Red degeneration of uterine fibroid

Case contributed by Alexandra Stanislavsky

Presentation

Right lower quadrant pain and fevers D10 post egg pick up for IVF. Collection post egg-retrieval?

Patient Data

Age: 25 years
Gender: Female
ultrasound

The uterus is anteverted and enlarged, measuring 99 x 133 x 105 mm (vol: 725 ml).

There is a large solitary fibroid measuring 76 x 76 x 71 mm. It is heterogeneous with increased echogeniticy relative to the myometrium. 

Heterogeneous, mobile material is present within the endometrial cavity, to a volume of approximately 25ml. This likely represents blood.

The right ovary measures 52 mm x 34 mm x 39 mm (36 cc) and contains 16 follicles with the largest follicle measuring 24 mm. 

The left ovary measures 54 mm x 39 mm x 42 mm (46 cc) and contains 15 follicles with the largest follicle measuring 24 mm.

No free fluid or collection in the pelvis.

The uterus is anteverted and enlarged due to the presence of a dominant fibroid.

Uterine dimensions: 11.8 x 10.2 x 10.1 cm; volume 644 cc.

The dominant fibroid characteristics are as follows.

Size: 8.1 x 7.2 x 7.0 cm (216 ml) - essentially unchanged since recent ultrasound.
Location: Anterior intramural
Signal characteristics: Heterogeneously T2 hyperintense. T1 hyperintense without fat suppression, particularly at the periphery is of the mass. This is suggestive of blood products. No significant restricted diffusion. Circumscribed margin with a low signal pseudocapsule, margin irregular in some areas which could be due to recent distension.Contrast enhancement: Complete absence of post-gadolinium enhancement suggests infarction of fibroid.

Two smaller intramural fibroids also noted - fundal submucosal (>50% intramural) (1.1 cm) and left lateral intramural (1.3 cm). 

Endometrium is thin, measuring 3mm. The small submucosal fibroid does not distort the endometrial contour.

Within the right ovary, there are 5 distinct cystic areas that are hyperintense on both T2 and on T1 weighted images without fat suppression, consistent with the presence of blood products. In this clinical context it is likely secondary to the recent egg retreival.  DDx small endometriomas but there are no additional features to suggest background endometriosis.

Within the left ovary, there are 4 cysts/follicles with similar characteristics to the right side.

No pelvic free fluid.

Incidental right femoral neck synovial herniation pit, which may be seen with femoroacetabular impingement.

Case Discussion

Features of fibroid red degeneration in the context of IVF/egg retreival.

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