Necrosis of the myomatous node is a complication of uterine fibroids associated with impaired vascularization and nutrition of the tumor and leading to irreversible changes in the tissues of the nodular formation. Disease is accompanied by the development of a picture of an acute abdomen with pain, nausea and vomiting, hyperthermia, tension of the anterior abdominal wall, dysuria and gas retention. The complication of uterine fibroids is diagnosed by general examination and vaginal examination, pelvic ultrasound, laparoscopy. Treatment of necrosis of the myomatous node is emergency surgical in the scope of conservative myomectomy, amputation of the uterus, hysterectomy, pangisterectomy.
Necrosis of the myomatous node is characterized by necrosis of tumor tissues due to twisting of the fibroid leg or violation of its vascularization. Necrotic changes can occur in nodes of any localization – submucous, subserous, intramural. The incidence of necrosis of the myomatous node in gynecology occurs in 7% of all cases of uterine fibroids. Signs of cystic degeneration or necrosis are found in 60% of the planned removed myomatous nodes. In necrotic tissues, edema, hemorrhages, degeneration, and aseptic inflammation develop. Further progression of necrosis of the myomatous node can lead to peritonitis.
The direct cause of circulatory disorders in the myomatous node may be an inflection or twisting of the tumor leg, venous congestion, ischemia or multiple thrombosis in the intramural nodes. Uterine fibroids, increasing in size, can cause deformation or complete compression of the vessels feeding it. Nodes of intramural localization often undergo necrosis and ischemia due to pronounced contractions of the myometrium after childbirth or the use of drugs that reduce uterine muscles. Subserous fibroids often have a thin leg, which, as a result of its mobility, often leads to twisting of the node.
Myomatous nodes can necrotize during pregnancy when, against the background of increased vascular tone, there is a decrease in arterial blood supply to the myometrium and a violation of venous outflow. It should also be borne in mind that myomatous nodes grow in parallel with the increase in the size of the pregnant uterus. Therefore, the management of pregnancy in women with uterine fibroids requires caution regarding the risk of necrosis of the myomatous node. The probability of developing necrosis of the myomatous node also increases due to physical exertion (sharp bends, lifting weights, jumping), in the postpartum period, after abortion.
According to morphological signs in gynecology, it is customary to distinguish between wet, dry and red necrosis of the myomatous node. Wet necrosis is characterized by softening and moist necrosis of tissues in which cystic cavities are formed. Dry necrosis of the myomatous node is characterized by wrinkling of necrotic tumor sites with the formation of cavernous cavities with remnants of dead tissues in these zones.
Intramurally located myomatous nodes in pregnant and recently delivered women are usually exposed to red necrosis. Macroscopically, with red necrosis, the myomatous node is colored reddish-brown, has a soft consistency, dilated veins with thrombosis.
Against the background of aseptic necrosis of the myomatous node, as a rule, infectious inflammation develops due to lymphogenic or hematogenic introduction of microbial pathogens (Staphylococcus, E. coli, streptococcus). Infection of necrotic nodes is associated with the risk of developing peritonitis or a generalized form of infection – sepsis.
The severity of clinical manifestations of necrosis of the myomatous node is determined by the degree of disorders that have occurred. In the case of twisting of the leg of the node, symptoms appear suddenly; the clinic of an acute abdomen develops with cramping pains, nausea and vomiting, chills, fever, dry mouth, intestinal dysfunction (constipation, flatulence).
In case of violation of the vascularization of the myomatous node, the symptoms are more erased and increase gradually. In this case, there are periodically increasing and weakening pulling pains in the lower back and lower abdomen. During a painful attack, subfebrility, tachycardia, chills, nausea, violation of urination and stool develop.
When diagnosing necrosis of the myomatous node, indications in the anamnesis for uterine fibroids, complaints, and clinical manifestations are taken into account. During physical examination, attention is drawn to the pale color of the skin, the coating of the tongue with a whitish coating, bloating, soreness and positive peritoneal symptoms in the lower abdomen.
Gynecological examination reveals an enlarged uterus with signs of fibroids, sharply painful in the area of the necrotic node. Ultrasound of the pelvis with necrosis of the myomatous node is characterized by the following acoustic signs: a decrease and heterogeneity of the density of formation, the appearance of cystic cavities in the node. With the help of Dopplerography, signs of impaired blood flow are detected inside the nodular formation and adjacent areas of the myometrium.
Diagnostic laparoscopy allows you to visually examine the pelvic organs and, if necessary, provide access for surgical intervention. Upon examination, an enlarged myomatous uterus with signs of necrosis is determined – edema, hemorrhages, cyanotic-purple node color. Necrosis of the myomatous node is differentiated with twisting of the leg of the ovarian cyst, ectopic pregnancy, ovarian apoplexy, acute appendicitis, pyosalpinx, piovar.
If necrosis of the myomatous node is suspected, emergency hospitalization and surgical assistance are required. In case of necrosis caused by twisting of the leg of the myomatous node, the choice of the volume of intervention depends on the age of the woman, the degree of necrotic changes, the presence of peritonitis. In women of the reproductive phase and in pregnant women in the absence of peritonitis, conservative myomectomy is limited, if possible. Patients in the pre- and postmenopausal period are shown radical interventions – supravaginal amputation of the uterus, hysterectomy without appendages or pangisterectomy.
With ischemia of the myomatous node, surgical intervention can be delayed for 24-48 hours; at this time, infusion therapy is carried out, aimed at reducing intoxication, normalizing the water-electrolyte balance. The volume of the operation is further determined by the same criteria.
Prognosis and prevention
If a picture of an acute abdomen appears against the background of existing uterine fibroids, immediate treatment to a gynecological or surgical hospital is required. With timely recognition and provision of surgical aid, the prognosis is satisfactory. The possibility of preserving reproductive capabilities depends on the surgical situation. With the progression of the phenomena of necrosis of the myomatous node with the development of diffuse peritonitis and sepsis, the disease may end unfavorably.
Prevention includes timely diagnosis, rational conservative treatment of uterine fibroids or its planned surgical removal. Annual preventive medical examination, including a gynecologist’s examination and ultrasound of the pelvic organs, allows you to avoid complications of uterine fibroids. When planning pregnancy, women with diagnosed uterine fibroids should take into account all possible risks.