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 Abstract
We present this case report of abdominal myomectomy for
huge myoma done during cesarean section in a patient who
presented with a transverse lie at term. Apart from moderate
intra-operative blood loss, there was no fetal or maternal
morbidity or mortality..
Introduction
Uterine leiomyomas (i.e., fibroids or myomas) are benign
clonal tumors arising from the smooth muscle cells of the uterus and contain an
increased amount of extracellular
matrix. They may be asymptomatic or can
be associated with uterine bleeding,
pain, or reproductive problems (1).
Uterine leiomyomas are found in approximately 2% of
pregnant women. One in ten women with myomas will have
complications related to myomas during pregnancy. The
major complications are the syndrome of painful myomas
of pregnancy, preterm premature rupture of membranes,
malpresentation, increased cesarean delivery rate, and
postpartum endomyometritis (2, 3). Myomectomy during
pregnancy should be avoided, if possible, because of the risk
for intra-operative hemorrhage and subsequent pregnancy
loss (4, 5). The myoma should not be touched during
cesarean section because of excessive blood loss although
it is done in selected cases (6).
The aim of presenting this case report is to help allay some
of the fears of increased short-term morbidity with cesarean myomectomy..
The Case
A 26-year old lady, gravida two, para one, attended our
private clinic at the 36th-week of her pregnancy. She had an
ultrasound scan which showed a cervical fibroid of 15cm by
15 cm in diameter without reference as to whether it was
anterior or posterior. The fetus was at 36 weeks gestation,
lying transversely. Full history and complete medical
examination were done which confirmed the ultrasound
findings. Ten days later the patient was examined again, the
same clinical findings were found. Pelvic examination was
done to confirm that the tumor was obstructing the birth
canal and revealed that the cervix was closed, high and
difficult to reach. In view of these findings, it was decided
to do a cesarean section. The patient was investigated and
discovered to have anemia (hemoglobin level=10 gm/dl).
Arrangement for admission to hospital for blood transfusion
of one unit of blood was done and her hemoglobin level
became 11gm/dl. Cesarean section was done after she
completed the 38th week of gestation.
Two primary surgeons did the operation. The abdomen
was opened through a longitudinal lower midline incision.
At laparotomy it was found that the lower segment was
distended by the fibroid. The fibroid looked bigger than the
ultrasound measurements. The upper uterine segment was
not visualized through this incision, so it was difficult to do
an upper segment cesarean section without extending the
abdominal wall incision to above the umbilicus, with the
attendant risk of increasing the morbidity of this operation.
A transverse incision on the lower uterine segment was
done, similar to that of a lower segment cesarean section. At
one centimeters depth the fibroid was reached; the capsule
was not very clear. Separation was rather difficult, more than
in an ordinary myomectomy, and was assisted by the use
of scissors. The fibroid size was bigger than the fetal head.
After the myomectomy, a further thin layer of muscle fibers
was incised at the base of the cavity and the operation was
completed as normal. Internal podalic version and breech
extraction accomplished delivery of the baby after 15
minutes. The cavity of the fibroid closed spontaneously as
the uterine incision was sutured. After closure the wound
appeared the same as an ordinary cesarean section. The
patient received one unit of blood intra-operativey. The
operative time was 55 minutes and the blood loss was
estimated to be about 1000 ml.
The patient had a smooth postoperative period, and she was
discharged home with her baby on the 3rd postoperative day
in good health. Her discharge hemoglobin level was 10 gm/
dl. She returned for suture removal without any complaint.
The histopathological report confirmed the diagnosis of
lieomyoma which measured 19cm by 17 cm in diameter.
The patient was followed up at 6 weeks postpartum without
any complications.
Discussion
Myomectomy at the time of cesarean delivery has
traditionally been discouraged (6). With the exception of
small, pedunculated fibroids, most of the leading obstetric
textbooks advise against myomectomy during cesarean
delivery due to theoretical risks of intractable hemorrhage
and increased post-operative morbidity (7, 8). During this
operation a difficult decision had to be taken. We had to
choose between two dangerous operations. Either to do
cesarean myomectomy or to do upper segment cesarean
section. Both operations have associated morbidity
risks and may endanger the maternal obstetrical future.
Myomectomy was chosen in this case because the fibroid
was more accessible than the upper segment.
For any operation to succeed it is important to consider
patient selection, adequate preparation and a plan to
manage the anticipated complications as well as a plan of
the presumed operative procedure. In this case there was
no patient selection because the operation was essential.
Preparation was done by blood transfusion because of
anticipated excessive blood loss. Two expert surgeons did
the operation. Longitudinal abdominal incision was chosen
because it gives a rapid access to the abdomen and so
rapid delivery of the fetus and adequate exposure of the
operative field.
The benefit of this operation was that there was one scar in
the uterus. This would allow the patient to undergo a trial
of labor in the next pregnancy rather than delivery by an
elective cesarean section.
Several recent studies have described techniques which can
minimize blood loss at cesarean myomectomy, including
uterine tourniquet (9, 10), bilateral uterine artery ligation
(10), and electro-cautery (11). Although none of these
techniques were used in our case, they may further reduce
blood loss during cesarean myomectomy.
We can conclude from this case report that in selected
patients, and in experienced hands, myomectomy during
cesarean delivery can be a safe procedure.
.
References
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