Author
Information
Changede P*, Gupta S**, Thakur V**, Chavan N***.
(* Assistant Professor, ** Registrar, *** Professor
(Addl.)
Department of Obstetrics and Gynecology, LTMMC & LTMGH, Mumbai , India
Abstract
Uterine leiomyomas are
benign clonal tumor arising from muscles cells of uterus and contain increased
amount of extracellular matrix. Uterine leiomyomas are common benign lesions in reproductive age group. As
their growth is related to exposure to circulating estrogens, leiomyomas attain
their maximum dimensions during the female reproductive period. Uterine leiomyomas are frequently seen
in pregnancy because of delayed child bearing. Traditionally, obstetricians are
trained to avoid myomectomies during cesarean sections as severe hemorrhages
can occur, which may often necessitate hysterectomies. Pedunculated leiomyomas
which can be easily removed are an exception. Uterine
leiomyomas are found in approximately 2% of pregnant women. We are reporting
one interesting case of cesarean myomectomy.
Introduction
The
incidence of uterine leiomyomas varies from 0.3 to 7.2% during pregnancy.[1,2]
The size of leiomyomas usually increases during pregnancy and causes effects
such as fetal malpresentation, preterm labor and hydronephrosis. Cesarean
myomectomy can be performed in selected patients. The
blood loss is usually severe as the size and the blood supply of the leiomyomas
are increased in pregnancy, especially at term. The risk of a hemorrhage is
reportedly less with pedunculated leiomyomas as compared to that with the
non-pedunculated ones.[3] We are reporting one interesting
case of cesarean myomectomy.
Case Report
A 38 year
old female was admitted to our tertiary hospital with a diagnosis of gravida 4
para 2 living 2 medical termination of pregnancy 1, with 34 weeks and 6 days of
gestation with placenta previa for safe confinement. She had previous two
normal vaginal deliveries. An ultrasonography (USG) done showed a single live
fetus in cephalic presentation of approximate gestational age of 33 weeks and 5
days, placenta anterior completely covering internal os, and a 5.4x3 cm size
ill-defined heterogeneous lesion in sub chorionic region at superior aspect of
the placenta, possibly abruption of the placenta. Estimated fetal weight was 2141 g.
On examination,
her Pulse rate was 84 beats/min and blood pressure was 110/70 mm of Hg. On per
abdominal examination, the uterus was found to be 34-36 weeks in size, relaxed,
with a cephalic presentation with head floating. Fetal heart rate was 145
beats/min. Per Vaginal examination was not done. Her hemoglobin was 10.6 g/dl,
blood group was B positive, HIV, HBSAg and VDRL were all non-reactive. She
received two doses of injection betamethasone. The USGs which were done in the
second trimester and the third
trimester were suggestive of low lying placenta.
She was taken for an
emergency lower segment cesarean section in view of bleeding placenta previa
with abruptio placenta, when she started bleeding. During the cesarean section,
a submucous leiomyoma (figure 1) of size 5x5 cm was noticed in the anterior
wall of the uterus, at the incision site. After the extraction of a live female
baby with a weight of 2470 g, a decision to perform a myomectomy was taken
because the leiomyoma was seen at the uterine incision site. Clamps were
applied at the base of leiomyoma and it was excised from the base and
hemostatic transfixation sutures were taken with polygalactin number 1 (figure
2). Complete hemostasis was achieved. The placenta was low lying and there was
no evidence of abruptio placenta which was mentioned in USG report. The
presence of the leiomyoma was misinterpreted as Abruptio placenta on USG. An
oxytocin infusion was started after the delivery of the baby and it was
continued for 12 hours. Broad spectrum antibiotics and analgesics were given in
the post-operative period. Her post-operative period was uneventful and her
post-operative hemoglobin was 9 g/dl. She did not require any blood
transfusion. She was discharged on the 5th
day.
Figure 1. Anterior wall leiomyoma size
5x5 cms at the level of uterine incision
Figure 2. Clamps at the base of leiomyoma
from the anterior wall of the uterus.
Discussion
Uterine
leiomyomas are frequently observed in pregnancy because of delayed child
bearing. Ultrasonography has detected leiomyoma’s in pregnancy.[4] In a study by Michalas et
al 16 out of 18 cases of cesarean myomectomy delivered uneventfully at term. It
was found that in one case eight leiomyomas
obstructing lower segment of
uterus were removed uneventfully.[5]
Burton et al reported that cesarean myomectomy is safe in selected patients.
One out of 13 cases had intraoperative hemorrhage.[6] Ehigieba
et al reported 25 cases of cesarean myomectomies which were done without any
complications in 12 women.[7] Kwawukume reported cesarean
myomectomies which were done in 12 women. Cesarean myomectomy is easier because
of looseness of the capsule.[8] Li H et al in a retrospective case
control study done to assess the effectiveness of cesarean myomectomy showed
that it was an effective and a safe procedure. [9] Hassiakos D et al reported that depending on the size and
location of the leiomyomas in pregnancy, the associated risks of the
myomectomies with cesarean sections were similar to those of the isolated
cesarean sections. [10] Kaymak O et
al., in a retrospective case-control study which compared incidence of
hemorrhage in patients undergoing cesarean myomectomy and cesarean section
alone was 12.5% and 11.3% respectively. The difference was not significant.
[11] A study by Celal et al showed
post-operative bleeding, maternal morbidity or mortality did not increase when
cesarean myomectomies were done in selected patients.[12] The future fertility and future pregnancies remained
unaffected by cesarean myomectomy.[13] In this case, cesarean myomectomy was easy without an increase
in amount of bleeding or the operative time. Post-operative period was
uneventful. Hence we conclude that cesarean myomectomy is a safe procedure when
done in selected cases.
References
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