(* Junior resident, ** Senior Resident, *** Professor, Department of Gynecology and Obstetrics, Seth G S Medical College and K E M Hospital, Mumbai, India.)
Intraoperatively, fibroid was not palpable. Baby’s head was deflexed. After delivery of the baby and placenta, an 8 x 8 x 4 cm intramural fibroid was seen protruding from the upper edge of the uterine incision (figure 1). This location of fibroid was least expected since antenatal ultrasonographic scans were suggestive of fundal fibroid. After careful examination of the fibroid size and position, decision of caesarean myomectomy was made, which if not done would make closure of uterine incision impossible. Required consent was sought and documented. Blunt and sharp dissection was done to free the myoma of its pseudocapsule. (Figure 2) Myoma specimen was of salmon pink colour and non hemorrhagic and sent for histopathological examination. Multiple figure of eight interrupted sutures were taken with no. 1 delayed absorbable sutures in the myoma bed and hemostasis was achieved. After this, it was possible for closure for the uterine incision with no difficulty. (Figure 3) Uterine incision closure was performed in single layer with continuous interlocking sutures. Injection tranexamic acid 1 gram intravenous infusion was started intraoperatively and oxytocin infusion was continued for 6 hours post-delivery. Post-operative recovery was uneventful. In view of estimated blood loss of around 1200 ml, she was transfused one unit of packed red cells post operatively. Hemoglobin done on third post-operative day was 8.6 gm %, and was discharged on oral iron. There were no wound complications.
Figure 1. Arrow pointing to intramural fibroid in lower uterine segment, just above uterine incision.
In this case, the earliest ultrasonography reported the fibroid to be fundal and intramural. Later done obstetric scans did not comment on any change on either the size or the location of the fibroid. In case the anterior low lying location was known prior, it may have helped in some preparation regarding the uterine incision in order to avoid a myomectomy. The decision of enucleation is made on the basis of tumor size, location, proximity to vascular areas and severity of symptoms. Large fundal intramural fibroids, intramural fibroids located near cornual region, isthmus region and seedling fibroids and fibroids in cornual region are best left untouched. Our patient had an obvious, easily accessible fibroid, which made the performance of myomectomy relatively easy.
Although ultrasound is a gold standard, dynamic MRI can give vital information about vascular supply or myometrial involvement in patients with fibroid related post-partum bleeding. Rarely complications like pyomyoma may create diagnostic dilemma in postpartum period. They can manifest postpartum and rarely, even months later. None of these complications were noted in our patient. As data on long term outcomes in women undergoing cesarean myomectomy are lacking, the procedure should be undertaken very cautiously.
Cesarean myomectomy is no more a rare procedure, but there is no unanimity of opinion on its safety. Prior to proceeding with cesarean section for any indication, it is advantageous to know the location of the fibroid. This case is presented to highlight that even if there was no preoperative plan, there may be an intraoperative need for a decision of cesarean myomectomy.
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