pregnant woman with a fibroid uterus develops severe acute pain abdomen at 28 weeks of gestation. There is no history of fever and the WBC count is 8000 cells/mL. The most likely diagnosis is: A. Red degeneration of fibroid B. Preterm labour C. Torsion of fibroid D. None of the above
Reading File
Finding Sources
Answer: A. Red degeneration of fibroid
Reasoning:
Red (carneous) degeneration is the classic cause of acute abdominal pain in a fibroid uterus during pregnancy, most often occurring in the second trimester (16-28 weeks), which fits this vignette exactly. As the pregnant uterus and fibroid grow rapidly, the fibroid's blood supply cannot keep pace, leading to venous thrombosis, hemorrhagic infarction, and aseptic necrosis within the tumor - this produces sudden, severe, localized abdominal pain, tenderness over the fibroid, and sometimes low-grade fever with mild leukocytosis (or a normal count, as here). Per Bailey and Love's Short Practice of Surgery: "women may present acutely with pain arising from torsion of a pedunculated fibroid or red degeneration, especially in pregnancy" - red degeneration being by far the more common of the two.
Why not the others:
- B. Preterm labour - would present with regular uterine contractions, cervical changes, not typically localized severe pain over a fibroid; the scenario specifically frames this as a fibroid-related complication.
- C. Torsion of fibroid - requires a pedunculated (usually subserosal) fibroid on a stalk; nothing in the vignette suggests a pedunculated fibroid, and torsion is far less common than red degeneration during pregnancy.
- D. None of the above - not applicable since red degeneration fits well.
The absence of fever and a normal/borderline WBC count (8000/mL) argues against an infective/inflammatory process (like torsion with necrosis progressing to peritonitis) and is consistent with the typically mild, self-limiting inflammatory response of red degeneration, which is managed conservatively with rest and analgesia (usually NSAIDs, used cautiously in pregnancy) since it is usually self-resolving over 4-7 days.
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