Case 7: Abdominal swelling

 

Case 7: Abdominal swelling

CASE 7: ABDOMINAL SWELLING

History

A 36-year-old African-Caribbean woman has noticed abdominal swelling for 10 months.

She has to wear larger clothes and people have asked her if she is pregnant, which she finds

distressing having been trying to conceive. She has no abdominal pain and her bowel habit is

normal. She feels nauseated when she eats large amounts. She has urinary frequency but no

dysuria or haematuria.

Her periods are regular, every 27 days, and have always been heavy, with clots and flooding

on the second and third days. She has never received any treatment for her heavy periods.

She has been with her partner for 7 years and despite not using contraception she has never

been pregnant.

Examination

The woman has a very distended abdomen. A smooth firm mass is palpable extending from

the symphysis pubis to midway between the umbilicus and the xiphisternum (equivalent to

a 32-week size pregnancy). It is non-tender and mobile. It is not fluctuant and it is not possible to palpate beneath the mass. On speculum examination it is not possible to visualize the

cervix. Bimanual examination reveals a non-tender firm mass occupying the pelvis.

INVESTIGATIONS

Normal range

Haemoglobin 6.3 g/dL 11.7–15.7 g/dL

Mean cell volume 68 fL 80–99 fL

White cell count 4.9×109/L 3.5–11×109/L

Platelets 267×109/L 150–440×109/L

Magnetic resonance images (MRIs) of the abdomen and pelvis are shown in Figs. 7.1

and 7.2.

Questions

• What is the diagnosis?

• How would you further investigate and manage this woman?

Figure 7.1 MRI of the

abdomen and pelvis.

Figure 7.2 MRI of the

abdomen and pelvis.100 Cases in Obstetrics and Gynaecology

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ANSWER 7

The woman has a large uterine fibroid (leiomyoma). This is causing menorrhagia and hence

the microcytic anaemia from iron deficiency. Urinary frequency occurs due to the pressure of

the large mass on the bladder. It is also likely that the fibroid is accounting for her infertility

history, although this warrants investigation as a separate problem.

Fibroids are benign tumours of the myometrium which may be extrinsic (subserous) as in

this case. Alternatively they may be intramural or submucosal (projecting into the endometrial cavity).

! Typical presentations of fibroids

• Menorrhagia

• Abdominal mass

• Pressure effect from pressure on the bladder, stomach or bowel

• Infertility

Fibroids are not typically painful unless they undergo degeneration, usually in pregnancy.

African-Caribbean women tend to develop fibroids more commonly than other ethnic groups.

Further investigation

Ferritin and folate levels should be checked to confirm the iron-deficiency status. It is also

advisable to arrange renal function tests and a renal tract ultrasound, as very large fibroids

can cause ureteric obstruction and hydronephrosis, which would need urgent treatment.

Management

The woman should be treated for her anaemia with ferrous sulphate. The menorrhagia can

be reduced with tranexamic acid during menstruation. Gonadotrophin-releasing hormone analogues temporarily shrink fibroids and cause amenorrhoea to allow correction

of iron deficiency. Gonadotropin-releasing hormone agonists (GnRHa) are useful in stopping bleeding temporarily to allow anaemia to recover prior to surgery, but are associated

with hypoestrogenic side effects such as hot flushes and night sweats. Treatment with

ulipristal acetate (a selective progesterone receptor modulator (SPRM) with progesterone

agonist and antagonist properties) also effectively controls excessive bleeding and reduces

the size of the fibroid with less side effects. Definitive treatment for fibroids is traditionally by hysterectomy or myomectomy. Myomectomy is favourable for this woman who

is keen to have a family, so conservation of the uterus is essential. Uterine artery embolization also causes fibroid degeneration by interruption of the blood supply. However

research into long-term safety and potential effects on uterine function during pregnancy

are not clear.

KEY POINTS

• Fibroids may be small and incidental or occupy most of the abdomen.

• Anaemia should be suspected in any women with menorrhagia.

• Treatment of fibroids depends on the presence of symptoms and the necessity to

preserve fertility.

• The optimal operative approach depends on the size and location of the fibroids