(* Second Year Resident, ** Professor, Department of Obstetrics and Gynecology, Seth GS
& KEM Hospital, ) Mumbai, India
We report a case of torsion of a large pedunculated fundal uterine leiomyoma. A 45 year old nulligravida presented to us with abdominal pain. With preoperative diagnosis of leiomyoma of the uterus patient was operated for total abdominal hysterectomy, but intra operatively a large fundal subserosal peduculated leiomyoma with one and half turn twist in its thick pedicle was seen. Mostly torsion of pedunculated leiomyoma presents with acute abdomen and needs emergency intervention but in our case the torsion was not suspected clinically. It was a chronic condition.
Uterine leiomyomas or leiomyomas are smooth muscle tumors with benign course. They are the most common gynecological tumors. In 25% women in the reproductive age group leiomyomas were diagnosed clinically and in almost 80% patients they were detected in surgically excised uteri.  Leiomyomas can be sub mucosal, intramural, and sub serosal. Sometimes subserosal myomas can become pedunculated and rarely can they undergo torsion to give acute symptoms. A torsion may cause ischemia and rapid clinical deterioration.  There are very few cases reported till now. We report a case of pedunculated sub serosal uterine myoma that underwent torsion.
A 45 year old nulligravida, a treated case of hyperthyroidism presented to us with complain of mild continuous abdominal discomfort. The patient did not have any acute symptoms, menstrual complaints or any difficulty in defecation or micturition. The pain was chronic dull aching in nature. On abdominal examination there was a 24 weeks size, non tender, hypogastric mass with side to side mobility. The mass was more towards right of the midline. On vaginal examination the uterus was not felt separately from the mass. Clinically a large single fundal leiomyoma was diagnosed. All hematological, biochemical and serological investigations were performed. All were within normal limits except that the peripheral blood smear showed target cells and occasional sickle cells. A hemoglobin electrophoresis was done which was negative for any hemoglobinopathies. Fragility test for sickling was negative. The patient was posted for elective total abdominal hysterectomy. Surgery was done under combined spinal and epidural anesthesia. The abdomen was opened by a midline infra-umbilical vertical incision which had to be extended 2 cm above the umbilicus. On entering the abdomen there was a large subserosal leiomyoma around 12x15 cm in size with a thick pedicle. The pedicle of the leiomyoma had twisted and the leiomyoma was lying behind the uterus. On exteriorizing the leiomyoma the thick pedicle showed a one and a half circle turn. The myoma was very vascular, congested with large dilated veins on its surface. The uterus, ovaries and fallopian tubes were normal. The leiomyoma weighed 1.2 kg. Hysterectomy was done. Histopathology was suggestive of a benign leiomyoma. The peripheral blood smear was repeated twice within the next 15 post operative days, but no abnormal cells were seen.
Figure 1. Large fibroid with a thick pedicle.
Figure 2. Posterior surface of the uterus.
Figure 3. Anterior surface of the fibroid.
Torsion of a subserosal uterine leiomyoma is very rare. Torsion is mostly seen in ovarian tumors. Torsion first occludes venous and then arterial supply and causes gangrene. The ischemia due to arterial occlusion leads to acute abdominal pain. Small subserous leiomyomas with thin pedicles may undergo torsion. In our case the pedicle was thick about 5 cm in width and hence the 1 and a 1/2 turn of the pedicle probably could out occlude the arterial supply. This obstructed the venous drainage only leading to congestion and a dull aching discomfort. The torsion was probably triggered by the large weight of the leiomyoma and also by the fact that the leiomyoma was broader than its height looking like a mushroom. The turning movements of the patient in recumbent position could have triggered the rotation of the pedicle. In leiomyomas with thin pedicles the torsion may be severe enough to obstruct arterial blood supply leading to ischemic necrosis and a surgical emergency. Hematological changes like anemia, polycythemia, thrombosis, thrombocytosis, and coagulopathies have been reported. In our case the the finding of target cells and few sickle cells were reported on peripheral smear, the significance of which remained undetermined. After the surgery the peripheral smear was again studied twice 15 days apart by the same laboratory senior scientific officer but no trace of those target cells or sickle cells could be found. We postulate that due to torsion and venous congestion the red blood corpuscles were distorted in the twisted pedicle which were then released in the circulation. No report regarding such cells could be found on Medscape, Pubmed, or internet search. In majority of the reported cases the patients presented mostly with acute pain and tenderness over abdomen needing urgent surgical intervention. On redirect questioning our patient gave history of intermittent episodes of moderate intensity pain which could be due to sub-acute episodes of torsion. Torsion was not detected on ultrasound Doppler signals as its blood supply was intact.
This case is interesting as a large leiomyoma underwent torsion. Thick pedicle rather than a thin pedicle was twisted and abnormal red blood cells were found preoperatively in the peripheral smear which disappeared after the twisted leiomyoma was removed.
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Available from: http://www.jpgo.org/2015/02/torsion-of-large-pedunculated.html Gupta AS.