Introduction
Leiomyosarcoma (LMS) is a rare and aggressive malignancy arising from smooth muscle tissue, particularly in the uterus. The incidental discovery of LMS during pregnancy is exceedingly rare, with fewer than a dozen cases documented. This article highlights a compelling case where a seemingly routine caesarean section led to the diagnosis of uterine LMS, underscoring the importance of vigilance during obstetric procedures. Visit https://www.obstetricgynecoljournal.com/ for more groundbreaking research in this field.

Background and Case Overview

• A 30-year-old woman, monitored for a stable fibroid since 2015, became pregnant naturally.
• During her second pregnancy, the fibroid enlarged to 11–13 cm but remained stable.
• At 38+3 weeks, she underwent a caesarean section for breech presentation.
• A 19 cm intramural/submucosal mass was noted intraoperatively, leading to a decision for myomectomy.
• Histological examination revealed high-grade spindle cell leiomyosarcoma.
• Read the full study at https://doi.org/10.29328/journal.cjog.1001094.

Management and Treatment Pathway
Following the unexpected diagnosis:

• A CT thorax, abdomen, and pelvis showed no metastasis.
• A total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed.
• Post-operative recovery was smooth, and histology confirmed Stage 1B high-grade leiomyosarcoma.
• Although chemotherapy was advised due to high recurrence risk, the patient opted for regular clinical-radiological monitoring instead.

Discussion and Broader Implications
Leiomyosarcoma in pregnancy poses diagnostic challenges:

• Symptoms often overlap with benign leiomyomas, complicating clinical suspicion.
• Routine imaging like ultrasound and MRI, though useful, cannot definitively distinguish LMS from benign fibroids.
• Removal of fibroids during caesarean section remains controversial because of hemorrhage risks, but might be warranted if malignancy is suspected or fibroids obstruct delivery.

The American College of Obstetricians and Gynecologists (ACOG) emphasizes the importance of careful counseling when myomectomy during cesarean delivery is considered, balancing risks against potential benefits

• LMS accounts for approximately 1.3% of uterine malignancies.
• No gold-standard imaging technique reliably identifies LMS during pregnancy.
• Surgical management remains the cornerstone, while the role of adjuvant chemotherapy is debated due to conflicting evidence from clinical studies.

Internal link: A detailed analysis on similar obstetric oncology cases can be found in our case reports section.

Learning Points

• Patients with fibroid uteri should be counseled about the rare but serious risk of occult malignancy.
• Surgeons must weigh the risks of intraoperative bleeding against the potential benefits of myomectomy.
• Collaborative decision-making between obstetricians and patients is critical for optimal outcomes.

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