AB140. SOH22ABS052. Back to basics: a complex case of a multiple fibroid uterus: a case report

Background: Uterine fibroids (leiomyomas) are benign smooth muscle tumours of the uterus. They are the commonest benign pelvic tumour in females. They occur in nearly 50% of women over 35 years of age, with an increased prevalence during the reproductive phase due to hormone-stimulated growth. 80% of African and approximately 70% of Caucasian women will have fibroids by the age of 50. There are both medical and surgical options for the management of uterine fibroids. We report a case of a 49-year-old Caucasian female, parity zero (P0), with a multiple fibroid uterus, the largest fibroid measuring 11 cm. She had opted against medical management (including GnRH analogues) and due to her medical history, she was unable to have uterine artery embolisation. She was admitted for elective total abdominal hysterectomy and bilateral salpingo-oophorectomy. This procedure proved to be difficult and complex due to the multiple large fibroids. Multiple fibroid enucleations were performed to gain access to the uterus, vagina, and cervix. We discuss the complexity and uniqueness of this surgical case and the current management options for uterine fibroids.

Methods: Case Report.

Results: Pelvic Ultrasound: multiple fibroids were seen and were distorting the normal uterine shape. The fibroids were coalescent and difficult to distinguish from each other. The largest fibroid measured nearly 11 cm in size. Repeat Pelvic Ultrasound: Bulky fibroid uterus. Multiple fibroids were again seen. Two subserous fibroids were noted, measuring approximately 5 cm each. A submucous fibroid measuring approximately 9 cm was seen, as well as an intramural fibroid measuring 3 cm in size. The endometrium was clearly visualized with a thickness of 4.5 mm. The endometrial cavity was distorted by the presence of the fibroids. There was no free fluid seen in the Pouch of Douglas. Both ovaries were poorly visualized. A pelvic magnetic resonance imaging (MRI) was unable to be performed as the patient had previous back surgery including spinal fusion.

Conclusions: Total abdominal hysterectomy and bilateral salpingo-oophorectomy proved to be a difficult, lengthy and complex procedure due to the multiple large fibroids. Multiple fibroid enucleations were performed to gain access to the uterus, vagina, and cervix. The procedure was completed once all fibroids had been removed. Estimated blood loss was 1.5 litres. Postoperative Hb was 8.5. Patient spent 24 hours in High Dependency Unit (HDU) for close monitoring given the blood loss. Patient recovered well and was discharged home on day 4. She was followed up in the GOPD 6 weeks later. Histology showed multiple benign leiomyomata in the myometrium. No evidence of malignancy was noted. This case illustrates the importance of good history taking and allowing the patient to make informed decisions. Management should be individualised to the case. This includes not only the location and size of the fibroids, but the patient’s age, symptoms, desire to maintain fertility and medical history should be considered. Management will also be guided by access to treatment and the experience of the gynaecologist. This case illustrates the importance of maintaining and developing surgical skills. It was a complex and challenging case that required surgical expertise. This expertise is sometimes lost as we develop new medical and less invasive treatments.

Keywords: Benign; bilateral salpingo-oophorectomy; gynaecology; total abdominal hysterectomy; uterine fibroids