Puzzler: A sneaky cause of hemorrhagic shock
Dr Takeshige is an attending physician at the Department of Obstetrics and Gynecology at Lincoln Medical and Mental Health Center, Bronx, New York.
Dr Rezai is a resident physician in the Department of Obstetrics and Gynecology at Lincoln Medical and Mental Health Center, Bronx, New York.
Mr Giovane is a medical student in Grenada, West Indies.
Dr Henderson is an attending physician at the Department of Obstetrics and Gynecology at Lincoln Medical and Mental Health Center, Bronx, New York.
None of the authors has a conflict of interest to report with respect to the content of this article.
The authors wish to thank Ms Judith Wilkinson, Medical Librarian, Lincoln Medical and Mental Health Center Science Library, New York, for her assistance.
A 35-year-old nulliparous Spanish woman was referred to our gynecology clinic for evaluation of worsening symptomatic fibroid uterus. The presenting complaints included increasing abdominal pressure, upper and lower quadrant pain, dyspepsia with intermittent vomiting, frequent urination, and nausea for several months. Gynecologic history was significant only for a fibroid uterus diagnosed several years before presentation for which the patient had received no treatment. She had no significant medical history and no prior surgery. Family history was significant for fibroid uterus; both her sister and mother had had hysterectomies for fibroids.
The patient’s vital signs were stable and physical examination was remarkable for an abdomen that was soft without tenderness; uterus was enlarged and extended to the level of xyphoid process. The work-up included a pelvic sonogram, which was limited due to a large mass in the pelvis extending to the abdomen measuring 13x10x11 cm most likely representing fibroids. Computed tomography reported a multinodular mass arising from the uterus measuring 25x16x17 cm, most compatible with myomas.
The patient was scheduled for abdominal myomectomies with possible hysterectomy due to her desire to remain fertile. Lupron was not administered preoperatively because of the large size of the uterus and the potential side effects of menopausal symptoms.
To preserve endometrial integrity, the endometrium was inflated with methylene blue via ZUMI intrauterine manipulator, allowing for identification of the endometrium during resection. An irregular uterus measuring 28x30 cm and enlarged ovaries bilaterally with prominent varicosity were noted intraoperatively. The uterus was exteriorized with difficulty due to its large size. Pitressin was administrated into the uterus to reduce bleeding. A total of 17 intramural myomas were removed, with variable sizes of 15x12 cm, 13x10 cm, 15x10 cm, 10x6 cm, 6x6 cm, and several 2x2 cm. Hemostasis of the uterus was achieved after closure of 3 layers and application of surgiflow (Ethicon); however, bleeding persisted from the abdominal cavity.