Academic OB/GYN Cases – Huge Prolapsed Fibroid
I recently was consulted to see a patient in the cardiac intensive care unit who had recently had a large anterior wall myocardial infarction, for the complaint of vaginal bleeding. She had had the heart attack two days previous, and was now on several cardiac meds and IV heparin. Her resultant ejection fraction was only 30%.
After admission to the hospital, she felt something come out of her vagina and she started having heavy vaginal bleeding. On exam she had a very large pedunculated fibroid.
Click the jump to see what we saw..
(***** This image has been temporarily removed but hopefully will be back soon ***** )
The patient reports that she had had some bleeding a year ago and had an exam which showed a mass in the vagina. She was told she needed a hysterectomy but she never followed up. Right after her heart attack, she felt a terrible pain like she was in labor, and passed this fibroid out the vagina.
As she had recently had an MI, we were hesitant to take this woman to the operating room, as general anesthesia in this situation carries significant risk. However, over the next several days she bled enough to require 5 units of blood transfusion over 72 hours. With that, coupled with the seeming ridiculousness of sending the woman home with the fibroid hanging out, we took her to the operating room and resected it. We were able to do it was MAC anesthesia only, using a Harmonic Wave to resect the fibroid. The uterus was partially inverted under the weight of this, so we used transabdominal ultrasound to locate the interface between the fibroid and the fundus, taking care not to perforate the fundus as the fibroid was resected.
After resection, the patient’s bleeding stopped and she felt better than she had in a long time, despite her heart attack. Most likely she will have a hysterectomy in the future for fibroids that are residual in the uterus.
Pedunculated fibroids start as submucosal fibroids growing in the uterine cavity. Typically they cause irregular and heavy bleeding, and lead to a woman presenting to a gynecologist for care. If they are not taken care of, they can get quite large, as we see in this case. Eventually, the weight of the fibroid will pull enough that a thin stalk is created. As the uterus will try to “deliver” anything that is in it, these fibroids lead to heavy cramping as the uterus tries to push the thing out. If the connection to the uterus is thin and stretchable enough, the uterus will eventually be successful, as we see in this case. In many cases the uterus will partially invert as the fibroid delivers. As such, the surgeon needs to take care not to perforate the uterus as the fibroid is resected. If a vaginal hysterectomy is planned, the fibroid can be resected more distally and the stalk can be pushed up a bit prior to initiating the hysterectomy. If not, the stalk should be transected as high as possible without entering the myometrium. Hysteroscopy can be useful in some cases.
Wow!
I hope you don’t mind if I ask a few questions (ones I could probably look up, but I’m on my way to school and only have a few minutes, and I am fascinated). What is MAC anesthesia? Could you do a spinal? Are the post-MI risks associated with regional anesthesia as well as general?
Why do you think a hysterectomy would be advised, and why didn’t you go ahead and do one at the time? How close is she to menopause? Are you going to wait and see if she still has heavy bleeding? Are any of her other fibroids pedunculated or large?
Thanks for sharing, and thanks to your patient for being willing to share her case.
I can talk about the disease process in general but don’t really want to specifically comment on the details of a particular patient, even if the identity is hidden. HIPPA rules technically allows this but I am still a bit wary.
MAC anesthesia is a anesthesia term that means the amount of anesthesia that would prevent 50% of people from moving if exposed to a noxious stimuli. This is deep enough to do minimally painful procedures without awakening the patient. The patient protects their own airway, and paralytics are not used. It is very useful for short procedures. As a pedunculated prolapsed fibroid is not innervated, MAC is a good way to go if it is going to be a short case. MAC is usually done with propofol and intravenous narcotics, but can theoretically be achieved with any combination of parenteral analgesics or inhaled anesthetic. An anesthesiologist could be more specific.
Typically women who prolapse a big fibroid have many other fibroids, and will continue to have problems and eventually go on to need a hyst. However, if the prolapsed fibroid is the only one, they may not need a hyst later.
Doing surgery on a patient with a recent MI entails a higher risk of cardiac complication, which has to be weighed in a risk-benefit analysis for the case. Typically the minimal case that fixes the patient’s problem would be the way to go, rather than a more extensive surgery, if possible.
Thanks for the reply!
Hypothetically, not discussing this actual patient….
Most MIs would present in someone who is nearing menopause, if not menopausal. For patients near menopause, are you more likely to use a more conservative approach to fibroids (if they’re not huge, pedunculated, causing labor pains and protruding from the vagina, of course) than in a younger woman, since they may shrink after menopause, and common complaint of heavy bleeding will no longer be an issue? Or, would you take a more liberal approach with hysterectomy, since the patient is unlikely to continue childbearing?
I am sure both come into play, depending on the patient.
As fibroids are typically not malignant, therapy is dependent on patient symptoms and desires. Women with moderate sized fibroids near menopause may choose to wait it out until after menopause, when fibroids will naturally get smaller. Other women prefer to have them treated. The irregular bleeding that comes from perimenopausal oligoovulation can be more severe in women with structural uterine defects as well.
Even after menopause, large fibroids can still cause pelvic bulk symptoms such as pressure, “heavy feeling”, and urinary urgency. In some cases the indication for hysterectomy is just that the woman doesn’t want a big ball of muscle tumors in her pelvis. I have had patients who were unaware that they had a 20 week size uterus, thinking that it was just belly fat or something, but one they found out what they were feeling through their abdomen they wanted it out. To each her own on that.
Certainly in younger women hysterectomy is avoided when possible, particularly if she desires future childbearing.