RED DEGENERATION OF A LEIOMYOMAMASQUERADING AS RETAINEDPRODUCTS OF CONCEPTION

Tina C. Mason, MD, MPHBrooklyn, New York

BACKGROUND: The incidence of leiomyomas in pregnancy is approximately 1%. Theirpresence has been linked to spontaneous abortion, premature labor, soft tissue dystocia, uterineinertia, fetopelvic disproportion, malposition of the fetus, retention of the placenta, and postpar-tum hemorrhage.

CASE: This case report documents a seldom-described event of a submucous leiomyomamasquerading as retained products of conception. The patient presented 4 weeks postpartumwith complaints of urinary retention and heavy bleeding with cramping. Examination revealeda large mass resembling placental tissue filling the vaginal vault. The necrotic mass was removedwith blunt and sharp dissection. The final pathology report revealed a degenerating leiomyoma.

CONCLUSION: Complicating factors associated with this fibroid included a history ofspontaneous abortion and preterm labor, as well as fetal malpresentation and carneous degen-eration of the leiomyoma. Gestational myomas, although rare, can have an unusual appearancethat may be misinterpreted. (J Natl Med Assoc. 2002;94:1 24-126.)

Leiomyomas vary in size from microscopic tomore than fifty pounds, and are considered themost frequent pelvic tumor."2, Autopsy studiesin women over the age of 30 have revealed anapproximate incidence of 20%.23 Epidemio-logic studies indicate African-American womenmay have a threefold increase in the risk ofdeveloping myomas compared to white, Asianand Hispanic women. Currently, the mecha-nism that accounts for the increased rate ofmyomas in African-American women are un-known.4 In pregnancy, leiomyomas occur ap-proximately 1% of the time, with a range of0.3% to 2.6%.4 Leiomyomas have been associ-

© 2002. From the Woodhull Medical Center, Brooklyn New York.Requests for reprints should be addressed to Tina Mason, MD,Woodhull Medical Center, 760 Broadway, Brooklyn, NY 1 1206.

ated with spontaneous abortion, premature la-bor, soft tissue dystocia, uterine inertia, fetopel-vic disproportion, fetal malposition duringpregnancy, retained placenta, and postpartumhemorrhage.45 After delivery, most leiomyo-mas regress. This case report documents therare event of a submucous leiomyoma mas-querading as retained products of conception4 weeks after delivery.

CASEThe patient is a 32-year-old G7 P2042 African

American who began her prenatal care at 13weeks gestation. At the initial presentation, theuterine size was approximately 17 weeks. Ultra-sound revealed a single intrauterine pregnancyappropriate for gestational age and a mass con-sistent with a leiomyomata in the lower uterine

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Table 1. Summary of the Laboratory Data of Case 1

HAART HIV-1 RNA Hct Ferritin Fe(serum) TIBC Fe saturationInitiated* CD4/mm3 Copies/mL Hb g/dL % ng/mL ,ug/dL ,ug/dL %

Dec. 96 135 5.2 19.4 <3 7 312 2Jun. 98 148 10600 6.4 20.7Jun. 00 135 57878 4.2 14.4 5 3 412 1Jul. 00 8.3 28.4Aug. 00 12.6 39.6 33 125 30Sep. 00 68 206400 10.8 32.9Nov. 00 HAART

initiatedJan. 01 190 2238 10.4 30.9 43 78 311 25* HAART.

segment measuring 11.2 X 9.2 X 10.0 cm. Themass originated in the anterior wall and therewas no cervical involvement. An anterior retro-placental leiomyoma was noted measuring5.8 X 4.0 X 5.6 cm that contained a cystic areameasuring 1.3 X 1.3 cm. At 29 weeks, the pa-tient was admitted to the labor and deliverysuite with preterm uterine contractions. Mag-nesium sulfate was administered, and the con-tractions abated with no appreciable cervicalchange. Scans at 20, 29 and 36 weeks revealedthe anterior leiomyoma to be unchanged, andfetal growth was normal.

At 40 weeks gestation, the patient deliveredvaginally a viable male infant in the occiputposterior position weighing 3393 g. The pla-centa was delivered intact with a three-vesselcord. Estimated blood loss was 200 mL. Thepostpartum course was unremarkable, and thepatient was discharged home on day two.

Four weeks postpartum, the patient pre-sented to the gynecology clinic with complaintsof urinary retention for one day and heavyvaginal bleeding with cramping. Speculumexam revealed a large mass resembling pla-centa filling the vaginal vault to the introitus.Bimanual exam revealed a 4- to 6-week-sizeduterus, soft and nontender. Attempts to re-move the tissue in the office were unsuccessful.Therefore, she was taken to the operatingroom for evaluation and treatment of probableretained products of conception. Hemoglo-bin/hematocrit was 9.4/28.6 g/dl. Under spi-

nal anesthesia, the cervical os was noted to beapproximately 7-cm dilated. There was a largenecrotic mass protruding through the os ex-tending to the introitus. The superior portionof the mass was attached to the anterior loweruterine segment by a 4-cm stalk. The necroticmass was removed with blunt and sharp dissec-tion. The stalk was cauterized, and intramuscu-lar methergine was given with prompt cessationof bleeding. This patient had an uncompli-cated postoperative recourse and the followingday was discharged home with iron and vita-mins. Hemoglobin and hematocrit at dischargewere 8.3/25.8 g/dl. Pathology revealed 250 g offragmented soft tissue measuring 15 X 15 X 3cm. The majority of fragments were extensivelynecrotic. Many of the fragments containeduterine smooth muscle, consistent with degen-erating leiomyomata.

CONCLUSIONThe reported incidence of myomas compli-

cating pregnancy is less than 1%.4 This patientexemplifies several of the known complicationsthat can occur with leiomyomas in pregnancy.The first is spontaneous abortion. This patienthas a past history of four spontaneous abor-tions. In one study, 25% of patients with uter-ine leiomyomas had a prior history of sponta-neous abortions. It is postulated that this couldhave resulted from an increase in the irritabilityand contractility of the uterus or changes inendometrial stroma and its vasculature.2 Pla-

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cental implantation over a submucous myomahas been shown to be related to spontaneousabortion.6

Various antenatal complications were alsoseen in this patient. These include a past his-tory of preterm labor and malposition of thisdelivering fetus. In a study by Hasan et al.,malpresentation was the most common compli-cation, occurring in 37% of patients with fi-broids.2 Preterm labor is increased in patientswith leiomyomas greater than 3.0 cm. This ismost likely due to a smaller uterine cavity withdecreased distensibility.7 Another precipitatingfactor, as reported by Blum, may be decreasedoxytocinase activity in the gravid myomatousuterus.8The fourth and final complicating factor as-

sociated with this patient was hemorrhagic, car-neous degeneration (which is the most com-mon type associated with pregnancy) withpartial expulsion. At presentation 4 weeks post-partum, the patient complained of pain, bleed-ing, and urinary retention. Examination re-vealed necrotic-appearing tissue that grosslyresembled placental tissue. Therefore, the dif-ferential diagnosis at the time included re-tained placental products, degenerating fi-broid with partial expulsion, and placental sitetumor. Considering there have been few casesreported in the literature of degenerating fi-broids with expulsion,4 it was felt that this wasretained placenta until the time of surgerywhen a stalk was noted attaching the tissue tothe anterior wall and HCG was negative.

In summary, this case report illustrates a his-tory of spontaneous abortion, preterm labor,fetal malposition, and carneous degeneration

associated with a large uterine leiomyoma inpregnancy. Gestational myomas, although rare,can have an unusual appearance that may bemisinterpreted.

REFERENCES1. Herbst AL, Mishell DR, Stenchever MA, Droegemueller

W. Comprehensive Gynecology. Missouri: Mosby Year Book; 1992:511-518.

2. Hasan F, Arumugan K, Sivanesaratnam V. Uterineleiomyomata in pregnancy. IntJ Gynecol Obstet. 1990;34:45-48.

3. Davis JL, Ray-Mazunder S., Hobel CJ, Baley K, SassoonD. Uterne Leiomyomas in Pregnancy: A Prospective Study. ObstetGynecol. 1990;75:41-44.

4. Visscher HC (Ed.). Precis V. Gynecology-An Update inObstetrics and Gynecology. Washington, DC: American Collegeof Obstetricians and Gynecologists. 1998.

5. Honore LH, Reid DWJ. Uncomplicated, spontaneousexpulsion of a uterine leiomyoma postpartum: a case report. JReproductive Med. 1985;30:358-359.

6. Glavind K, Palvio DHB, LauritsenJG. Uterine myoma inpregnancy. Acta Obstet Gynecol Scand. 1990;69:617-619.

7. Alexander E. Uterine leiomyoma: problems duringpregnancy. Kans Med. 1988;89:77-78.

8. Blum M. Comparative study of serum CAP activity dur-ing pregnancy in malformed and normal uterus. J Perinat Med.1978;6:165-168.

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