Giant symptomatic uterine fibroid: A rare case in Enugu, South East Nigeria

This was a case of a 42year-old nulipara female who presented to a private specialist hospital in Enugu because of unusual but gradual abdominal distension. Her ultrasound diagnosis was of extensive intramural and subserosal myoma. Abdominal swelling was initially noticed around the lower abdomen but progressively increased in size involving the upper abdomen, that she later found it diffi cult to wear her regular clothes and move around easily.

Fasting blood sugar and two hours post prandial were normal. Liver function test, CA 125, serum electrolyte, and full blood counts were within normal range. She was counseled on her condition, and she consented to total abdominal hysterectomy. Figure 2 shows the fi broid masses intraoperatively after an incision was made on the abdominal wall and peritoneum. This was performed three week after presentation with good outcome. She was transfused with two units of blood intra operatively, and she was commenced on intravenous fl uid, antibiotics, and analgesics throughout the surgery and post-operative recovery. Her post-operative management was uneventful, and she was discharged on 6th post-operative day. She was followed up in the clinic for 6months without any complaint and was hence discharged off clinic Analysis of the fi broid mass indicated a weight of 14.5kg, and the microscopic examination revealed a benign mesenchymal proliferation composed of bundles of spindled cells. There were no atypical cells present, and histological diagnosis of leiomyoma was made by a pathologist.
as 70% of uteri removed at hysterectomy [3]. It is estimated that by their fi fth decade, as many as 50% of women of African descent will have leiomyoma [4]. The incidence is decreased with prolonged use of the oral contraceptive pill as well as increasing numbers of term pregnancies.
Uterine fi broids are described as giant when the fi broid tissues weigh more than 11.4kg or have a diameter more than 17cm or dimension of 33×28×22cm [5]. Giant fi broids are potentially life threatening, because they can exert a pressure effect on the surrounding organs, especially the heart and lungs. They are more common in nulliparous women with poor health-seeking attitudes, and they are 2-3 times more prevalent in black women compared with Caucasian, Hispanic or Asian women [3]. Mrs C. E was a black African, and nulliparous.
The etiology of uterine fi broids remains unknown. The main hormones implicated in the growth of fi broid are ovarian steroids (estradiol and progesterone), and the populations of receptors to these hormones are increased in fi broids [2]. Progesterone down-regulates apoptosis in a tumour while estrogen increases the production of extracellular matrix. Cytogenic abnormalities occur in 50% of fi broids, involving most commonly translocation within or deletion of chromosome [7], translocations of chromosomes 12 and 14 and occasionally, structural aberrations of chromosome [6]. In addition, mutations in the gene encoding fumarate hydratase were shown to predispose women to multiple fi broids [2].
Clinically, they present with grossly distended abdomen and pressure symptoms, such as a sensation of bloating, increased urinary frequency, respiratory diffi culty [3] and bowel disturbances. 6 Giant fi broids distend the abdomen with a feeling of dragging(of the abdomen), which may be aesthetically displeasing to many women as was seen in Mrs C. E, who felt embarrassed by her increased abdominal girth.
Due to distension of the anterior abdominal wall and the large volume of the abdominal cavity as uterine fi broids can grow into extremely large sizes [7]. the surgery were additional precautions taken to reduce post-operative adhesions, which can complicate abdominal hysterectomy.

Conclusion
In conclusion, giant fi broids are rarely found in modern times, but they do pose a management challenge. Grossly distended abdomen in a woman of reproductive age with no evidence of malignancy is the most obvious symptoms of a giant uterine fi broid mass. When found, giant fi broids can be a life threatening condition, if they are not managed promptly. This is due mainly to their pressure effects on surrounding organs [4]. The case presented had a successful outcome following expert management.