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Differential diagnosis of leiomyoma in pregnancy: rapid growth, rapid regression and progestogenic effects

2015; Wiley; Volume: 47; Issue: 2 Linguagem: Inglês

10.1002/uog.15677

1469-0705

R Scuderi, Maria Grazia Giovannini, Vittorio Villani, T. Canino, D Antonaci,

Ectopic Pregnancy Diagnosis and Management

A 28-year-old woman, at 7 weeks of amenorrhea, was referred to our department following an ultrasound diagnosis of partial hydatidiform mole. While admitted as an inpatient, we observed that her free beta-human chorionic gonadotropin (β-hCG) levels were increased but not as high as would be expected for a case of partial hydatidiform mole. Alternative diagnoses included uterine sarcoma and colliquative myoma. The uterine mass grew rapidly (from 13 cm to 18 cm in 6 days) (Figure S1) and developed the unusual appearance of both a myoma and a mole. As free β-hCG values continued to be lower than those expected with mole, a sarcoma was suspected. However, examination by Doppler ultrasound did not support this diagnosis as diffuse color Doppler spots and infiltration into the uterine wall were not observed (Figure S2), as they would be in a case of sarcoma. During the ultrasound examination, we observed a gestational sac within the uterine cavity at the right ostium, containing an embryo with fetal heart activity. On the contralateral side, we identified the site of the mass. On first visualization, this appeared to be a mole, but it did not have all the ultrasound characteristics for diagnosis, such as multivesicular collection with multiple septa and/or daughter cysts (resembling a bee's nest). Follow-up examination by magnetic resonance imaging of the suspected mole did not identify it as such, as multicystic areas, larger than the ‘mole’ itself were visible (Figure 1). We then suspected that the mass was an echinococcosis cyst. However, tests proved negative. During the observational period, levels of free β-hCG increased from 1061 IU to 28 375 IU (Figure S3), and we proceeded with endometrial biopsy. Histological analysis was reported as ‘two myoma fragments without atypia’. However, there was some uncertainty as to whether the biopsy result was accurate given the large size of the mass. The woman decided to terminate the pregnancy for personal reasons. We proposed that she proceed with excision of the mass once free β-hCG values returned to normal. This would enable us to give a definitive prognosis regarding potential malignancy. Following termination, levels of free β-hCG declined (Figure S3) and the mass unexpectedly shrunk rapidly in size from 17 cm to 5.2 cm, allaying our concern that it was malignant. Given these findings, we suspected that the mass was a colliquative myoma that had regressed rapidly with termination of pregnancy. When levels of free β-hCG returned to normal a hysteroscopy was performed and, despite observing the presence of a 7-cm intramural myoma on ultrasound examination, the uterine cavity was empty and normal. The myoma was removed some days later by laparotomy (Figure 2), and was found to be totally intramuscular and 5 cm in size. Histological examination showed ‘cellular leiomyoma with infarct-type necrosis’. The rapid regression seen in our case following termination of pregnancy points to a reversal of the progestogenic effect of pregnancy on myoma growth1, 2. R. Scuderi*†, M. Giovannini‡, V. Villani§, T. Canino§ and D. Antonaci¶ †Obstetrical Surveillance Service, Sandro Pertini Hospital, Rome, Italy; ‡Department of Obstetrics and Gynaecology, Sandro Pertini Hospital, Rome, Italy; §Hysteroscopy and Surgery Service, Sandro Pertini Hospital, Rome, Italy; ¶Endometriosis Service, Sandro Pertini Hospital, Rome, Italy *Correspondence. (e-mail: [email protected]) Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.