lesions—devoid of normal vascular layers—renders them highly susceptible to rupture under arterial pressure. This pathological characteristic directly explains the massive hemoperitoneum observed intraoperatively (Fig. F) and the patient’s subsequent hemorrhagic shock 2. Diagnostic Challenges and Imaging Clues Preoperative differentiation of pedunculated leiomyomas from ovarian neoplasms is often difficult, especially with cystic degeneration[10, 11]. However, CTA (Fig. C–D) provided critical clues in our case: the 2.0 cm enhancing round structure at the stalk base, combined with tortuous uterine artery supply, is a hallmark of pseudoaneurysm[12]. This aligns with literature indicating that CTA has 92% sensitivity for detecting uterine vascular anomalies[13] —superior to ultrasound, which may misdiagnose pseudoaneurysms as "cystic degeneration". 3. Clinical Implications for Management For pedunculated leiomyomas with suspected vascular complications, emergent surgical intervention is critical. Our case required hysterectomy due to active arterial bleeding, but uterine artery embolization (UAE) may be a minimally invasive alternative for hemodynamically stable patients. Notably, delayed diagnosis of stalk pseudoaneurysm increases mortality risk[14]—thus, CTA should be prioritized in patients with "pedunculated masses + acute abdominal pain." Conclusion This case underscores pedunculated uterine leiomyomas should be evaluated for vascular stalk anomalies in patients with acute abdominal pain. CTA is the imaging modality of choice for detecting pseudoaneurysms, and prompt surgical/embolization intervention is life-saving. Awareness of this rare complication can reduce diagnostic delays and improve outcomes. Abbreviations UAE: Uterine Artery Embolization；VEGF: Vascular Endothelial Growth Factor； CTA: Computed Tomography Angiography；MRI: Magnetic Resonance Imaging；RI: Resistive Index； HGB: Hemoglobin；H&E: Hematoxylin and Eosin Declarations Ethics approval and consent to participate Not applicable Consent for publication Informed consent was obtained from the patient for publication of this case report and accompanying images. Availability of data and materials The data that support the findings of this study are available from the corresponding author upon reasonable request. Funding Guangxi Medical and Health Appropriate Technology Development and Promotion Application， Project grant number, S2020025 and S2019099. Guangxi Key Research and Development Program, grant number AB20238002. Competing Interests The authors declare no conflicts of interest. Authors' contributions Juntao Feng: Conceptualization, Data curation (clinical data, imaging materials), Drafting the original manuscript. Xiaomei Qin: Investigation (patient follow-up, pathological data collection), Methodology (imaging and pathological result analysis), Reviewing and editing the manuscript. Guirong Qin: Supervision, Validation (clinical diagnosis and treatment plan confirmation), Funding acquisition, Final approval of the version to be published. Acknowledgements Not applicable. References Bulun SE, Yin P, Wei J, Zuberi A, Iizuka T, Suzuki T, Saini P, Goad J, Parker JB, Adli M, et al. Uterine Fibroids. Physiol Rev. 2025;105(4):1947–88. Feng J, Liang K, Ding W, Mo X. Pedunculated subserous uterine leiomyoma with torsion, rupture and hemorrhage in a postmenopausal woman: A rare complication. Asian J Surg 2024. Elkbuli A, Shaikh S, McKenney M, Boneva D. Life-threatening hemoperitoneum secondary to rupture of a uterine leiomyoma: A case report and review of the literature. Int J Surg Case Rep. 2019;61:51–5. Daimon A, Tanaka T, Kogata Y, Tanaka Y, Fujita D, Ohmichi M. Hemoperitoneum associated with uterine fibroids: A case report. Med (Baltim). 2021;100(10):e24024. Tajima S, Yonezawa I, Waki M, Hoshi S. Massive hemoperitoneum following spontaneous rupture of an arterial aneurysm overlying a uterine myoma. Int J Clin Exp Med. 2015;8(2):3002–5. Sethupathy T, Madathupalayam M, Arun Prasad K. Intra-Abdominal Hemorrhagic Catastrophe due to Large Subserous Myomatous Capsular Venous Rupture. Case Rep Obstet Gynecol 2022, 2022:2696213. Stewart EA, Laughlin-Tommaso SK. Uterine Fibroids. N Engl J Med. 2024;391(18):1721–33. Boldu-Fernandez S, Lliberos C, Simon C, Mas A. Mapping Human Uterine Disorders Through Single-Cell Transcriptomics. Cells 2025, 14(3). Yahyayev A, Guven K, Bulakci M, Ucar A, Aghayev A, Yekeler E. Spontaneous thrombosis of uterine artery pseudoaneurysm: follow-up with Doppler ultrasonography and interventional management. J Clin Ultrasound. 2011;39(7):408–9. Matsubara S, Usui R, Sato T, Kuwata T, Ohkuchi A, Nakata M. Adenomyomectomy, curettage, and then uterine artery pseudoaneurysm occupying the entire uterine cavity. J Obstet Gynaecol Res. 2013;39(5):1103–6. Yarwood RL, Arroyo E. Cystic degeneration of a uterine leiomyoma masquerading as a postmenopausal ovarian cyst. A case report. J Reprod Med. 1999;44(7):649–52. Kwon JH, Kim GS. Obstetric iatrogenic arterial injuries of the uterus: diagnosis with US and treatment with transcatheter arterial embolization. Radiographics. 2002;22(1):35–46. Bouchet P, Chabrot P, Fontarensky M, Delabaere A, Bonnin M, Gallot D. Pitfalls in diagnosis of uterine artery pseudoaneurysm after Cesarean section. Ultrasound Obstet Gynecol. 2012;40(4):482–3. Alboni C, Rosati F, Sansavini S, Bartalena T, Mancini F, De Iaco P, de Aloysio D, Orsini LF. Three-dimensional power Doppler imaging of uterine artery pseudoaneurysm treated unsuccessfully with selective embolization. Ultrasound Obstet Gynecol. 2009;33(5):614–6. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 27 Jun, 2026 Reviewers agreed at journal 27 Jun, 2026 Reviewers agreed at journal 26 Jun, 2026 Reviews received at journal 18 May, 2026 Reviewers agreed at journal 18 May, 2026 Reviewers invited by journal 20 Jan, 2026 Editor assigned by journal 20 Jan, 2026 Editor invited by journal 18 Jan, 2026 Submission checks completed at journal 14 Jan, 2026 First submitted to journal 14 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8572984","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":578245984,"identity":"2e82eb3b-1821-4c08-928f-d258d78b6a03","order_by":0,"name":"juntao 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07:07:08","extension":"html","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":43823,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8572984/v1/9dfe675173f767c44ad522a3.html"},{"id":100951365,"identity":"6da1be8e-ba39-4c98-90b4-69198d8ee902","added_by":"auto","created_at":"2026-01-23 07:10:32","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":69269,"visible":true,"origin":"","legend":"\u003cp\u003eDiagnostic imaging, intraoperative findings, and pathological examination in a case of hemorrhagic shock secondary to ruptured vascular pseudocyst within a giant uterine fibroid.\u003c/p\u003e\n\u003cp\u003eA-\u003cstrong\u003eB: \u003c/strong\u003ePelvic MRI (sagittal A, axial B) demonstrating a large pedunculated tumor (T) arising from the anterior wall of the lower uterine segment (ut). Yellow arrows highlight the vascular stalk, illustrating its origin from the uterine wall.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eC-D: \u003c/strong\u003ePelvic CTA (sagittal C, axial D) reveals aberrant, tortuous vasculature at the uterine anterior wall, fed by hypertrophied uterine arteries. A 2.0 cm intensely enhancing, round structure (vascular pseudocyst/pseudoaneurysm) is evident at the stalk base (yellow box).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eE-F: \u003c/strong\u003eIntraoperative images. (E) The 25 cm pelvic-abdominal mass (T) arising from the lower uterine segment; ut (uterus), tu (fallopian tube), ov (ovary). (F) Close-up view of the broad, highly vascularized stalk (yellow arrow) connecting the mass to the uterus.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eG-H: \u003c/strong\u003eGross specimen. (G) The bisected uterus (ut) and attached tumor (T), showing the stalk attachment site. (H) Close-up view of the stalk base (yellow box) within the myometrium, revealing the ruptured cavity (cavity) communicating with the uterine wall.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eI: \u003c/strong\u003eHistopathology (H\u0026amp;E staining). Photomicrograph confirms benign uterine leiomyoma, with no evidence of nuclear atypia or increased mitotic activity (consistent with non-malignant features).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eJ: \u003c/strong\u003eHistopathology (H\u0026amp;E staining). Photomicrograph of the tumor stalk: the yellow arrow indicates a pseudoaneurysm formation—the cavity contains abundant blood, and the wall lacks intact endothelial cell coverage (consistent with pseudocyst/pseudoaneurysm morphology).\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8572984/v1/3c56446acbb73601a6ee71f4.jpeg"},{"id":100953014,"identity":"d8e2cd86-5b26-4dff-b0cf-e667a302c116","added_by":"auto","created_at":"2026-01-23 07:19:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":458531,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8572984/v1/ed5d9f24-3ade-4382-a972-04f4a21c956d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Giant Uterine Fibroid with Vascular Pseudocyst and Intrauterine Rupture: A Rare Life- Threatening Emergency","fulltext":[{"header":"Introduction","content":"\u003cp\u003eUterine fibroids are the most common benign tumors in women of reproductive age, with the vast majority remaining clinically stable and asymptomatic[1]. However, in extremely rare cases, they can lead to catastrophic complications requiring urgent intervention. Here, we report a life-threatening case of a giant fibroid with vascular pseudocyst formation and intrauterine rupture, highlighting the importance of recognizing such atypical presentations. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA 45-year-old premenopausal woman presented with 10 days of recurrent painless vaginal bleeding, which culminated in hemorrhagic shock (hemoglobin [HGB] 57 g/L) at admission. Pelvic MRI (Fig 1A-B) revealed a 25 cm pelvic-abdominal pedunculated mass arising from the anterior wall of the lower uterine segment, accompanied by cystic degeneration and a vascularized stalk (Doppler resistive index [RI] = 0.47) communicating with the cervical canal. Further pelvic CTA (Fig 1C-D) delineated a 2.0 \u0026times; 1.5 cm vascular pseudocyst/pseudoaneurysm at the stalk base, with supply from aberrant hypertrophied uterine arteries and evidence of rupture into the uterine cavity. Emergency hysterectomy was performed, and intraoperative findings (Fig 1E-H) confirmed the imaging observations: the pseudocyst was localized to the fibroid\u0026rsquo;s peduncle base, with active arterial bleeding from the aberrant vasculature. Histopathological examinations were performed separately on the tumor and stalk tissues: Fig 1I (H\u0026amp;E staining) confirmed a degenerated uterine leiomyoma, with no nuclear atypia, increased mitotic activity, or other malignant features; Fig 1J (H\u0026amp;E staining) demonstrated pseudoaneurysm formation at the stalk, characterized by a cavity filled with abundant blood and lacking intact endothelial cell coverage.\u003c/p\u003e\n\u003cp\u003eThis case, along with our previous report of a postmenopausal woman with a torsioned and ruptured subserosal fibroid[2], demonstrates that uterine fibroids\u0026mdash;despite their typically benign nature\u0026mdash;can rarely lead to life-threatening complications in both pre- and postmenopausal women.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eUterine leiomyomas are the most common benign gynecologic tumors, affecting 20%\u0026ndash;40% of reproductive-aged women, but\u0026nbsp;pedunculated leiomyomas with stalk pseudoaneurysm rupture are extremely rare[3, 4] . Our case highlights a life-threatening complication of a large pedunculated uterine leiomyoma: pseudoaneurysm formation at the stalk base, leading to hemorrhagic shock\u0026mdash;a presentation reported in fewer than 50 cases globally[5, 6].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1. Pathological Mechanism of Stalk Pseudoaneurysm\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe vascular pseudoaneurysm identified at the fibroid stalk in this case is proposed to originate through a sequential pathophysiological process, integrating structural, vascular, and molecular drivers.\u003c/p\u003e\n\u003cp\u003eFirst,\u0026nbsp;hemorrhagic degeneration\u0026nbsp;of the giant leiomyoma laid the foundational lesion: rapid tumor growth (25 cm in maximum diameter) outpaced the capacity of its pedunculated vascular supply, leading to central ischemia, necrosis, and liquefaction. This degenerative pattern is well-documented in large uterine fibroids, occurring in approximately 15% of lesions exceeding 10 cm[7]\u0026nbsp;, and creates a potential space for subsequent vascular abnormality formation.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; Second, aberrant high-flow vasculature exacerbated the lesion\u0026rsquo;s progression. Doppler ultrasound revealed a low resistive index (RI = 0.47)\u0026mdash;a hallmark of increased vascular perfusion and neovascularization\u0026mdash;while CTA confirmed hypertrophied uterine arteries supplying the fibroid stalk. This vascular dysregulation is likely mediated by vascular endothelial growth factor (VEGF) overexpression, a key molecular driver of fibroid angiogenesis. Boldu-Fern\u0026aacute;ndez et al[8] demonstrated that uterine fibroids exhibit robust upregulation of VEGF signaling pathways, particularly in specialized endothelial cell subpopulations; these VEGF-enriched endothelial cells display enhanced angiogenic activity and are tightly correlated with tumor growth and vascular density. Notably, this dysregulated neovascularization may compromise vessel wall integrity, predisposing to structural breakdown.\u003c/p\u003e\n\u003cp\u003eFinally,\u0026nbsp;pseudoaneurysm formation and rupture\u0026nbsp;ensued. Histopathological examination (Fig. J, H\u0026amp;E staining) confirmed the lesion lacked intact endothelial coverage \u0026mdash; a defining feature of pseudoaneurysms, distinguishing them from true aneurysms with intact tunica intima. Consistent with prior reports, this pseudoaneurysm arose from disruption of the arterial tunica media and adventitia, with blood pooling within a fibrous capsule formed by surrounding connective tissue[9]. The inherently weak wall structure of such lesions\u0026mdash;devoid of normal vascular layers\u0026mdash;renders them highly susceptible to rupture under arterial pressure. This pathological characteristic directly explains the massive hemoperitoneum observed intraoperatively (Fig. F) and the patient\u0026rsquo;s subsequent hemorrhagic shock\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2. Diagnostic Challenges and Imaging Clues\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePreoperative differentiation of pedunculated leiomyomas from ovarian neoplasms is often difficult, especially with cystic degeneration[10, 11]. However,\u0026nbsp;CTA (Fig. C\u0026ndash;D) provided critical clues\u0026nbsp;in our case: the 2.0 cm enhancing round structure at the stalk base, combined with tortuous uterine artery supply, is a hallmark of pseudoaneurysm[12]. This aligns with literature indicating that\u0026nbsp;CTA has 92% sensitivity for detecting uterine vascular anomalies[13] \u0026mdash;superior to ultrasound, which may misdiagnose pseudoaneurysms as \u0026quot;cystic degeneration\u0026quot;.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.\u0026nbsp;Clinical Implications for Management\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor pedunculated leiomyomas with suspected vascular complications, emergent surgical intervention is critical. Our case required hysterectomy due to active arterial bleeding, but uterine artery embolization (UAE) may be a minimally invasive alternative for hemodynamically stable patients. Notably, delayed diagnosis of stalk pseudoaneurysm increases mortality risk[14]\u0026mdash;thus, CTA should be prioritized in patients with \u0026quot;pedunculated masses + acute abdominal pain.\u0026quot;\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis case underscores pedunculated uterine leiomyomas should be evaluated for vascular stalk anomalies in patients with acute abdominal pain. CTA is the imaging modality of choice for detecting pseudoaneurysms, and prompt surgical/embolization intervention is life-saving. Awareness of this rare complication can reduce diagnostic delays and improve outcomes.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eUAE: Uterine Artery Embolization；VEGF: Vascular Endothelial Growth Factor； CTA: Computed Tomography Angiography；MRI: Magnetic Resonance Imaging；RI: Resistive Index； HGB: Hemoglobin；H\u0026E: Hematoxylin and Eosin\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from the patient for publication of this case report and accompanying images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGuangxi Medical and Health Appropriate Technology Development and Promotion Application， Project grant number, S2020025 and S2019099. Guangxi Key Research and Development Program, grant number AB20238002.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eJuntao Feng: Conceptualization, Data curation (clinical data, imaging materials), Drafting the original manuscript.\u003c/li\u003e\n \u003cli\u003eXiaomei Qin: Investigation (patient follow-up, pathological data collection), Methodology (imaging and pathological result analysis), Reviewing and editing the manuscript.\u003c/li\u003e\n \u003cli\u003eGuirong Qin: Supervision, Validation (clinical diagnosis and treatment plan confirmation), Funding acquisition, Final approval of the version to be published.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBulun SE, Yin P, Wei J, Zuberi A, Iizuka T, Suzuki T, Saini P, Goad J, Parker JB, Adli M, et al. Uterine Fibroids. Physiol Rev. 2025;105(4):1947\u0026ndash;88.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFeng J, Liang K, Ding W, Mo X. Pedunculated subserous uterine leiomyoma with torsion, rupture and hemorrhage in a postmenopausal woman: A rare complication. Asian J Surg 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElkbuli A, Shaikh S, McKenney M, Boneva D. Life-threatening hemoperitoneum secondary to rupture of a uterine leiomyoma: A case report and review of the literature. Int J Surg Case Rep. 2019;61:51\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDaimon A, Tanaka T, Kogata Y, Tanaka Y, Fujita D, Ohmichi M. Hemoperitoneum associated with uterine fibroids: A case report. Med (Baltim). 2021;100(10):e24024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTajima S, Yonezawa I, Waki M, Hoshi S. Massive hemoperitoneum following spontaneous rupture of an arterial aneurysm overlying a uterine myoma. Int J Clin Exp Med. 2015;8(2):3002\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSethupathy T, Madathupalayam M, Arun Prasad K. Intra-Abdominal Hemorrhagic Catastrophe due to Large Subserous Myomatous Capsular Venous Rupture. \u003cem\u003eCase Rep Obstet Gynecol\u003c/em\u003e 2022, 2022:2696213.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStewart EA, Laughlin-Tommaso SK. Uterine Fibroids. N Engl J Med. 2024;391(18):1721\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoldu-Fernandez S, Lliberos C, Simon C, Mas A. Mapping Human Uterine Disorders Through Single-Cell Transcriptomics. Cells 2025, 14(3).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYahyayev A, Guven K, Bulakci M, Ucar A, Aghayev A, Yekeler E. Spontaneous thrombosis of uterine artery pseudoaneurysm: follow-up with Doppler ultrasonography and interventional management. J Clin Ultrasound. 2011;39(7):408\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMatsubara S, Usui R, Sato T, Kuwata T, Ohkuchi A, Nakata M. Adenomyomectomy, curettage, and then uterine artery pseudoaneurysm occupying the entire uterine cavity. J Obstet Gynaecol Res. 2013;39(5):1103\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYarwood RL, Arroyo E. Cystic degeneration of a uterine leiomyoma masquerading as a postmenopausal ovarian cyst. A case report. J Reprod Med. 1999;44(7):649\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKwon JH, Kim GS. Obstetric iatrogenic arterial injuries of the uterus: diagnosis with US and treatment with transcatheter arterial embolization. Radiographics. 2002;22(1):35\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBouchet P, Chabrot P, Fontarensky M, Delabaere A, Bonnin M, Gallot D. Pitfalls in diagnosis of uterine artery pseudoaneurysm after Cesarean section. Ultrasound Obstet Gynecol. 2012;40(4):482\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlboni C, Rosati F, Sansavini S, Bartalena T, Mancini F, De Iaco P, de Aloysio D, Orsini LF. Three-dimensional power Doppler imaging of uterine artery pseudoaneurysm treated unsuccessfully with selective embolization. Ultrasound Obstet Gynecol. 2009;33(5):614\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Uterine fibroid, Vascular pseudocyst, Hemorrhagic shock, Emergency surgery, Rare complication","lastPublishedDoi":"10.21203/rs.3.rs-8572984/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8572984/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUterine fibroids are common benign tumors, yet their potential for life-threatening vascular complications is exceedingly rare. This report details an exceptional case of hemorrhagic shock caused by a ruptured vascular pseudocyst (pseudoaneurysm) arising from the stalk of a giant pedunculated uterine fibroid.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase Presentation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA 45-year-old premenopausal woman presented with painless vaginal bleeding culminating in hemorrhagic shock (hemoglobin 57 g/L). Pelvic imaging revealed a 25 cm pedunculated fibroid originating from the lower uterine segment. Computed tomography angiography (CTA) identified a critical finding: a 2.0 × 1.5 cm vascular pseudocyst at the stalk base, supplied by aberrant hypertrophied uterine arteries and showing evidence of rupture. Emergency hysterectomy confirmed a bleeding pseudoaneurysm at the fibroid's peduncle. Histopathology confirmed a benign, degenerated leiomyoma and a pseudoaneurysmal cavity devoid of endothelial lining, consistent with a vascular pseudocyst.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis case illustrates that large pedunculated uterine fibroids, while typically benign, can rarely develop stalk-based vascular pseudocysts (pseudoaneurysms) leading to catastrophic hemorrhage. In patients presenting with a pedunculated pelvic mass and acute symptoms, prompt CTA evaluation for vascular anomalies is crucial. Early recognition and immediate surgical or interventional radiological management are vital to prevent life-threatening outcomes.\u003c/p\u003e","manuscriptTitle":"Giant Uterine Fibroid with Vascular Pseudocyst and Intrauterine Rupture: A Rare Life- Threatening Emergency","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-22 14:51:38","doi":"10.21203/rs.3.rs-8572984/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"58162793088039683453603870635788202582","date":"2026-06-27T20:54:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"313130840982067455205690450544495352753","date":"2026-06-27T19:53:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"109379267166951666802560529388521153413","date":"2026-06-26T04:28:54+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-18T04:43:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"327801553508681323719707424914082844308","date":"2026-05-18T04:29:36+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-20T23:09:14+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-20T23:00:01+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-18T15:07:46+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-14T07:56:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Women's Health","date":"2026-01-14T07:46:43+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"28070ada-c995-4d0c-9715-d2a522d1bae4","owner":[],"postedDate":"January 22nd, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"58162793088039683453603870635788202582","date":"2026-06-27T20:54:34+00:00","index":66,"fulltext":""},{"type":"reviewerAgreed","content":"313130840982067455205690450544495352753","date":"2026-06-27T19:53:31+00:00","index":65,"fulltext":""},{"type":"reviewerAgreed","content":"109379267166951666802560529388521153413","date":"2026-06-26T04:28:54+00:00","index":63,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-22T14:51:38+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-22 14:51:38","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8572984","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8572984","identity":"rs-8572984","version":["v1"]},"buildId":"0SHbDDIpRTBOrFPTvp6pu","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}