CASE REPORT


https://doi.org/10.5005/jp-journals-10006-2368
Journal of South Asian Federation of Obstetrics and Gynaecology
Volume 16 | Issue 1 | Year 2024

Uterine Fibroid as a Cause of Severe Preeclampsia: A Case Report


Ruchika Garg1, Shubhangi Sharma2, Rekha Rani3, Prabhat Agrawal4

1–3Department of Obstetrics and Gynaecology, SN Medical College, Agra, Uttar Pradesh, India

4Department of Medicine, SN Medical College, Agra, Uttar Pradesh, India

Corresponding Author: Ruchika Garg, Department of Obstetrics and Gynaecology, SN Medical College, Agra, Uttar Pradesh, India, e-mail: ruchikagargagra@gmail.com

How to cite this article: Garg R, Sharma S, Rani R, et al. Uterine Fibroid as a Cause of Severe Preeclampsia: A Case Report. J South Asian Feder Obst Gynae 2024;16(1):60–62.

Source of support: Nil

Conflict of interest: Dr Ruchika Garg is associated as Associate Editor of this journal and this manuscript was subjected to this journal’s standard review procedures, with this peer review handled independently of the Associate editor and her research group.

Patient consent statement: The author(s) have obtained written informed consent from the patient for publication of the case report details and related images.

Received on: 15 November 2023; Accepted on: 20 December 2023; Published on: 10 January 2024

ABSTRACT

Introduction: Uterine fibroid during pregnancy are associated with high risk of preeclampsia in pregnant females with adverse obstetric complications.

Materials and methods: Here we report a case of a 31-year-old female presenting with 36 weeks gestation with headache, blurring of vision and epigastric pain with severe preeclampsia. She was managed conservatively initially but her blood pressure could not be controlled and her symptoms were not relieved; hence, lower segment cesarean section was done for termination of pregnancy and multiple uterine fibroids were found intra operatively incidentally. Therefore, cesarean myomectomy was done and the patient was discharged on 9th postoperative day in satisfactory condition.

Conclusion: Uterine fibroids are associated with high risk of preeclampsia during pregnancy, hence these patients must be closely monitored during antenatal period.

Keywords: Case report, Fibroid, High blood pressure, Preeclampsia, Pregnancy, Pregnancy-induced hypertension, Uterine fibroids.

INTRODUCTION

Preeclampsia is one of the major causes of maternal and perinatal morbidity and mortality worldwide which is associated with adverse obstetric complications.1,2 Uterine fibroids are the most common cause of benign pelvic tumor with reported prevalence during pregnancy is 1–4%.3 Uterine fibroids are associated with multiple adverse outcomes during pregnancy, such as pain, spontaneous abortions, degenerations, preterm labor, preeclampsia, abruption, postpartum hemorrhage, and retained placenta. Several studies showed that the risk of preeclampsia is higher in women with uterine fibroid compared with those without it.46 The pathophysiology of oxidative stress and endothelial dysfunction hypothesized the occurrence of preeclampsia in pregnant female with fibroids. Mostly, uterine fibroids are asymptomatic initially and diagnosed incidentally on ultrasound in early pregnancy.7 Under rapid hormonal changes, notable fibroid growth is observed during the first trimester of pregnancy,8 leading to an increased incidence of obstetric complications.9 Hypertension represents a “proatherogenic” state that enhances risk for fibroid development and/or growth in uterine smooth muscle in a manner analogous to atherosclerotic changes in arterial smooth muscle. The relationship between fibroid and preeclampsia is documented in several studies but still its direct relationship is unclear.

Here, we present a case report of multiple uterine fibroids during pregnancy and its effect on blood pressure profile of the patient.

CASE DESCRIPTION

A 31-year-old female (G1P0L0A0) came to the emergency department with amenorrhea for 8 months and complaining of headaches, blurring of vision and epigastric pain since 10 days. She had been married for 4 years and had a history of infertility, and she had undergone myomectomy surgery to remove uterine fibroid 2 years back, but no records were available with the patient. On admission, her vitals were: pulse rate—96 beats/min, blood pressure—220/130 mm Hg, oxygen saturation was normal with chest bilaterally clear, bilateral pedal edema was present and pallor was mild When the patient’s history was taken, she did not take any hypertensive medication and there had been no previous antenatal visits. Immediately, injection labetalol 20 mg was given. After 20 minutes, her repeat blood pressure was 200/120 mm Hg. Repeat injection labetalol and magnesium sulfate loading dose was given. Meanwhile, her obstetric examination was done. On per abdomen examination, fundal height was 30–32 week with cephalic presentation, and the fetal heart rate was regular of 140 beats/min and no uterine contractions. Upon vaginal examination, her internal os was closed and cervix was posterior. Strict vital monitoring was done. Poor maternal and fetal prognosis regarding severe preeclampsia was explained (Fig. 1).

Fig. 1: Uterine multiple fibroids

Other antihypertensives along with labetalol were given. Strict fetal heart rate monitoring was done. Her blood pressure could not be controlled despite medications and remained in range of 170/110–200/120 mm Hg. Magnesium sulfate was administered. The patient’s headache and epigastric pain were not relieved by medications. Ultrasound was suggestive of A single, live, intrauterine pregnancy of 33 weeks 6 days with a cephalic presentation and a fundoanterior placenta with adequate liquor was suggested by ultrasound. Her blood pressure could not be controlled and her symptoms were not relieved, so decision for termination of pregnancy was taken. All maternal and fetal high risks explained. Patient was taken for cesarean section with one unit blood arrangement preoperatively (Fig. 2).

Fig. 2: Removal of fundal fibroid

When abdomen was opened, a myoma of size 4 × 5 cm was seen at the lower uterine segment on the anterior surface of the uterus. Transverse incision was given above the fibroid. As cavity was not reached due to myoma musculature, finger was inserted, amniotic sac was palpated and ruptured with long artery forcep. Baby was delivered out with difficulty with fundal pressure and female growth restricted baby of 1.4 kg with immediate cry delivered out and handed over to pediatrician. The myoma encroaching the stich line was removed. Uterus was exteriorized, multiple fibroids were seen over the uterus with two fibroids above the stich line of 2 × 3 cm which were removed. About 3–4 subserosal fibroids of around 3 × 2 cm on fundal and posterior surface of the uterus were removed. About 3–4 seedling fibroids which appeared in the stich line plane during uterine closure were removed. In toto 7–8 fibroids were removed during same setting. Two units of blood were transfused. Hemostasis was achieved. The removed myomas were sent for histopathological examination.

Uterine fibroids during cesarean section was an incidental finding in this case, as no previous ultrasound report was mentioned about it. During postoperative period, the blood pressure dropped to 160/100 mm Hg for which antihypertensives were given. Baby was kept under observation in neonatal ICU. Her postoperative period was uneventful and patient discharged satisfactorily after 9 days from the hospital (Fig. 3).

Fig. 3: Number of myoma removed

DISCUSSION

Preeclampsia is detected in the early stage and in one-third of patients with uterine fibroids were observed. Patients with fibroid have chronic inflammation which causes increased production of inflammatory cytokines with oxidative stress leading to endothelial dysfunction which is the main mechanism causing hypertension.1012 Fibroids causing poor placental perfusion and sometimes undergo rapid and remarkable growth. The overproduction of extracellular matrix, a central component of uterine leiomyoma pathophysiology may also be related to elevated blood pressure.13 Increased BMI, central obesity, hyperlipidemia, insulin resistance may increase the risk of uterine fibroids through inflammatory mechanisms.14 Prospective analyses demonstrate a strong and independent association between blood pressure and fibroid risk. In the early stages of pregnancy, defects in spiral artery remodeling lead to ischemia, hypoxia, and poor placental formation. The degree of spiral artery remodeling is closely related to the occurrence of PE.15 Endothelial activation and the role of vasoconstriction in the second and third trimester cause an increase in blood pressure and other obstetric complications like abruption, etc. It had been demonstrated that fibroids undergo rapid and remarkable growth during pregnancy and also there are chances of red degenerations in fibroid during pregnancy particularly in the second trimester.16 Therefore, it is reasonable to say that the rapid expansion of fibroids in early pregnancy may result in poor placental perfusion by compressing the uterine blood vessels, which contributes to the increased risk of preeclampsia. Moreover, molecules secreted by fibroids may induce inflammation, oxidative stress response, and endothelial dysfunction, and are involved in the development of preeclampsia.

Uterine fibroids causing preeclampsia is directly demonstrated by several studies. A meta-analysis of 8,361 women found women with fibroids had a 44% increased risk of high blood pressure.17 Fibroids have high risk of rapid growth in the early pregnancy which can result in abortions and can be a cause of preeclampsia and other obstetric complications during the second and third trimester.18

CONCLUSION

Uterine fibroids are associated with high risk of preeclampsia during second and third trimester. These patients should have regular follow-up during antenatal period and their blood pressure should be closely monitored.

The decision of cesarean myomectomy must depend on surgical skill, location of the fibroid, size of the fibroid, availability of the infrastructure, blood and blood products, expert assistants, and intensive care. Subserosal pedunculated fibroids must be removed always.

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