Laparoscopic Management Of An Atypical Presentation Of A Large Degenerated Fibroid During Pregnancy

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Video Description

This video highlights key strategic steps in evaluating an atypical presentation of uterine fibroid degeneration during pregnancy. Management strategies include a careful review of the patient’s history, appropriate physical exam, and evaluation of prior imaging studies. The role of expert ultrasound evaluation is crucial to the patient’s care as it provides more insight into the pathology encountered, which will facilitate an appropriate treatment plan after reviewing the available options. Collaboration with other teams is essential to provide a complete analysis that will ultimately ensure patients’ autonomy in the process.

In addition to the above, laparoscopic surgery is a feasible option during pregnancy that allows direct evaluation and specifically in this case diagnosis and surgical intervention with the aim to prolong a safe pregnancy.

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Video Transcript: Laparoscopic Management Of An Atypical Presentation Of A Large Degenerated Fibroid During Pregnancy

The Minimally Invasive Group is happy to present Laparoscopic Management of an Atypical Presentation of a Large Degenerative Fibroid During Pregnancy. The key principles in our management strategy are highlighted by sharing the story of our patient, who was referred by a Maternal Foetal Medicine consultant colleague at 16 weeks gestational age with a large uterine mass found incidentally during pregnancy. Our patient had no significant past medical or surgical history. Specifically, there was no known history of fibroids, endometriosis or adenomyosis. This was a spontaneous and wanted pregnancy with no history of infertility.

The patient was comfortable and in no apparent distress. On inspection, there was a visibly noticeable large abdominal mass. The mass was equivalent to a 32-weeks gestational age pregnancy. At the time, as per our Maternal Foetal Medicine colleague, the presence of this mass was not having a noticeable effect on fetal wellbeing. At this point, the diagnosis of the uterine mass was unclear, so a thorough review of past imaging studies was done.

The pregnancy was displaced by the mass into the right upper quadrant. Amniocentesis was challenging due to the proximity of the pregnancy to the liver, which was overcome by the left lateral decubitus position. A previous MRI was reviewed. The mass was described as uniform in its outer aspect, with cystic changes within. Images were reviewed to determine the location and extent of involvement of the uterine wall, which is shown in this MRI image. The gynecologic oncology group was not concerned about uterine sarcoma and suggested referral to our team for ongoing work-up and management.

Again, one can clearly appreciate the proximity of the gravid uterus to the liver in the right upper quadrant. Conducted an expert sonologist-led ultrasound. Findings revealed a large solid cystic mass measuring 30 x 30 x 28cm. Within the mass, there were cystic changes with pockets of mixed echogenic fluid filling the mass. Extrapolating ovarian mass assessment principles, the surrounding solid components could be thought of as papillary projections. 

These solid components of the mass did not show any abnormal vascular Doppler pattern. The sonologist-led scan was comprehensive by performing multiple video sweeps through the entirety of the mass, ensuring a careful review of all solid components, loculations and vascularity.

The patient was eager for an intervention. Beyond simply managing the mass, she wanted an accurate diagnosis of the pathology. To facilitate both objectives of diagnosis and management, surgery was decided. We did discuss the possible role of intervention radiology, which was not chosen by the patient. We reviewed the surgical technique, which included three main components, ultrasound-guided laparoscopic drainage of the uterine mass, obtaining a biopsy from within the mass, and leaving a drain within the mass to prevent re-accumulation of the fluid. This is intended to prevent ongoing drainage of the solid cystic mass, with adequate uterine distension as the pregnancy advanced.

The surgery was commenced with direct visual entry at Palmer’s point. Prior to this, we mapped the planned area of port placement with ultrasound and confirmed the absence of the mass or any large vessels. A careful anatomic survey was undertaken, revealing a large uterine mass with an appearance consistent with a massive fibroid. Meanwhile, the pregnancy within the uterine cavity was visualized in close proximity to the liver. Engorged blood vessels and serous fluid was seen within the abdominal cavity, which was sent for cytology.

The engorged blood vessels were mapped to guide the insertion of our accessory ports. Ultrasound was also used to plan port placement. The main use of ultrasound was to identify the thinnest and least vascular area of the uterine mass, through which we planned to directly introduce our 12mm balloon blunt-tip trocar. Bipolar energy was used for the hemostasis of the entry site for the trocar that would be used to drain the mass. As the 12mm trocar was placed, serous fluid from the mass was seen. We drained 3 litres of serous fluid from the mass.

At this point, thinking this was a degenerated fibroid, we used the term myomoscopy to describe direct visualization within the fibroid. With this technique, we noted devascularized tissue and particular debris within the fluid. As expected, based on the ultrasound appearance, no abnormal vasculature was noted within the solid tissue of the mass. This awareness of the interior provided us with the confidence to obtain a biopsy of the solid tissue. We did this by using a fenestrated grasping forceps into the mass, under ultrasound guidance and sampling tissue.

To facilitate placement of the drain directly into the mass without causing spillage of the fluid content into the abdomen, we guided a 24 French 3-way Foley catheter through the port. The balloon bulb was filled with 50cc of sterile saline, and an ultrasound was used to confirm placement. Fluid was allowed to expel via this drain, which was connected to a gentle NEMO VAC negative-pressure drainage bag. In order to remove the port around the Foley catheter drain, we used an orthopedic wire-cutting tool. 

The Foley catheter was secured under tension to the skin, suspending the uterine mass to the anterior abdominal wall, again with the intent to prevent spillage of the mass content. A final look was made, and the surgery was complete. The patient tolerated the procedure well. The fetal heart was documented at the end of the procedure, and she was discharged the following day in good clinical condition.

The uterine mass specimen revealed degeneration and infarct-type necrosis within a fibroid. No evidence of malignancy was identified. Our patient continued her care with both the Maternal Foetal Medicine team and the Minimally Invasive Gynecologic Surgery Group. She was also evaluated via a multidisciplinary team that included infectious disease, who had no special recommendations for antibiotic prophylaxis during the pregnancy. 

Our patient continued the pregnancy until 32 weeks and 5 days of gestation when she underwent an urgent Caesarean Section. Several days prior, she developed an abscess within the degenerated fibroid, and chorioamnionitis. Collaboration with the Maternal Foetal Medicine team permitted the administration of cortical steroids and pre-delivery consultation with Paediatrics. 

This video highlights the important considerations of the management of the atypical presentation of a fibroid during pregnancy. This includes careful assessment of the patient’s past history, review of past imaging studies, understanding the important role of expert ultrasound in such case assessment, and discussing management options accordingly while ensuring the patient’s autonomy. And finally, the important role of collaboration with other team members, and in such cases, the gyne-oncology team and the Maternal Foetal Medicine Group.