Pregnancy complicated by a large prolapsing cervical fibroid requiring antepartum vaginal myomectomy—A case report

Uterine fibroids are the most common benign tumors of the female reproductive tract, with an estimated prevalence of 70%–80% in women by the age of 50 years. ¹ Although most remain asymptomatic during pregnancy, certain subtypes, particularly large or cervical fibroids, can lead to complications such as pain, miscarriage, preterm labor, and obstructed labor, and rarely can prolapse into the vaginal canal. ² , ³ , ⁴ Prolapsed cervical fibroids are exceedingly rare and pose unique risks including hemorrhage, infection, and necrosis. ⁵

Management of fibroids during pregnancy, particularly when surgical intervention is required, remains controversial. Conservative management is typically preferred because of the significant maternal and fetal risks associated with antepartum myomectomy, including hemorrhage, preterm labor, and, rarely, hysterectomy. ⁶ , ⁷ , ⁸ The most cited indication for surgical management is severe, intractable abdominal pain unresponsive to medical therapy. ⁶ In a prospective cohort study, laparotomic myomectomy performed between 14 and 16 weeks of pregnancy was associated with an intraoperative miscarriage rate of 14.3% and a postoperative threatened preterm birth rate of 32.1%, although 85.7% of patients ultimately delivered at term. ⁷

Systematic reviews suggest that antepartum myomectomies are most often performed via laparotomy and involve subserosal or pedunculated fibroids. Although outcomes are generally favorable in carefully selected cases, the consensus remains that surgical intervention during pregnancy should be reserved for refractory cases after thorough counseling. ⁶ , ⁸ Cesarean myomectomy is considered a separate clinical entity and is not directly applicable to antepartum cases, as its safety and efficacy remain uncertain. ⁹

We present the case of a 36‐year‐old woman, gravida 2, para 2, live 1, known to have a large posterior cervical fibroid. Her antepartum history was significant for triage visit at 20 weeks for increased vaginal pressure. On speculum examination, the cervix was not visible, but a firm globular mass was palpated in the posterior vaginal fornix. Ultrasound confirmed that the fibroid was not prolapsing through the cervix (Figure 1a). Given her hemodynamic stability, and reassuring fetal status, and the unclear extent of the fibroid, a conservative approach was adopted.

FIGURE 1.

(a) Transabdominal ultrasound at 18 weeks of pregnancy indicating the posterior cervical fibroid (8.5 × 5.8 cm) and the cervical canal anteriorly. (b) Prolapsing cervical fibroid (25.5 × 15.3 × 9.5 cm) with view of anterior cervical lip (gray arrow). (c) Fibroid base along posterior cervical lip after myomectomy. (d) Fibroid base after approximation of tissues with 0 Vicryl interrupted sutures. Cervical canal is indicated by an asterisk.

At 24⁺¹ weeks of pregnancy, she re‐presented with the fibroid now prolapsing 6 cm past the vaginal introitus, showing signs of necrosis. Despite this, she remained hemodynamically stable and was not in acute distress. Fetal heart tracing was reassuring. Prophylactic antibiotics (azithromycin and metronidazole) were initiated, and a vaginal myomectomy was scheduled for the following morning. She also received the first dose of betamethasone for fetal lung maturation.

Overnight, the fibroid continued to prolapse past the introitus, rendering the cervix fully visible circumferentially, and measuring approximately 15 cm in length (Figure 1b). The patient developed acute intractable pain refractory to fentanyl and ketamine, with associated fetal variable decelerations. An emergency vaginal myomectomy was performed.

Intraoperatively, vasopressin was injected at the superior aspect of the fibroid base, which was then incised using cutting cautery. The fibroid was carefully enucleated from the posterior lip of the cervix, and the defect was repaired in multiple layers using interrupted 0 Vicryl sutures, reattaching it to the posterior cervix (Figure 1c,d). Hemostasis was successfully achieved, and there were no intraoperative complications. The patient remained hospitalized for 3 days, during which she received the second dose of betamethasone and a 24‐h course of magnesium sulfate for fetal neuroprotection.

At 27⁺³ weeks of pregnancy, she was readmitted with preterm premature rupture of membranes and suspected chorioamnionitis, presenting with abundant purulent vaginal discharge. An emergency cesarean section was performed that evening due to fetal heart decelerations and fetal malpresentation (transverse lie). A female infant weighing 1040 g was delivered with Apgar scores of 2, 7, and 8 at 1, 5, and 10 min, respectively. Final pathology confirmed the presence of a uterine leiomyoma with areas of hemorrhage and hyalinization, measuring 25.5 × 15.3 × 9.5 cm and weighing 1391 g.

This case highlights the complexity and risks involved in managing prolapsed cervical fibroids during pregnancy. At 20 weeks, there was no indication for surgical intervention, and conservative management was appropriately chosen. When the patient re‐presented at 24 weeks, despite the fibroid's partial prolapse and necrosis, the patient remained stable and the plan for surgery was appropriately timed. The complete extrusion of the fibroid overnight unexpectedly clarified the anatomy, enabling a safer and more controlled vaginal myomectomy.

Additionally, this case reinforces the importance of individualized, case‐specific surgical planning based on evolving clinical context, gestational age, and available resources. Antepartum myomectomy should remain reserved for patients with severe, refractory symptoms or complications, in alignment with the current literature. Further research is warranted to develop standardized treatment pathways and improve evidence‐based management of rare pregnancy complications such as prolapsed cervical fibroids.

AUTHOR CONTRIBUTIONS

ST contributed to conceptualization, wrote the original draft, and contributed to the reviewing and editing; AT contributed to conceptualization and to the reviewing and editing; and VM contributed to the reviewing and editing.

CONFLICT OF INTEREST STATEMENT

The authors have no conflicts of interest.

Taylor S, Tshala A, Marcoux V. Pregnancy complicated by a large prolapsing cervical fibroid requiring antepartum vaginal myomectomy—A case report. Int J Gynecol Obstet. 2026;172:1255‐1. doi: 10.1002/ijgo.70442

DATA AVAILABILITY STATEMENT

Data sharing is not applicable to this article as no new data were created or analyzed in this study.