Author Information
Shukla H*, Kakade AS
(* Second Year Resident,
** Associate Professor. Department of Obstetrics & Gynecology, Bharati Vidyapeeth
University Medical
College , Bharati Hospital & Research
center, Pune , India
Abstract
Uterine leiomyomas are
seen in 1.6 to 4 % of pregnancies. They affect pregnancy in many ways and
subsequently the pregnancy also affects the leiomyoma in different ways. We
present such case of large intramural leiomyoma encountered during antenatal
period and the challenges faced in the antenatal, intra-partum and postnatal
period.
Introduction
Uterine leiomyomas are
seen in 1.6 to 4 % of pregnancies.[1] They affect pregnancy in many
ways and subsequently the pregnancy also affects the leiomyoma in different
ways. With the advances in imaging techniques more and more leiomyomas are
diagnosed. They provide a challenge to the treating obstetrician during the
pregnancy. A vigilant approach with an outlook of the possible complications
can lead to a successful pregnancy outcome.
Case report
A 32 years old Gravida
2, Abortion 1, known to have a prenatal large leiomyoma in the uterus, visited
the antenatal outpatient department for routine care at 10 weeks of gestation.
She did not have any presenting complaint. She had a spontaneous abortion one
year ago for with a dilatation and evacuation was performed. She has excessive
bleeding after that and was transfused with one unit of packed cell volume. She
was married for two years and was not using any form of contraception.
Her hemoglobin was 10.8
g/dL and her plasma glucose 2 h after oral load of 75 g glucose was 127 mg/dL.
Ultrasound revealed a large leiomyoma of 9 X 10.2 X 7 cm in the left lateral
wall of the uterus on the lower side and compressing the pregnancy. There was a
single live intrauterine pregnancy of around 18 weeks and no detectable fetal
anomalies. She had one admission at 14 weeks for threatened abortion which was
treated with micronized progesterone and bed rest.
The patient and her
relatives were counseled regarding the risk of leiomyoma in pregnancy and
effect of pregnancy on the leiomyoma. She was asked to follow up every two
weekly with an advice to follow up immediately in case of any bleeding per vaginum
or pain in abdomen. She was started on oral micronized progesterone. The
pregnancy was monitored by every 4 weekly ultrasounds with Doppler analysis
till 37 completed weeks.
At term the leiomyoma
was found to be abutting the lower fetal pole pushing the uterus and the fetus
to the right side of the abdomen. There was mild fetal growth restriction. She
was posted for elective cesarean section. Two units of packed cell were kept
reserved. She delivered a baby girl of weight 2.9 kg. Intra-operatively there
was a large fundal and isthmic fibroid (figure 1). The third stage was managed
by giving inj. oxytocin 10 u intravenously at the delivery of anterior
shoulder. She had atonic post-partum hemorrhage which was controlled using
injection 15-S-15-methyl PGF2α 250 micrograms intramuscularly. She required one
unit of packed cell volume and injection of iron ferrous carboxymaltose post
operatively. Her post-operative period was uneventful and she did not require
any blood transfusions. She was discharged on 7th day after suture
removal.
Figure 1. Arrow pointing
towards fibroid after delivery of baby.
Discussion
Leiomyomas are the most
frequently encountered gynecological tumors during pregnancy. Increasing women
are delaying pregnancy until their late thirties and this is also the likely
time for most fibroids to occur. Most of the myomas remain asymptomatic during
the tenure of pregnancy. Ultrasonography has improved the detection of these
tumors and helped in the evaluation of possible complications. Leiomyoma can lead to multiple complications
like spontaneous abortion, antepartum hemorrhage, preterm delivery, premature
rupture of membranes, in coordinate uterine activity. It can lead to
malpresentations, dystocia and increased incidence of caesarean deliveries.[2]
They are known to cause postpartum hemorrhage and sub-involution of the uterus.
Pregnancy can lead to
increase in the size of the fibroid, make it more vascular, soft and cause red
degeneration in the fibroid. The risk and type of complication appear to be
related to the size, number and location of the myoma.[3] Thus
pregnancy with a fibroid is a challenging situation for the treating
obstetrician.
The reported case had an
early antenatally detected fibroid of size 10 cm. She had threatened abortion
and it was a challenge to continue the pregnancy till term. She was labeled as
a high risk pregnancy and was counseled regarding the possible complications,
their presenting features, need of fetal surveillance, and institutional
delivery. She did not report any other untoward event during the antenatal
period. She underwent a cesarean section for the leiomyoma obstructing the
passage. The anticipated risk of postpartum hemorrhage was tackled with
prophylactic uterotonic agent, active management of third stage and packed cell
volume transfusion. Many a cases of leiomyomas in pregnancy have a turbulent antenatal
period with unfavorable outcome. The reported case had a huge fibroid where all
the complications were anticipated and prevented.
Leiomyomas complicating
pregnancies are on the rise due to delayed age of conception in women and the
increasing use of ultrasonography. leiomyomas can cause complications in all
the trimesters of pregnancy and during the intrapartum and postpartum period
also. Vigilant approach during pregnancy can lead to successful outcome in
these cases.
References
Shukla H,Kakade AS. Pregnancy Complicated By A Large Leiomyoma: A Case Report.
- Ardovino M, Ardovino I, Castaldi MA, Monteverde A, Colacurci N, Cobellis L. Laparoscopic myomectomy of a subserous pedunculated fibroid at 14 weeks pregnancy: a case report. Journal of Medical Case Reports 2011;5: 545.
- Muram D, Gillieson M, Walters JH. Myomas of the uterus in pregnancy: ultrasonographic follow-up. Am J Obstet Gynecol 1980;138: 6-9.
- Phelan JP. Myomas and Pregnancy . Obstet Gynecol Clin North Am 1995;22: 801-805.
Shukla H,