doi:10.1111/j.1447-0756.2008.00986.

J. Obstet. Gynaecol. Res. Vol. 35, No. 4: 794796, August 2009

Hypovolemic shock due to massive edema of a pedunculated uterine myoma after delivery
jog_986 794..796

Keiko Koide, Akihiko Sekizawa, Masamitsu Nakamura, Ryu Matsuoka and Takashi Okai
Department of Obstetrics and Gynecology, Showa University School of Medicine, Tokyo, Japan

Abstract
Although most patients with uterine myomas are asymptomatic during pregnancy, profound enlargement of a pedunculated myoma has serious consequences. In the present case, gradual enlargement of a pedunculated myoma was observed throughout a womans pregnancy, worsening after delivery and causing hypovolemic shock, without evidence of external or intra-abdominal hemorrhage. Laparotomy revealed a severely edematous myoma containing a large amount of blood. It is speculated that partial occlusion had obstructed venous return, but not arterial blood ow, which caused rapid enlargement of the myoma. Key words: massive edema, myoma, pregnancy, uterus.

Case Report
A 37-year-old woman, gravida 0, was conrmed to be pregnant at 6 weeks of gestation and to have an 8 11 cm abdominal tumor. Transvaginal ultrasonography revealed a subserosal myoma located on the posterior of her uterus, which was solid and homogeneous. The myoma gradually increased to 15 15 cm at 19 weeks of gestation. The distance between the fundus of the uterus and the symphysis pubis was 37 cm at 32 weeks, 38 cm at 34 weeks, and 42 cm at 36 weeks. Because the cervical os faced upward and the position of the fetal head was high at 37 weeks, an elective cesarean section was performed. A transverse incision of the lower uterine segment was made and a viable male infant weighing 2918 g was delivered. The myoma was located at the posterior of the uterus and occupied the entire abdominal cavity. The connection between the uterus and the myoma could not be observed. A blood loss of 1565 mL with a hemoglobin level of 9.1 g/dL occurred immediately following the cesarean section.

Twelve hours after delivery of the infant, the woman became hypotensive (55/28 mmHg) and tachycardic (130 b.p.m.). Her blood pressure was restored after she was given a blood transfusion and albumin. However, she again developed hypotension (79/45 mmHg) and tachycardia (152 b.p.m.) 24 h after delivery. She was then transferred to our hospital with a diagnosis of hypovolemic shock. When the patient arrived at our hospital, her consciousness was deteriorating and her blood pressure was 112/67 mmHg with a pulse rate of 163 b.p.m. Her hemoglobin level was 5.6 g/dL with markedly reduced urine output. She was given 16 units of blood by transfusion. Her platelet counts and coagulation factor levels were slightly decreased. We replenished her coagulation factors by administering fresh frozen plasma and an anti-thrombin III preparation. The patient was presumed to have an intra-abdominal hemorrhage; transabdominal sonography did not show any intraperitoneal uid, but revealed a solid tumor occupying her entire abdominal cavity. A contrast computed tomography (CT) scan demonstrated a massive 23 25 cm myoma behind the uterus with no obvious

Received: October 4 2007. Accepted: September 8 2008. Reprint request to: Dr Akihiko Sekizawa, Department of Obstetrics and Gynecology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8666, Japan. Email: sekizawa@med.showa-u.ac.jp

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Massive edema of a uterine myoma

Ut i M Uterine Myoma

Figure 2 Haematoxylin-eosin staining of the myoma. (a) Magnication: 100. (b) Magnication: 400. Spindle tumor cells were observed with changes suggestive of hemorrhage, congestion, edema, and inammatory cellular inltration. The tumor cells resembled smooth muscle cells and broblasts.

Fallopian Tube Uterine Corpus PUBIS

Figure 1 Photograph taken during the surgery. The myoma was observed behind the uterus.

hematoma or ascites. Furthermore, intra-tumor bleeding was considered unlikely because the tumor appearance was not enhanced using contrast medium. The following day, the patient reported abdominal pain and slight dyspnea. Her hemoglobin level fell from 10.1 to 6.9 g/dL in the 36 h following delivery, at which point a second CT scan was performed. This scan showed that the tumor had increased to 25 27 cm in size with no ndings suggestive of intraabdominal or intra-tumor hemorrhage. We presumed that rapid enlargement of the tumor had led to the patients increasing dyspnea. Surgical removal of the tumor was performed on the third day of hospitalization. A small amount of ascites was observed with no hematoma within the abdominal cavity. The uterus was 10 10 12 cm in size and grayish-white in color, indicating ischemia. The patients ovaries were normal. Behind the uterus, a rm, dark red tumor was observed. The entire abdominal cavity was occupied by this tumor (Fig. 1), which was connected to the posterior of the uterus isthmus by a 4-cm pedicle. A hysterectomy was performed because we could not estimate the pathogenesis of the case. The weight of the resected specimen was 13 kg; this decreased to 9 kg 1 h after surgery due to deuxion of blood from the tumor. Total blood loss was 1915 mL and 14 units of blood were transfused during surgery. The patient was discharged from the hospital on postoperative day 10 with no complications.

The cut surface of the resected myoma was grayish and homogenous. Microscopically, spindle tumor cells with changes suggestive of hemorrhage, congestion, edema and inammatory cellular inltration were observed (Fig. 2). The tumor cells resembled smooth muscle cells and broblasts without necrotic features. The tumor characteristics resembled massive edema of the ovary.

Discussion
It is thought that uterine myoma size increases during pregnancy due to increasing estrogen levels and blood ow. In the present case, although the enlargement rate of the myoma was normal early in the pregnancy, the growth rate became abnormal later on. Furthermore, after delivery, rapid enlargement of the myoma caused hypovolemic shock, requiring a total of 30 units of blood. Pathologic analysis of the myoma revealed massive and diffuse intercellular edema within the myoma. The myoma was connected to the posterior wall of the lower uterine segment by a pedicle, which contained veins and feeding arteries. Some of the veins may have been compressed during the pregnancy, enhancing growth of the myoma. After delivery, partial compression may have obstructed venous return, but not arterial ow into the myoma. Thus, we speculated that hypovolemic shock following delivery was due to a large amount of blood sequestration from the maternal circulation into the myoma without overt hemorrhage. In the present case, the cause of partial occlusion is unknown. It is possible that after delivery, involution of the uterus and removal of the baby moved the tumor into a position that partially occluded venous blood from the pedicle. Therefore, it is suggested that

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hypovolemic shock might be avoided by removing pedunculated myomas, which may potentially undergo partial occlusion or torsion. A similar phenomenon has been described in the ovary.1,2 Kalstone et al. originally described partial torsion of the ovary leading to ovarian swelling.1 Microscopically, extensive parenchymal edematous change with occasional local stromal cell proliferation occurs in the ovary. One case of massive edema of a uterine myoma has been reported previously.3 In that case, rapid growth of the tumor was observed in the rst trimester, giving the impression of a malignant ovarian tumor. At 8 weeks of gestation, celiotomy revealed that the tumor was a uterine myoma connected to the fundus of the uterus by a pedicle. The tumor weighed 10 kg and its cut surface was grayish-white in color. Histologically, marked edematous change was noted. The tumor behaved similarly to that described in the present case. Although myomectomy performed during a cesarean section has been traditionally discouraged because

of a higher risk of bleeding, it has been reported that careful case selection could be benecial to patients. In the present case, subserosal myomectomy during a cesarean section was recommended to avoid subsequent partial occlusion or torsion. To the best of our knowledge, our case is only the second one of its kind to be reported. Although it occurs rarely, it is important to recognize that marked growth of a uterine myoma can occur in pregnancy and cause hypovolemic shock, particularly a subserosal myoma connected by a pedicle.

References
1. Kalstone CE, Jaffe RB, Abell MR. Massive edema of the ovary simulating broma. Obstet Gynecol 1969; 34: 564571. 2. Kanbour AI, Salazar H, Tobon H. Massive ovarian edema: A nonneoplastic pelvic mass of young women. Arch Pathol Lab Med 1979; 103: 4245. 3. Kawarabayashi T, Uchiyama Y, Nakamura S, Sugimori H. A huge rapidly growing leiomyoma in the rst trimester of pregnancy. Asia Oceania J Obstet Gynaecol 1985; 11: 557561.

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