Intratumor hemorrhage in pedunculated subserosal leiomyoma mimic intraabdominal bleeding: a case report

Abstract

A 43-year-old para 2-0-0-2 woman with a history of three cesarean sections and tubal sterilization presented with chronic pelvic pain and heavy menstrual bleeding due to a large subserous myoma (16 x 9 cm). Two months after initial presentation, she was admitted to the emergency department with acute abdominal pain and dyspnea. Physical examination revealed a distended abdomen, generalized tenderness, and a 24-week-sized mass. Laboratory tests indicated anemia with a hemoglobin level of 8.8 g/dL. Transabdominal ultrasound and contrast-enhanced computed tomography (CT) identified significant free fluid in the abdominal cavity and a large exophytic uterine mass, suspected to be a pedunculated subserous myoma. Exploratory laparotomy confirmed 500 mL of intraperitoneal serosanguinous fluid and a pedunculated subserous myoma measuring 27 cm, with evidence of intra-tumor hemorrhage. A total abdominal hysterectomy with bilateral salpingectomy was performed, with six units of packed red blood cells transfused. Pathological examination confirmed a subserous leiomyoma with hemorrhage and congestion. This case illustrates the rare complication of intra-tumor hemorrhage with intra-peritoneal fluid reaction, typically presenting as acute abdominal pain. Emergency surgery is required for diagnosis and management, especially in the absence of trauma.