Postpartum Expulsion of an Infected Intramural Uterine Myoma: Rapid Growth in Pregnancy and Definitive Management by Abdominal Hysterectomy

TL;DR

A rare case of a large uterine myoma growing during pregnancy and expelling postpartum, requiring surgery to prevent severe infection and bleeding.

Contribution

First documented case of postpartum intramural myoma expulsion managed by abdominal hysterectomy after GnRH antagonist use.

Findings

The myoma grew from 3 cm to 21 cm during pregnancy and caused deep vein thrombosis due to vena cava compression.

Postpartum, the myoma expelled into the cervical canal and became infected, requiring abdominal hysterectomy for definitive treatment.

Histopathology confirmed pyomyoma with extensive neutrophil infiltration and cultures identified Escherichia coli and Morganella morganii.

Abstract

Uterine myomas during pregnancy can cause significant complications, but postpartum expulsion is rare, particularly from intramural lesions without a stalk. We report the case of a 40-year-old primigravida whose posterior wall intramural myoma enlarged from 3 cm to 21 cm during infertility treatment and pregnancy. The myoma caused inferior vena cava compression, leading to deep vein thrombosis, and remained stable in size after mid-gestation. Vaginal delivery at term was uneventful. Postpartum, the patient developed recurrent genital bleeding and inflammatory signs. Magnetic resonance imaging initially suggested red degeneration, but later revealed penetration of the myoma into the cervical canal, indicating expulsion. Intraoperative findings showed a necrotic, malodorous myoma; cultures grew Escherichia coli and Morganella morganii. Histopathology confirmed pyomyoma with extensive neutrophil infiltration. Given the absence of a stalk and the high risk of sepsis and hemorrhage, a total abdominal hysterectomy was performed, resulting in full recovery. This is the first documented case of postpartum intramural myoma expulsion requiring abdominal hysterectomy following gonadotropin-releasing hormone (GnRH) antagonist administration. Early recognition of infection-related degeneration, careful assessment of myoma morphology, and timely surgical intervention are essential to prevent life-threatening complications in similar cases.

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