Uppal M*, Samant PY**, Jagtap J***, Agarwal P*
(* Junior Resident, ** Additional Professor, *** Senior Resident. Department of Obstetrics and Gynecology, Seth G S Medical College and KEM Hospital, Mumbai, India.)
We present an interesting case of suspected uterine perforation and omental prolapse into the vagina during surgical evacuation of missed abortion. The patient required two step surgical procedures to remove a submucosal fibroid that had undergone ischemic necrosis and partial expulsion. The case was a surgical challenge due to high chance of uterine injury, inversion and septicemia. It also highlights imaging errors.
Submucosal fibroids are a risk factor for a spectrum of pregnancy related problems from early pregnancy loss, abruption, growth restriction, need for cesarean section, postpartum hemorrhage and inversion. Women with submucosal fibroid seeking surgical abortion often present a unique challenge. When the uterine cavity is significantly enlarged or distorted, it makes surgical evacuation difficult or impossible. Possible complications in such cases could be error in clinically estimating gestational age, pregnancy loss, incomplete evacuation, uterine perforation, hemorrhage, bowel/ bladder injury, cervical laceration and hematometra.
A 25 year old G3P2L2SA1 was referred to our institute on the 6th post operative day after curettage with suspected uterine perforation and omental prolapse. She had 2 full term normal deliveries in the past. She had undergone dilatation evacuation with Cu-T insertion for missed abortion of 8 weeks and 6 days pregnancy. On the 4th post evacuation day, she complained of abdominal pain, fever and multiple episodes of vomiting. Pelvic ultrasonography (USG) from the private hospital was suggestive of bulky uterus with rent in the left posterolateral wall at the junction of the body of the uterus and cervix with prolapse of omentum into the uterine cavity and vagina. She was referred to our hospital for further management with this report.
On examination her general condition was stable. There was mild pallor. She was afebrile, with pulse rate of 86/ minute, and blood pressure of 110/70 mm of Hg. Systemic examination was unremarkable. Abdomen was soft with no guarding, rigidity or tenderness. There was no abdominal distension and peristaltic sounds were normal. There was suprapubic fullness. On speculum examination, a necrotic polypoidal structure was seen through the cervical canal (figure 1) In addition a shaggy necrotic foul smelling pale pinkish flimsy tissue was seen from the left lateral surface between the polyp and the cervical wall. Cu-T was found in the vagina. On bimanual examination, uterus was 12 weeks in size, anteverted, with a firm polypoidal structure felt in the cervical canal. Cervical swab was collected for culture and antibiotic sensitivity. Detached part of the shaggy tissue was sent for histopathological examination. No forniceal fullness or tenderness was appreciated. Foley’s catheterization was done and 200 ml of clear urine was drained out. USG was repeated at our institute. It was suggestive of a 2 cm rent within the uterus in the left posterior lateral aspect with multiple air specs within the uterine cavity. CT Scan was suggestive of multiple air specs and heterogeneous content in the uterine cavity. The suspicious rent in the wall of uterus was not well appreciated on CT scan. Her laboratory reports were unremarkable. On considering her abdominal complaints and after confirming availability of blood and products, exploratory laparotomy was performed under antibiotic cover. Intraoperatively, peritoneal cavity was clean without any visceral injury. Uterus was bulky with variegated consistency. As the exploratory laparotomy was negative she was given a lithotomy position and a speculum examination was performed. The cervical os was open and a fibroid polyp was hanging out, uterus was 14 weeks in size. An additional intracavitary fibroid was felt. Uterine sound could not be passed easily around it. Fibroid polyp was removed and sent for histopathological examination. She tolerated the procedure and anesthesia well. Two units of packed cells were transfused perioperatively. Enterococcus was grown on culture and she was treated with intravenous linezolid.
Figure 1. Omentum like structure at the cervical os.
Figure 3. Foley catheter tamponade.
On retrospection, our patient did not give any history of dysmenorrhea, abnormal uterine bleeding attributed to fibroids. Detailed history would probably have avoided the infection and the unnecessary laparotomy. Laparoscopy would have been a preferred alternative to laparotomy but it was not available during the emergency hours.
Submucosal fibroids cause numerous fetal complications in addition to fibroid enlargement and degeneration.[1,2,3] Surgical evacuation poses a challenge in cases of missed abortion. Omental extrusion with perforation of uterus is a known complication and depending on presence or absence of bowel herniation, ischemia or perforating injury the morbidity and mortality increases.
Spontaneous expulsion of a degenerated submucosal fibroid is known in post partum period. However, our patient did not complain of pain indicating extrusion; hence we were misled to trust the imaging reports. If the bleeding after polypectomy is not torrential, tamponade with catheter balloon saves unnecessary interventions like embolization or hysterectomy.
With infection noted at initial presentation, excision of intrauterine fibroid would have caused severe bleeding needing hysterectomy or interventional radiological procedure. So we opted for a two-step procedure. Omentum like degenerated fibroid caused concern. Erroneous USG, CT scan and MRI reports cost the patient an unnecessary laparotomy.
Cautious history taking, examination under anesthesia, judicious use of imaging modalities and careful surgical approach helps in avoiding unnecessary hysterectomies.
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Uppal M, Samant PY, Jagtap J, Agarwal P. Submucosal Fibroid: a Diagnostic And Management Challenge In a Case Of Missed Abortion. JPGO 2018. Volume 5 No.10. Available from: http://www.jpgo.org/2018/10/submucosal-fibroid-diagnostic-and.html