Author Information
Nidhi
Bang*, Hajaram Chaudhary**, Shruti Panchbudhe***, Meena Satia****
(*Third
Year Resident, **Second Year Resident, ** Assistant Professor, *** Professor. Department of Obstetrics and
Gynecology, Seth GS Medical College and KEM
Hospital , Mumbai , India
Abstract
Uterine fibroids are the
commonest pelvic tumors over the age of 30 years, as more women are delaying
childbearing until their late thirties which is the time for the greatest risk
of myoma growth. A 7 × 6 cm submucosal fibroid was incidentally found during
caesarean section after the delivery of the baby, on the inner aspect of the
lower uterine segment at the incision site. In view of difficulty in suturing
of the uterine incision, myomectomy was performed.
Introduction
Uterine leiomyoma are
the commonest type of benign tumor of female reproductive tract during the
reproductive age group with an incidence ranging from 5.4 to 7.7%.[1,2].
This is associated with increased amount of circulating estrogen.[2]
The incidence of uterine myoma during pregnancy has been reported to be2%.[3]
The blood loss during caesarean
myomectomy is usually severe as the size and blood supply to the myoma are
increased during pregnancy. Traditionally obstetricians avoided myomectomy
during cesarean section due to severe hemorrhage often necessitating
hysterectomy and also it lead to increase in postoperative morbidity. In most
cases it is wise to defer myomectomy until the uterus has completely involuted,
preferably for 6 months. Uterine involution causes ischemia and vascular
remodeling within the myometrium which cause shrinkage in the size of uterine
myoma. A few previous reports have recently suggested that cesarean myomectomy
is a safe surgical procedure, provided
it is performed in carefully selected patients and also improves
subsequent pregnancy outcomes.
Case report
A 35 years old women,
second gravida with previous lower segment caesarean section was admitted at 39
weeks 2 days of gestation in view of false labor. Her vital parameters were stable and systemic
examination revealed no abnormality. On abdominal examination uterus was full
term with fetus in oblique lie with head in left iliac fossa, with minimal uterine
activity and fetal heart sounds were 140 beats per minute and were regular. On
vaginal examination cervix was closed, uneffaced and posterior. After two days
patient went into spontaneous labor and hence decision for emergency lower
segment caesarean section was taken in view of previous caesarean section with
fetus in oblique lie. Baby was delivered by vertex presentation and there was
no difficulty in extraction. A submucosal fibroid of size 7×6 cm was
incidentally noted on the inner aspect of the lower uterine segment at the
incision site, more towards the right uterine angle. In view of difficulty in
approximation of upper and lower uterine segment, decision for myomectomy was
taken. A plane was created between the myometrium and myoma, and it was
enucleated with electrocautery in order to reduce the bleeding. Multiple
hemostatic sutures were taken in the myoma bed with polyglactin910 no.1 and
hemostasis achieved. This was followed by closure of the uterine incision.
After the delivery of the baby, oxytocin infusion was started and was continued
for 12 hours. Broad spectrum antibiotics and analgesics were given in the
postoperative period. There was no significant difference observed in the
intraoperative hemorrhage and postoperative pain and hospital stay in this
patient and other post cesarean section patients.
Figure 50.1.
Intraoperative finding showing 7×6 cm submucosal myoma situated at the inner
aspect of the lower uterine segment at the incision site near the left angle.
Figure 50.2. Myoma
enucleated with electrocautery by creating a plane between myoma and the
uterine myometrium.
Figure 50.3. Complete
enucleation by electrocautery.
Figure 50.4. Enucleated
myoma.
Figure 50.5. Myoma bed
after removal of myoma.
Figure 50.6. Uterine
closure after caesarean myomectomy.
Discussion
Myomectomy is rarely
performed during an ongoing pregnancy because of the risk of uncontrolled
hemorrhage which may require hysterectomy. Although the majority of pregnant
women with fibroids are usually asymptomatic, and most affected pregnancies
will be uneventful, serious complications can occur during pregnancy leading to
poor outcomes. Complications are
reported in only 10% of the pregnant women.[4] Pregnancy with
coexisting fibroids is associated with
increased incidence of first trimester abortions, pressure symptoms,
pain due to red or carneous degeneration , torsion of a pedunculated fibroid,
malpresentations, dysfunctional labor, preterm labor, preterm rupture of
membranes, placental abruption, obstructed labor from a cervical or lower
segment fibroid ,retained placenta, subinvolution of the uterus and
postpartum hemorrhage.[5] Less common complications like urinary
retention in the first trimester, fetal limb anomalies and head deformities due
to compression , hypercalcemia, uterine inversion and acute renal failure have
also been reported in the literature.[5] The gold standard for
initial management has traditionally been conservative treatment for pain
symptoms. The treatment options during pregnancy depends on multiple factors
like size of the myoma, location and position of the tumor relative to the
lower uterine segment, proximity to vessels, severity of symptoms and patients
desire for nonconservative treatment. Myomas near the fundus and ostia of the
tubes should be avoided to prevent adhesions and future fertility problems.
Myomectomy during
caesarean section cannot be avoided during varied presentation of the myoma
such as severe abdominal pain due to
torsion of pedunculated subserous myomas, red degeneration not responding to
medical treatment, unusual intraoperative appearance of the tumor and
pedunculated uterine fibroids due to increase risk of torsion in future. Other
indications are patients in whom fibroids are obstructing the lower uterine
segment causing difficulty in baby delivery and with uterine incision closure
as was seen in our case.[6,7] The various techniques described to
reduce bleeding during caesarean myomectomy includes tourniquet application
through avascular area of broad ligament to compress both uterine arteries, bilateral
uterine artery ligation, pericervical tourniquet application, electrocautery and oxytocin infusion after
the delivery of the baby.[8]
Myomectomy
done in properly selected patients, during caesarean deliveries, prevents the
added morbidity of a separate procedure either laparotomy or laparoscopy for
removal of fibroids in future, adhesion formation, justifies the cost
effectiveness and also prevents complications related to anesthesia.
In
conclusion, we do not always recommend myomectomy during cesarean section, but
may be performed in unavoidable conditions like in our present case. With
proper patient selection, adequate experience, and effective haemostatic
measures, the procedure does not appear as hazardous as was initially thought.
References
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Citation
Bang N, Chaudhary H, Panchbudhe S,
Satia MN. A
Successful Cesarean Myomectomy. JPGO 2014 Volume 1 Number 6 Available from: http://www.jpgo.org/2014/06/a-successful-cesarean-myomectomy.html