Author Information
Sneha V*, Kale K**, Chauhan AR***.
(* First Year Resident, ** Assistant Professor, *** Professor, Department of Obstetrics and Gynecology, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, India.)
Abstract
There has always been much reluctance among surgeons to perform myomectomy during cesarean section (CS) because of the theoretical risk of massive hemorrhage and postoperative morbidity. However, in recent times, better patient selection, better hemostatic measures and postoperative care have led to more surgeons attempting myomectomy at CS. Here we report a case of a large lower segment fibroid obstructing the delivery of the fetus, necessitating myomectomy at CS.
Introduction
Leiomyomata (fibroids) are benign smooth muscle cell tumors of the uterus and female pelvis. The incidence of fibroids during pregnancy is estimated to be 0.1 to 12.5%.[1] Most often they do not pose any problem during pregnancy; however, around 10 to 30% of pregnant women are symptomatic and have pain and pressure symptoms due to complications like torsion or red degeneration. There could also be intrapartum complications like obstructed labor, postpartum hemorrhage and subinvolution of the uterus. [1] With increase in maternal age at pregnancy, the incidence of fibroids encountered during cesarean section is also on the rise and poses a management challenge to the surgeon.
Case Report
A 36-year-old primigravida conceived after infertility treatment, was referred to our tertiary care center at 33 weeks of gestation in view of ultrasonography (USG) showing severe oligohydramnios with intrauterine growth restriction (IUGR) and large lower uterine segment intramural fibroid of 8 x 10 cm. Patient had undergone a cervical cerclage at 20 weeks of gestation in view of short cervical length.
All routine antenatal investigations were normal. On examination, her pulse was 86 beats per minute; her BP was 120/80 mm Hg. On abdominal examination, uterus was smaller than expected for her gestation age and was only 28 weeks’ size; fetus was in cephalic presentation, with normal fetal heart sounds. The fibroid was palpable anteriorly on the left side, approximately 8 cm in size; it was non-tender. On per vaginal examination, cervical os was closed and uneffaced, knot of encerclage was in place, and pelvis was adequate for the fetus.
USG performed at our center showed severe oligohydramnios (amniotic fluid index of 0-1) with IUGR and absent diastolic flow on obstetric Doppler. There was an intramural fibroid of 8 x 10 cm in the anterolateral wall on the left side.
In view of these findings and history of infertility with large lower segment fibroid, she was scheduled for an elective lower segment CS. Cesarean myomectomy was anticipated hence patient and her relatives were counseled about the same and consent was taken. Adequate blood was cross matched and kept ready.
Patient was operated under regional anesthesia; abdomen was opened through a vertical midline incision till the uterus was reached. In situ, there was evidence of a intramural fibroid of approximately 8 -10 cm diameter at the junction of the upper and lower uterine segment with the uterovesical fold of peritoneum running midway over the fibroid. The uterovesical fold was dissected and the bladder was mobilized inferiorly. The lower edge of the fibroid was palpated, and a transverse incision was made below the lower margin of the fibroid in the lower segment. Amniotomy was done; however, the fetal head which was small could not be delivered due to obstruction by the fibroid. Hence, the decision for cesarean myomectomy was taken. Going through the upper margin of the uterine incision, the fibroid was rapidly dissected and enucleated by sharp and blunt dissection in the usual manner, as seen in Figures 1 and 2.
Figure 1. Fibroid being enucleated. A – The fibroid, B – Upper edge of uterine incision.
Figure 2. Uterine and fibroid cavities after myomectomy. A – Myoma bed. B - Uterine cavity. C – Upper edge of uterine incision. D – Lower edge of uterine incision.
Once the myomectomy was performed, a live male child of 1.14 kg was easily delivered. The newborn had an Apgar score of 9 and required neonatal intensive care unit admission. Base of the myoma was sutured in three layers, as seen in Figure 3, followed by suturing of uterine incision and closure of abdomen as usual in layers. The patient tolerated the procedure well and postoperative course was uneventful. There was no postpartum hemorrhage or infective complications. Blood transfusion was not required. She was discharged from our center on postoperative day 5. On further follow up at day 15, there was no evidence of subinvolution or secondary postpartum hemorrhage.
Figure 3. Base of the fibroid sutured. A – Sutured myoma bed. B - Upper edge of the incision. C - Lower edge of the incision.
Discussion
Fibroids encountered during cesarean section pose a therapeutic dilemma. Myomectomy has traditionally been discouraged during cesarean section due to fear of excessive bleeding from an obstetric uterus. However, recently, many case reports and studies in literature have reliably shown that cesarean myomectomy in properly selected patients and in experienced hands, is a relatively safe procedure. Studies have demonstrated no significant increase in the rates of intraoperative and postpartum hemorrhage, blood transfusion, infections, duration of surgery and length of hospital stay in patients undergoing cesarean myomectomy as compared to those undergoing cesarean section alone. [2, 3] Several techniques have been described for achieving hemostasis during cesarean myomectomy. These include- three layered suturing of the base of the fibroid as was done in our case, application of tourniquet at the base of the broad ligament and the infundibulopelvic ligament, bilateral uterine artery ligation, prophylactic high dose oxytocin infusion in intra and postoperative periods or a combination of these methods.[4]
Most important factors influencing decision of myomectomy during CS include type, location and to some extent, size of the fibroid. Large anterior wall fibroids obstructing delivery of baby necessitate myomectomy, as was evident in our case. Some authors have advocated routine removal of all anterior wall uterine fibroids during cesarean section.[5] Fibroids which are subserous, pedunculated, those causing difficulty in closure of uterine incision and those with unusual intraoperative appearance are the ones that are most frequently removed during cesarean myomectomy.[4] As far as the size is concerned, fibroids as small as 1 cm to as large as 40 cm have been successfully removed during cesarean section in reported cases, the average size being 6– 10 cm.[3,6]
The main advantage of cesarean myomectomy is its cost effectiveness and avoidance of a future operation which is important especially in low-resource settings. [4] This is applicable to many parts of our country where patients are not likely to follow up and there are limited healthcare facilities. Studies have also confirmed no significant adverse effect of cesarean myomectomy on future fertility and/or subsequent pregnancy outcome.[7] Cesarean myomectomy when performed through the lower uterine segment, increases the chances of vaginal birth after cesarean section (VBAC) in subsequent pregnancies. When compared with interval myomectomy, the scar integrity following cesarean myomectomy has been shown to be better (assessed with ultrasound/ at the time of repeat cesarean section in subsequent pregnancies). [4, 8]
Conclusion
Thus, cesarean myomectomy in selected cases and in experienced hands may be considered safe and effective. By avoiding a future surgery and additional costs on healthcare system, it may be especially relevant in low resource settings like India. However, it should be noted that most studies published in literature are retrospective in nature and results from more extensive, randomized controlled trials are awaited before cesarean myomectomy is routinely recommended.
References
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Sneha V, Kale K, Chauhan AR. Necessary Myomectomy At Cesarean Section. JPGO 2017. Volume 4 No. 1. Available from: http://www.jpgo.org/2017/01/necessary-myomectomy-at-cesarean-section.html