Successful myomectomy following infected ischaemic necrosis of uterine fibroids after uterine artery embolisation

Abstract

Case reportA 39 year old woman came to the gynaecology clinic with a four year history of pelvic pain and secondary infertility. She had had a miscarriage in the first trimester.One year previously she had undergone open myomectomy. Examination revealed a bulky uterus. An ultrasound scan and magnetic resonance imaging showed a fibroid on the posterior wall of the uterus measuring 9 cm in diameter.She requested uterine artery embolisation as she was keen to avoid repeat surgery and she wanted to preserve her fertility.She underwent uterine artery embolisation using particles of polyvinyl alcohol. She received a single intravenous dose of 1.2 g co-amoxyclav prophylactically before the procedure was started. She went home on the following day.Four weeks after embolisation, she came to the accident and emergency department with a one week history of abdominal pain, fever and an offensive vaginal discharge. Her general practitioner had prescribed antibiotics (375 mg co-amoxyclav three times daily for five days).Her temperature was 38jC and she was tender on abdominal and pelvic examination. Her white blood cell count was 20,300/mL and C-reactive protein was 230 mg/L. An ultrasound scan of her uterus showed a posterior fibroid measuring 13 cm in diameter containing an echogenic linear echo highly suspicious of infection or abscess. Her clinical features also suggested that infection could have complicated the post-embolisation ischaemic necrosis. She was given intravenous antibiotic therapy including cephalosporins and metronidazole. It was decided to perform a laparotomy. During discussions before her operation, she was informed that a hysterectomy could be necessary depending on the operative findings. She made it clear that she wanted us to do everything possible to save her uterus as she was still hoping to conceive.A large necrotic intramural fibroid was detected in the posterior uterine wall extending to the uterine cavity. There were no signs of generalised peritonitis and the uterus did not appear necrotic. The fibroid was shelled out and sent for histopathological examination. Parts of the fibroid and some peritoneal fluid were also sent for microbiological culture. There was minimal bleeding and the posterior uterine wall retained a pinkish colour. Tissue viability was tested by using a vital dye (methylene blue). Debridement was carried out until healthy, bleeding tissue was identified. Debridement appeared to be complete. It was therefore decided not to carry out a hysterectomy and the uterine incision was closed. The debrided wound was irrigated with hydrogen peroxide solution. Intra-abdominal and intrauterine drains were left in situ, the latter being inserted through the uterine incision and pushed down into the vagina.The histological findings revealed an infarcted and partly necrotic leiomyoma, weighing 650 g.Microbiological investigation of the fibroid tissue showed a mixed growth with a prevalence of coliform species. The culture failed to clarify which other organisms were responsible for the infec...

Radiofrequency Thermal Ablation of Submucosal Leiomyoma: A Preliminary Report on Health, Symptom, and Quality of Life Outcomes

“…13 Leiomyomas undergo hydropic degeneration and necrosis after myolysis, 14 and ischemic necrosis after embolization. 15 Walker et al 16 reported that 58% of the women who had undergone embolization presented with increased vaginal discharge after the procedure; of these women, the discharge lasted for less than 4 weeks in 28%, 4-8 weeks in 20%, and more than 8 weeks in 16%. These researchers also reported that the persistent discharge in these patients was caused by a superficial cavity within the infarcted leiomyoma communicating with the endometrial cavity.…”