A 34-year-old gravid female was referred to a tertiary hospital at 38+ weeks with a large cystic pelvi-abdominal (PA) mass detected on ultrasound. She had no known medical co-morbidities and one previous uneventful pregnancy culminating in a normal vaginal delivery (NVD) at full term. On presentation, the patient was asymptomatic and examination revealed only an increased symphysis-pubis fundal height (SFH) for expected gestation. Urine analysis showed proteinuria and blood tests revealed a minimally elevated cancer antigen-125 of 48 kU/L (normal range 0-35 kU/L) and a normal carcinoembryonic antigen level of 0.7 ng/mL (normal < 5.0 ng/mL).
Transabdominal ultrasound showed a thick-walled cystic mass measuring approximately 25 cm x 14 cm x 15 cm with no internal vascularity. The mass was assumed to be ovarian in origin. A singleton intra-uterine pregnancy with foetal heartbeat was confirmed. A transvaginal ultrasound scan was not performed.
The decision was made to induce labour based on the unclassified proteinuria and the clinical suspicion of possible underlying pre-eclampsia. During the induction of labour, foetal monitoring showed subtle signs of foetal distress, which warranted continuous monitoring, but despite in-patient care and continuous foetal monitoring, there was subsequent intra-uterine foetal demise and the patient delivered a stillborn baby via NVD. Following delivery, the patient's condition deteriorated in the ward, developing a persistent unexplained tachycardia of approximately 150 bpm, a blood pressure of 156/119 mmHg and a serum calcium level well above normal limits (4.25 mmol/L, normal limit is 2.62 mmol/L). Emergent cross-sectional imaging in the form of contrasted CT abdomen showed a large cystic mass with a thick, irregular enhancing wall and septations (Figure 1), which was inseparable from the uterine fundus (Figure 2). In addition, extensive left ovarian and pelvic vein thrombosis (Figure 3) and an enlarged, poorly enhancing left ovary were noted (Figure 4).
Exploratory laparotomy revealed a large, friable, thick-walled, pedunculated fundal mass, left ovarian vein thrombosis, necrosis of the left ovary and broad ligament and offensive intra-uterine contents. The decision to proceed to total abdominal hysterectomy and left salpingo-oophorectomy was taken based on significant intra-operative bleeding, friable necrotic tissue and haemodynamic instability. Histopathological evaluation revealed a subserosal uterine leiomyoma with extensive hyaline degeneration and necrosis, left ovarian vein thrombosis, haemorrhagic infarction of the left ovary and endometrial and myometrial necrosis.
No patient identifiable information has been presented. Informed verbal consent was obtained from the patient prior to publication.