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

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 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.