Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

Users Online : 116600

AbstractCase ReportDiscussionConclusionAcknowledgementReferencesDOI and Others
Article in PDF How to Cite Citation Manager Readers' Comments (0) Audio Visual Article Statistics Link to PUBMED Print this Article Send to a Friend
Advertisers Access Statistics Resources

Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"

Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018

Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."

Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018

Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."

Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018

Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."

Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
On Sep 2018

Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."

Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata

Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
On Aug 2018

Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".

Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
On Aug 2018

Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".

Dr. Mamta Gupta
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018

Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.

Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."

Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Case report
Year : 2022 | Month : October | Volume : 16 | Issue : 10 | Page : QD01 - QD03 Full Version

Acute Abdomen during Pregnancy with Fibroid Uterus: Red Degeneration or Torsion?

Published: October 1, 2022 | DOI:
Vignesh Durai, Poojitha Kalyani Kanikaram, Chitra Thyagarajan, Papa Dasari

1. Junior Resident, Department of Obstetrics and Gynaecology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India. 2. Senior Resident, Department of Obstetrics and Gynaecology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India. 3. Additional Professor, Department of Obstetrics and Gynaecology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India. 4. Professor, Department of Obstetrics and Gynaecology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India.

Correspondence Address :
Dr. Papa Dasari,
Professor, Department of Obstetrics and Gynaecology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry-605006, India.


During pregnancy, red degeneration and torsion of subserosal fibroid may present with acute abdomen, creating a diagnostic dilemma. Red degeneration of fibroid during pregnancy responds to conservative management, whereas torsion of a subserosal fibroid requires emergency myomectomy. This case report describes a clinical scenario wherein difficulties were encountered in diagnosing the cause of acute abdomen during mid-trimester in a pregnant woman with fibroid uterus and the role of imaging to differentiate the above two clinical conditions. A 26-year-old staff nurse, a primigravida with subserous fibroid presented at 19 weeks with pain in abdomen and vomiting. She was provisionally diagnosed with red degeneration and treated conservatively for 48 hours. Her symptoms persisted, and hence torsion of the subserous fibroid was suspected. However, no pedicle was visualised on 2D Ultrasound (USG). Therefore, Magnetic Resonance Imaging (MRI) was done, which revealed the pedicle, and accordingly, the decision for emergency laparotomy was taken, and the fibroid was excised. Histopathology revealed infarction of leiomyoma. The pregnancy continued in a regular course.


Emergency laparotomy, Myomectomy, Torsion of pedunculated fibroid, Uterine fibroid

Case Report

A 26-year-old staff nurse, a primigravida with fibroid uterus at 19 weeks of gestation, presented to the emergency facility with sudden onset of lower abdominal pain. The pain was continuous, dull aching, and was referred to the lower back. There was no history of vomiting or fever. Her general condition was fair on clinical examination; her pulse rate was 96 beats per minute, blood pressure was 100/60 mmHg, and her abdominal examination revealed 18 weeks size gravid uterus, which was non tender. Vaginal examination revealed discharge suggestive of candidiasis, and she has advised treatment with the clotrimazole vaginal pessary for the above. She was reassured and was asked to follow-up on an outpatient basis.

Within 24 hours, she presented again with increasing severity of pain abdomen associated with two episodes of vomiting, and there was no history of fever or obstipation. Abdominal examination revealed tenderness over the mass occupying the left lumbar region and a gravid uterus of 18 weeks in size. Ultrasound (USG) revealed a live foetus of 18 weeks gestational age, posterior placenta with good liquor, no retroplacental clot, and a 6.4×6.2 cm subserosal fibroid visualised towards the left-side of the uterine fundus. Doppler showed the presence of decreased internal vascularity in the mass, and the pedicle could not be visualised. A provisional clinical diagnosis of red degeneration of the fibroid was made, and she was hospitalised and managed conservatively with intravenous fluids and analgesics for 48 hours.

Her present pregnancy was confirmed at 10 weeks of pregnancy by USG. Single live intrauterine gestation with Crown-Rump Length (CRL) of 32 mm was seen. There was a subserosal fibroid on the anterior wall of the uterus, which measured 6×6.2 cm. She was advised to take folate tablets and review at 13 weeks for Nuchal Translucency (NT) scan. NT measured 1.6 mm at a CRL of 72 mm, and the fibroid measured 6.4×6.2 cm. She did not experience discomfort or pain during the first and early second trimesters.

Now at 19+3 weeks after admission with a provisional diagnosis of red degeneration, the abdominopelvic pain increased in severity, and she developed an increased frequency of micturition and vomiting, which persisted for more than 48 hours; hence torsion of fibroid was suspected. Her USG findings in the non pregnant states were reviewed, but there was no mention regarding whether the subserous fibroid was pedunculated or not. Hence, Magnetic Resonance Imaging (MRI) of the abdomen and pelvis was performed to differentiate between torsion of subserous fibroid and red degeneration. The MRI revealed a large subserosal pedunculated fibroid along the left lateral myometrium, which showed heterogeneous signal intensity with internal areas of haemorrhage, possibly red degeneration of fibroid (Table/Fig 1),(Table/Fig 2). A diagnosis of torsion of the pedunculated subserosal fibroid was made along with clinical features.

She was counselled regarding the need for surgery and the operative and postoperative risks associated with uterine surgery during pregnancy. A senior obstetrician and two assistants performed an emergency laparotomy under spinal anaesthesia at 19+3 weeks. Considering the fibroid location and size, a vertical supraumbilical incision extending 2 cm below the umbilicus was given. The haemorrhagic fluid of approximately 100 mL was present inside the peritoneal cavity. A large mass of 12×6 cm {International Federation of Gynaecology and Obstetrics (FIGO) type 7} arising from the left anterior wall of the uterine fundal region with a small (<1 cm) partially necrotic pedicle with partial torsion was present in the left posterolateral aspect of the gravid uterus causing minimal torsion of the gravid uterus to the left. The mass was gently brought out of the incision, and the pedicle was detorted, clamped, cut, and ligated. After closing the abdomen, a USG was performed for foetal cardiac activity and amniotic fluid, which were normal. The removed mass was larger than the preoperative imaging estimated, and it was soft in consistency. The cut-section showed bluish necrotic areas with areas of infarction (Table/Fig 3),(Table/Fig 4).

The histopathology of the mass was found to have interlacing fascicles of smooth muscle cells, elongated nucleus, bland chromatin, eosinophilic cytoplasm with hyalinisation and large areas of infarction. The final diagnosis was reported as leiomyoma with extensive areas of infarction (Table/Fig 5). The postoperative hospitalisation lasted five days, while antibiotics, tocolysis with nifedipine, and progesterone therapy were maintained. The pregnancy continued normally, and she delivered vaginally a 2.9 kg healthy male baby at 39 weeks after a spontaneous onset of labour.


Fibroids are hormone-sensitive benign tumours of uterine smooth muscles, commonly encountered during pregnancy. The prevalence in non pregnant women ranges from 10-50%, but in pregnancy, it is reported to be 2-10% (1),(2). Fibroids are typically asymptomatic during pregnancy, but some women experience pain for various reasons. Red degeneration, torsion, abortion and infection that complicate pregnancy may present with acute pain abdomen apart from preterm labour and antepartum haemorrhage in late pregnancy (3),(4).

Fibroid-related complications occur in 10-20% of women during pregnancy (5), and red degeneration occur in 8% (6). The fibroid’s red/carneous degeneration is defined as haemorrhagic infarction of a previously hyalinised myoma caused by ischaemic necrosis, as the rapid fibroid growth outweighs its blood supply (7). It most often occurs during pregnancy and is associated with oral contraceptive use. However, the patient did not have any history of taking oral contraceptive pills. Red degeneration can also occur rarely in non pregnant women (8). Clinically, this condition is characterised by acute onset focal abdominal pain, mild fever, nausea and vomiting, localised tenderness over the fibroid and leucocytosis (9). Torsion of the fibroid must be suspected when pain persists beyond a reasonable period or a previously diagnosed pedunculated fibroid. Rare reports of uterine torsion in the third trimester secondary to large or multiple subserous fibroids have also been described (10),(11). The incidence of torsion of a uterine fibroid is less than 0.25% in non pregnant individuals (12).

Red degeneration and torsion of fibroid during pregnancy have similar clinical features, leading to a diagnostic dilemma as in the present case.Therefore, it is essential to differentiate between red degeneration and torsion, as red degeneration is managed by conservative treatment, whereas torsion needs surgical management. Imaging plays a significant role in deciding the management in this challenging situation.

Close inpatient monitoring of the patient’s symptoms like persistent or increased pain, and vomiting, despite conservative management with analgesics, must lead to clinical suspicion of torsion of the fibroid. Still, confirmation is necessary to avoid unnecessary surgical procedures during pregnancy, leading to pregnancy loss. A brief literature review also suggests that the clinical features of red degeneration of fibroid and torsion of the subserosal fibroid overlap, and imaging is required to arrive at an accurate clinical diagnosis. USG doppler and MRI are usual imaging modalities. MRI has the highest diagnostic accuracy in differentiating these two conditions (13). With 2D USG, it can be challenging to identify very small pedicles of subserosal fibroids. Either transabdominal or transvaginal ultrasound is a simple, non expensive way to locate fibroid and diagnose degeneration if present. In the present case, 2D USG could not identify the subserous fibroid’s small pedicle (<1cm), and MRI was more helpful in reaching an accurate diagnosis. The sensitivity and specificity of MRI in diagnosing degeneration of uterine fibroids are 60% and 93.7%, respectively (14). MRI should be considered in conditions where the pain persists beyond a reasonable period as it helps to evaluate acute leiomyoma complications during pregnancy. Fibroids with red degeneration appear as peripheral or diffuse hyperintensity on T1 weighted images, and variable signal intensity with the hypointense rim on T2 weighted images (15). Torsion of a leiomyoma on MRI shows a high-intensity signal on the T1 image, and the centre of the mass would be more intense than the periphery of the mass on the T2 image (16). The pelvic mass appears without enhancement due to a lack of vascularity compared to an adequately perfused enhanced uterus in the post-contrast study (16). In the present case, the small pedicle was visualised by MRI, and it was reported that there were areas of haemorrhage suggesting that it was a pedunculated fibroid that may have undergone torsion.

Conservative management is the gold standard for red degeneration of fibroid, including hospitalisation, analgesics, intravenous fluids, and antiemetics, which are almost always successful (7). Low-dose narcotic analgesia is preferred over Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) as there is a risk of premature closure of ductus arteriosus on prolonged NSAID usage (7). A timely diagnosis and management are required as there can be a possibility of spontaneous perforation/rupture of a red degenerated fibroid which may require peripartum hysterectomy due to uncontrollable bleeding (17). Red degeneration can also result in intracapsular bleed causing haemodynamic instability and requiring exploratory laparotomy (18). One such case was reported by Kaur H and Kumar N, wherein a 27 week primigravida underwent laparotomy for a 28 cm multilobulated fibroid uterus and had a subtotal hysterectomy due to torrential haemorrhage (18).

The surgical management of fibroid during pregnancy includes torsion, failure of medical management (more than three days) of a degenerated fibroid and severe pressure symptoms (19). In most individuals, laparotomy is performed, though laparoscopy has been used for a 24 cm subserosal pedunculated myoma in a woman at 15 weeks gestation (20). Hence, laparoscopy can successfully be performed mainly when the torsion occurs in the first trimester (21). Laparotomic myomectomy is rarely done during an ongoing pregnancy due to the increased risk of stillbirth, abortion, and preterm labour. Most patients of laparotomic myomectomy described in the literature have been done during a caesarean section, while few case reports of antepartum myomectomy are described. To prevent adverse foetal outcomes, care must be taken to avoid electrocautery use and limited manipulation of the uterus during myomectomy. In a clinical case reported by Umezurike C and Feyi-Waboso P, a 30-year-old primigravida presented at 19 weeks of gestation had a gradually increasing abdominal swelling over three months associated with pain and severe epigastric discomfort (22). USG revealed a 30 cm multiloculated cystic tumour at the right posterosuperior aspect uterus. Because of the severity of symptoms and USG findings, surgery was proposed, and laparotomy was done. A cystic subserosal fibroid of 32 cm arising from the right posteriorsuperior aspect of the uterus was removed. The histopathology was consistent with hyaline degeneration without any evidence of malignancy. She had an uneventful spontaneous vaginal delivery at 38 weeks. An operated pedunculated myoma in mid-trimester can be allowed for a vaginal delivery provided there are no obstetric indications for caesarean section. A successful vaginal delivery at term following laparotomic myomectomy for a failed medical management of a suspected necrotic fibroid had been reported. Intraoperatively there were three subserous pedunculated myomas, of which the largest measured 15 cm and had a torted pedicle. A successful myomectomy was performed at 17 weeks, and the cut surface of the myoma showed widespread necrotic areas (23).

An important differential diagnosis of acute abdominal pain related to leiomyoma in pregnancy is torsion of a pedunculated subserosal fibroid which is challenging to diagnose with a 2D USG. Therefore, a higher imaging modality like MRI is required when there is a diagnostic dilemma.


This clinical case report illustrates the diagnostic difficulties often encountered in managing acute abdomen during pregnancy complicated by fibroid uterus. MRI is a beneficial adjunct investigation to differentiate red degeneration from torsion of fibroid, as clinically both conditions have similar clinical features. In this case, ischaemia and infarction occurred following torsion of the fibroid.


Authors are grateful to Department of Radiodiagnosis for performing timely MRI and Department of Pathology.


Qidwai GI, Caughey AB, Jacoby AF. Obstetric outcomes in women with sonographically identified uterine leiomyomata. Obstet Gynecol. 2006;107(2 Pt 1):376-82. [crossref] [PubMed]
Laughlin SK, Baird DD, Savitz DA, Herring AH, Hartmann KE. Prevalence of uterine leiomyomas in the first trimester of pregnancy: An ultrasound-screening study. Obstet Gynecol. 2009;113(3):630-35. [crossref] [PubMed]
Stout MJ, Odibo AO, Graseck AS, Macones GA, Crane JP, Cahill AG, et al. Leiomyomas at routine second-trimester ultrasound examination and adverse obstetric outcomes. Obstet Gynecol. 2010;116(5):1056-63. [crossref] [PubMed]
Saleh HS, Mowafy HE, Hameid AAAE, Sherif HE, Mahfouz EM. Does uterine fibroid adversely affect obstetric outcome of pregnancy? Biomed Res Int. 2018;2018:8367068. [crossref] [PubMed]
Cerdeira AS, Tome M, Moore N, Lim L. Seeing red degeneration in uterine fibroids in pregnancy: Proceed with caution. Lancet. 2019;394(10212):e37. [crossref] [PubMed]
Kawakami S, Togashi K, Konishi I, Kimura I, Fukuoka M, Mori T, et al. Red degeneration of uterine leiomyoma: MR appearance. J Comput Assist Tomogr. 1994;18(6):925-28. [crossref] [PubMed]
Lee HJ, Norwitz ER, Shaw J. Contemporary management of fibroids in pregnancy. Rev Obstet Gynecol. 2010;3(1):20-27.
Somalwar SA, Agrawal N, Kawthalkar A, Mahore S, Vijay N. Red degeneration of leiomyoma: An unusual presentation. J South Asian Feder Obst Gynae. 2019;11(5):318-20. [crossref]
Zaima A, Ash A. Fibroid in pregnancy: Characteristics, complications, and management. Postgrad Med J. 2011;87(1034):819-28. [crossref] [PubMed]
Somani A, Shukla A, Kumari A. Uterine torsion of term pregnant uterus due to anterior fibroid. Indian J Obstet Gynecol Res. 2021;8(2):285-88. [crossref]
Yin FL, Huang HX, Zhang M, Xia XK, Xu H, Liu T, et al. Clinical analysis of uterine torsion and fibroids in full-term pregnancy: A case report and review of the literature. J Int Med Res. 2020;48(6):300060520920404. [crossref] [PubMed]
Lai YL, Chen YL, Chen CA, Cheng WF. Torsion of pedunculated subserous uterine leiomyoma: A rare complication of a common disease. Taiwan J Obstet Gynecol. 2018;57(2):300-03. [crossref] [PubMed]
Costa MDL, Cunha TM. Torsion of a pedunculated subserous leiomyoma: A case report of a rare cause of acute abdominal pain in a pregnant woman. Egypt J Radiol Nucl Med. 2020;147(51). [crossref]
Posh S, Rafiq S, Manzoor F, Ashraf O, Ahmad M. Accuracy of magnetic resonance imaging in assessing types of degeneration in leiomyoma. J Mahatma Gandhi Inst Med Sci. 2020;25(2):99. [crossref]
Takeuchi M, Matsuzaki K, Bando Y, Harada M. Evaluation of red degeneration of uterine leiomyoma with susceptibility-weighted MR imaging. Magn Reson Med Sci. 2019;18(2):158-62. [crossref] [PubMed]
Saber M. Torsion of a subserosal uterine leiomyoma. Case study, Radiopaedia. org. (accessed on 09 Aug 2022) [crossref]
Ayan FT, Çakmak B. Uterine rupture associated with red degeneration of a large fibroid: A case report. Journal of Contemporary Medicine 2013;3(1):56-57.
Kaur H, Kumar N. A Rare Case of Large Uterine Myoma in an Antenatal Women with Situs Inversus: A Case Report. Obstet Gynecol Cases. 2019;144(6). [crossref] [PubMed]
Lozza V, Pieralli A, Corioni S, Longinotti M, Penna C. Multiple laparotomic myomectomy during pregnancy: A case report. Arch Gynecol Obstet. 2011;284(3):613-16. [crossref] [PubMed]
Saccardi C, Visentin S, Noventa M, Cosmi E, Litta P, Gizzo S, et al. Uncertainties about laparoscopic myomectomy during pregnancy: A lack of evidence or an inherited misconception? A critical literature review starting from a peculiar case. Minim Invasive Ther Allied Technol. 2015;24(4):189-94. [crossref] [PubMed]
Currie A, Bradley E, McEwen M, Al-Shabibi N, Willson PD. Laparoscopic approach to fibroid torsion presenting as an acute abdomen in pregnancy. JSLS. 2013;17(4):665-67. [crossref] [PubMed]
Umezurike C, Feyi-Waboso P. Successful myomectomy during pregnancy: A case report. Reprod Health. 2005;2:06. [crossref] [PubMed]
Basso A, Catalano MR, Loverro G, Nocera S, Di Naro E, Loverro M, et al. Uterine fibroid torsion during pregnancy: A case of laparotomic myomectomy at 18 weeks’ gestation with systematic review of the literature. Case Rep Obstet Gynecol. 2017;2017:4970802. [crossref] [PubMed]

DOI and Others

DOI: 10.7860/JCDR/2022/58415.17017

Date of Submission: Jun 13, 2022
Date of Peer Review: Jul 28, 2022
Date of Acceptance: Aug 27, 2022
Date of Publishing: Oct 01, 2022

• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

• Plagiarism X-checker: Jun 19, 2022
• Manual Googling: Jul 30, 2022
• iThenticate Software: Aug 22, 2022 (5%)

ETYMOLOGY: Author Origin

JCDR is now Monthly and more widely Indexed .
  • Emerging Sources Citation Index (Web of Science, thomsonreuters)
  • Index Copernicus ICV 2017: 134.54
  • Academic Search Complete Database
  • Directory of Open Access Journals (DOAJ)
  • Embase
  • EBSCOhost
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)