(* Second Year Resident, ** Associate Professor. Department of Obstetrics & Gynecology,
College, Bharati Hospital & Research
center, .) Pune, India
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.
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. 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.
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.
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. 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. 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.
JPGO 2015. Volume 2
No. 3. Available from: http://www.jpgo.org/2015/03/pregnancy-complicated-by-large.html Kakade AS. Pregnancy Complicated By A Large Leiomyoma: A Case Report.
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