Gupta AS

Leiomyomas and abnormal uterine bleeding are the most common reasons for consultation with a gynecologist. Obstetricians are increasingly seeing patients with leiomyomas complicating pregnancy. Prevalence of fibroids in pregnancy ranges anywhere between 1.6 to 10.7 %. This wide range is probably due to the varying sizes and the varying gestational ages at the time of detection of the fibroids. The general belief regarding the behavior of fibroids in pregnancy that they increase in size is being challenged by various researchers who are following the size of a fibroid by serial ultrasound examinations. The current information that is gathering shows that 50-60% of the fibroids do not show significant change in their size and only about 22-32 % fibroids increase during pregnancy. Fibroids commonly cause pain during pregnancy and the occurrence of reproductive loss, placentation disorders, malpresentations, accidental hemorrhage, dysfunctional and preterm labors may increase slightly in some women.
Route of the delivery is influenced by multiple factors like the fetal presentation, size and position of the myomas. Most of the time if there is no malpresentation, the placenta is not below the presenting part or not obstructing the birth canal, uterus is unscarred it would be prudent to consider a vaginal delivery in a center equipped with facilities for emergency cesarean section and a well equipped blood bank. In the eventuality that a cesarean delivery is considered the placement of the hysterotomy incision should be carefully evaluated. If the lower segment can be reached, an incision transecting the myoma can be avoided, exposure for delivery would be adequate then a lower segment cesarean section should be done. However,  a classical cesarean delivery may be needed in case the myoma is occupying the lower segment, and an incision over the myoma to reach the fetus cannot be avoided.
Conventional practice and teaching discourages myomectomy during pregnancy or delivery especially during cesarean sections. The chances of torrential bleeding and maternal mortality being the real dangers which still exist. However, myomectomy is still indicated in pregnancy for pedunculated subserosal fibroids that can be clamped and removed or such fibroids undergoing torsion and resulting in acute abdomen. Sometimes the fibroid protrudes into the hysterotomy incision and prevents suturing of the same. Myomectomy will inadvertently have to be performed prior to closure of such an incision.  Focally morbidly adhered placenta may necessitate a myomectomy. But this may not be successful in all cases and life threatening hemorrhage may require a hysterectomy.
Adequate counseling of such patients and consent for an inadvertent myomectomy or an obstetric hysterectomy for uncontrollable hemorrhage during the time of cesarean section may prevent future litigation.

From this issue we have added a write up on one of the personalities who has made significant contributions in the field of Obstetrics & Gynecology. We hope the readers  would enjoy this additional feature.