Changede P*, Gupta S**, Thakur V**, Chavan N***.
(* Assistant Professor, ** Registrar, *** Professor (Addl.)
Department of Obstetrics and Gynecology, LTMMC & LTMGH,
) Mumbai, India
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.
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. We are reporting one interesting case of cesarean myomectomy.
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.
Uterine leiomyomas are frequently observed in pregnancy because of delayed child bearing. Ultrasonography has detected leiomyoma’s in pregnancy. 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. Burton et al reported that cesarean myomectomy is safe in selected patients. One out of 13 cases had intraoperative hemorrhage. Ehigieba et al reported 25 cases of cesarean myomectomies which were done without any complications in 12 women. Kwawukume reported cesarean myomectomies which were done in 12 women. Cesarean myomectomy is easier because of looseness of the capsule. 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.  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.  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.  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. The future fertility and future pregnancies remained unaffected by cesarean myomectomy. 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.
- Practice Committee of the American Society for Reproductive Medicine. Definitions of infertility and recurrent pregnancy loss. Fertil Steril. 2008; 89(6):1603.
- Ansari AH, Kirkpatrick B. Recurrent pregnancy loss. An update. J Reprod Med. 1998; 43(9):806.
- Daya S, Ward S, Burrows E. Progesterone profiles in luteal phase defect cycles and outcome of progesterone treatment in patients with recurrent spontaneous abortion. Am J Obstet Gynecol. 1988; 158:225.
- Davis JL, Ray-Mazumder S, Hobel CJ, Baley K, Sassoon D. Uterine leiomyomas in pregnancy: a prospective study. Obstet Gynecol. 1990;75(1):41-44.
- Michalas SP, Oreopoulou FV, Papageorgioujs. Myomectomy during pregnancy and cesarean section. Hum Reprod 1995;10:1869-70
- Burton CA, Grimes DA, March CM. Surgical management of leiomyomata during pregnancy. Obstet Gynecol 1989;74(5):707-09.
- Ehigiegba AE, Ande AB, Ojobo SI. Myomectomy during cesarean section. Int J Gynaecol Obstet. 2001;75(1):21-25.
- Kwawukume EY. Myomectomy during cesarean section. Int J Gynecol Obstet. 2002;76:183-84.
- Li H, Du J, Jin L, Shi Z, Liu M. Myomectomy during cesarean section. Obstetrical and Gynecological Survey. 2009; 64(6): 363-64.
- Hassiakos D, Christopoulos P, Vitoratos N, Xarchoulakou E, Vaggos G, Papadias K. Myomectomy during cesarean section: a safe procedure? Ann N Y Acad Sci. 2006 Dec; 1092:408-13.
- Kaymak O, Ustunyurt E, Okyay RE, Kalyoncu S, Mollamahmutoglu L. Myomectomy during cesarean section. Int J Gynaecol Obstet. 2005 May;89(2):90-93.
- Celal K, Hülya C. The evaluation of myomectomies performed during cesarean section in our clinic. Niger Med J. 2011 Jul;52(3):186-88.
- Adesiyun AG, Ojabo A, Durosinlorun-Mohammed A. Fertility and obstetric outcome after cesarean myomectomy. J Obstet Gynaecol. 2008 Oct;28(7):710-12.