A pregnant woman with fibroid uterus develops acute pain in abdomen with low grade fever and mild leucocytosis at 28 week. The most likely diagnosis is :
Ans. is c I.e. Red degeneration of fibroid Friends, the answer is quite obvious but let's see how other options can be ruled out. Option "a-Preterm labour Points in our Patient is pregnant Pain in abdomen at 28 weeks (Preterm labour is where labour stas before the 37'" completed weeks. The lower limit is 28 wks in developing countries and 20 wks in developed countries Points against Preterm labour is diagnosed - When there are regular uterine contractions. (Not acute pain) With or without pain at least in every 10 minutes. Dilatation of cervix is > 2 cms -- Effacement of cervix = 80% - Length of cervix as measured by TVS < 2.5 cms & funneling of the internal OS. Pelvic pressure backache, vaginal discharge or bleeding. None of the above criteria are being fulfilled. Presence of leucocytosis & fever can also go against it as even if there is intraamniotic infection causing preterm labour - features like : fever, leukocytosis, uterine tenderness and fetal tachycardia are absent. Rather if these features are present it means a final stage of uterine infection has reached. And here our patient is having fever, Leukocytosis without regular uterine contractions (off and on pair) but with acute pain in abdomen so it can be ruled out . Points in our Points against Patient has fibroid (Though no mention has * Torsion is not associated with fever been made whether it is pedunculated and leucocytosis. or not, Remember torsion is seen in subserous pedunculated Myomas)deg Patient is complaining of acute pain in abdomen. Option "d" Infection of fibroid Points in our Points against Presence of fibroid * Acute pain in abdomen (Remember : Infection is common (Infection of fibroid will not cause acute pain in abdomen). in submucous fibroids)deg * Infection of fibroid occurs following aboion or labour Fever (Here patient is pregnant but there is no history of Option "c" Red degeneration of fibroid Red degeneration of fibroid : also called as Cameous degeneration. It is seen mostly during pregnancy mid pregnancydeg (But can occur at other times as well and in non pregnant females also).deg It is an aseptic condition.deg The myoma suddenly becomes acutely painfuldeg, enlargeddeg and tenderdeg. Patient presents with : Acute abdominal paindeg Vomittingdeg Malaisedeg - Slight feverdeg Lab investigations : - Moderate leucocytosisdeg Raised esrdeg Pathological changes in the tumour : Fibroid becomes soft. necrotic or homogenous especially in its centre. It is stained Salmon pinkdeg, or red (due to Diffusion of blood pigments from the thrombosed vessels). It has fishy odourdeg (due to secondary infection with coliform organisms) Histologically : There is evidence of thrombosis in some vessels.deg Pathogenesis : There is subacute necrosis of the myoma caused by an interference in blood supply (aseptic infarction).deg Management : Conservative managementdeg Patient is advised restdeg Analgesics are given to relieve the pain.deg The acute symptoms subside in 3-10 daysdeg and pregnancy proceeds uneventfully. Diagnosis is by ultrasound. D/D Appendicitisdeg, Twisted ovarian cystdeg, Pyelitisdeg and Accidental haemorrhagedeg. So amongst above options - Red degeneration is the correct answer.
Preterm labour
Torsion of fibroid
Red degeneration of fibroid
Infection in fibroid