Uterine leiomyomas are prevalent in women of reproductive age, and they are associated with complications during pregnancy, labor, and delivery.
1 Size and location of the leiomyoma are the greatest predictors of morbidity.
12 In the current case, in addition to the risks associated with all leiomyomas during pregnancy, the retroplacental location of the leiomyoma increased the likelihood of placental abruption and postpartum hemorrhage, which could have been caused by retained products of conception.
9,13 The patient had an uncomplicated term delivery; however, an immediate postpartum hemorrhage with a high suspicion for retained products of conception necessitated emergent dilation and curettage in tandem with the administration of uterotonics. The patient's irregular lochia and pain late in the postpartum period was attributed to the degenerative leiomyoma. It is possible that postpartum curettage caused a disruption of the myometrium at the placental implantation site, allowing the degenerating leiomyoma to erode through the uterine submucosa into the endometrial cavity. Involution and degeneration continued, allowing for delayed postpartum prolapse of a large portion of the leiomyoma. Manual removal of the majority of the tissue was possible due to the degenerative process and partially pedunculated nature, but the inability to remove the mass in its entirety was likely due to the true intramural location of the leiomyoma. Management of prolapsed leiomyoma typically involves surgical intervention via a vaginal or abdominal approach through either a myomectomy or hysterectomy.
14 A vaginal myomectomy is largely successful after prolapse occurs.
15 In the current case, it was possible to alleviate the patient's symptoms (ie, pain and bleeding) in the short term and then use a second, delayed attempt at removal with a minimally invasive hysteroscopic technique.