Respiratory arrest caused by a large uterine myoma: A case report

Abstract

Large abdominal masses increase intra-abdominal pressure, thus changing the haemodynamics of the patient by elevating the diaphragm and causing partial occlusion of the inferior vena cava (IVC). Large abdominal masses present many challenges, including life-threatening risks due to severe cardiovascular, pulmonary, and circulatory problems, as well as technical difficulties of surgery and postoperative complications. We report a case of a large pelvic-abdominal myoma with perioperative pulmonary compromise. The goal of this report was to familiarise other surgeons with the alterations in the pathophysiology and management of large abdominal masses. Seongnam-si, Gyeonggi-do, Korea Corresponding author: M C Choi (oursk79@cha.ac.kr) It is rare to see patients present with exertional dyspnoea caused by a pelvic mass such as uterine myoma without underlying cardiopulmonary disease. The most common symptom of myoma is menstrual disturbance. However, in cases of large uterine myoma, intraabdominal pressure (IAP) can increase, which interferes with the pulmonary, renal, splanchnic and cardiovascular systems by elevating and splinting the diaphragm and partially occluding the inferior vena cava (IVC). S Afr J Obstet Gynaecol[1] If untreated, IAP rises and multiple organ failure begins, and may progress to abdominal compartment syndrome (ACS), defined as a sustained IAP of 20 mmHg or higher and associated with new organ dysfunction.[2] Removal of the mass is the treatment of choice for ACS; however, gradual decompression is necessary. We report a case of perioperative respiratory failure precipitated by increased IAP, which was caused by a large abdo mino pelvic myoma. Case reportA 42-year-old virgin woman presented to the emergency room for gradually worsening exertional dyspnoea and remarkable abdominal distension. Gradual abdominal distension had been noted by the patient over the past 3 years, but she became symptomatic only a week before admission. Medical and surgical histories were unremarkable. The patient complained of tachypnoea, and her oxygen saturation (SpO 2 ) on room air was 89%. Abdominal examination revealed generalised abdominal distension with a mass located through the entire abdomen. The patient's height was 170 cm, and weight was 55 kg. Laboratory tests indicated hypoxaemia in arterial blood gas analysis (pH 7.43, partial pressure of carbon dioxide (pCO 2 ) 45.5 mmHg, partial pressure of oxygen (pO 2 ) 54.7 mmHg) and mildly elevated liver enzymes (aspartate aminotransferase (AST) 68 IU/L, alanine transferase (ALT) 72 IU/L). Other biochemical parameters, including tumour marker levels (CA 125 15.3 U/mL and CA 19-9 26.82 U/mL) were within normal ranges. Abdominopelvic computed tomography (CT) revealed a large, heterogeneous, multiseptated ovoid pelvic mass measuring 37 × 25 × 12 cm, occupying the pelvis and abdomen up to the diaphragm. It was unclear whether it was from the uterus, adnexa, or another organ (Fig. 1). Chest CT angiogram showed no signs of pulmonary embolism and the echocardiogram ...