Abbreviations

BMI – body mass index
CIN – cervical intra-epithelial neoplasia

Introduction

Uterine leiomyomas are benign neoplasms which are very prevalent in gynaecology practice, affecting mainly women in reproductive age (₁). In pregnancy fibromyomas may increase in size and, in some cases, undergo benign symptomatic degenerative changes (₂, ₃).

Sometimes fibroids create adhesions with other organs, particularly to bowel, and in extreme situations may even become parasitic. There are no published description in literature about adhesions between uterus and liver.

Case Report

We report a case of a 37 year-old Caucasian woman, obese (BMI 44) and smoker (20 cigarettes per day), with ultrasonographic diagnosis of two uterine fibromyomas (one of them with cystic degeneration) proposed for multiple myomectomy, in view of her wish to maintain fertility.

In her gynaecological history, our patient had menarche at 12 years old, regular cycles 30/8 days and underwent a laser cone excision for CIN III one year before surgery.

Regarding her obstetric history she had two pregnancies. The first was a left tubal pregnancy, managed with methotrexate, at age 35. By that time two subserous myomas were detected: the larger one fundic, with 10 cm diameter, and the other, left corporal, with 3.5 cm diameter.

Her second pregnancy (one month after the first) was complicated by an hospital admission between the 14^th and 22^nd weeks with a clinical picture characterized by abdominal pain, leucocytosis, c-reactive protein elevation and an abdominal ultrasound showing a great increase in the dimensions of the myoma (fundic with 16 cm and isthmic with 6 cm diameter) with aspects suggesting cystic degeneration of the larger one, which was reaching the diaphragm. The remaining of the gestation progressed without intercurrences. By the 37^th week, she had an elective c-section (neonate male sex, weight 3015g, Apgar Index 9/10), with reference only to parietal-uterine adhesions.

The ultrasonographic pelvic revaluation (one year after the c-section) demonstrated two fibroids, one fundic with 15 cm diameter with cystic degeneration, and another isthmic with 3 cm diameter. According to these findings, the patient was offered multiple myomectomy, attending to her express wish to preserve fertility. During laparotomy a dense vascular adhesion was identified between the degenerative area of the fundic myoma and the inferior surface of the left hepatic lobe (Figure 1 and 2). Adhesion ligation and hepatic haemostasis were performed, followed by total hysterectomy. There were no complications in the post-operatory period. The pathology report stated two uterine leiomyomas, one of them with extreme hyaline degeneration.

Figure 1

Figure 1: Hysterectomy specimen – deformed uterus with one isthmic fibroid and another fundic, larger.

Figure 2

Figure 2: Hysterectomy specimen – top view: surface of hepatic adhesion.

Discussion

Acute degeneration of uterine fibroids can occasionally occur during pregnancy, with localized abdominal pain, fever, abdominal tenderness and leucocytosis (₂). In this case, we assumed that the uterus-hepatic adhesion formation, which probably occurred during pregnancy, was, on one hand, a consequence of the structures contiguity and, in the other hand, a result of the fibromyoma degeneration, which favoured neovascularization from the liver.

Correspondence to

ALEXANDRA CORDEIRO Rua Virgilio Correia, 32, 4° Esq 1600-224 Lisboa PORTUGAL Telephone: +351936677027 E-mail: alexandra.cordeiro@sapo.pt