Hemoperitoneum Secondary to an Avulsed Pedunculated Fibroid: A Case Report [ID 1285]

INTRODUCTION: Uterine fibroids are common benign gynecologic tumors that most significantly affect women of reproductive age. Their clinical presentation is variable, but can include abnormal uterine bleeding (AUB), symptomatic anemia, and bulk symptoms. In extremely rare cases, fibroids have been identified as the etiology of intraabdominal hemorrhage, but making a correct diagnosis in these situations is challenging given the rarity of the phenomenon and wide differential diagnosis. METHODS: We present a case report of a patient with history of AUB-L who presented in hemorrhagic shock due to partial avulsion of an intraperitoneal, pedunculated fibroid. The subject of this case report provided written consent for the publication of her deidentified information. RESULTS: A 46-year-old female with a past medical history of AUB, symptomatic anemia, and hypertension was brought to the emergency department in respiratory distress. Point-of-care ultrasound and computed tomography of the abdomen and pelvis revealed a large fibroid uterus and concern for hemoperitoneum. Emergent exploratory laparotomy was performed by the general surgery team in conjunction with the obstetrics and gynecology (ob-gyn) team. Venous bleeding was noted from the stalk of a 16-cm pedunculated fibroid. Myomectomy was initially performed, followed by supracervical hysterectomy and bilateral salpingectomy. CONCLUSIONS/IMPLICATIONS: Intra-abdominal hemorrhage secondary to fibroids is exceedingly rare, with only 125 cases reported in the literature from 1902 to 2018 and correct preoperative diagnosis made 5.6% of the time. Given the challenge of accurate diagnosis, but potential for rapid deterioration, ob-gyn, emergency, and general surgery providers should maintain a wide differential when women with a history of fibroids present in undifferentiated shock.