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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 4  |  Issue : 4  |  Page : 127-129

Myomectomy of incision site uterine fibroid during cesarean section


Department of Obstetrics and Gynaecology, SKIMS, Srinagar, Jammu and Kashmir, India

Date of Submission13-Jul-2020
Date of Acceptance04-Aug-2020
Date of Web Publication9-Oct-2020

Correspondence Address:
Dr. Sheema Posh
Department of Obstetrics and Gynaecology, SKIMS, Srinagar, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/MTSM.MTSM_25_20

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  Abstract 


Myomectomy is the most common surgery with cesarean section. There is a controversy between obstetricians about doing myomectomy with cesarean section. A 29-year-old primigravida patient presented with a massive lower segment myoma, who underwent myomectomy during cesarean section at term pregnancy. She did not have intraoperative hemorrhage or any postpartum complications. There seems to be no absolute contraindication for myomectomy during cesarean section especially if the surgeon has enough experience even if the myoma is large, located at the lower segment.

Keywords: Fibroid, lower segment cesarean section, myoma, myomectomy, ultrasonography


How to cite this article:
Khurshid R, Wani S, Posh S, Ahmad A. Myomectomy of incision site uterine fibroid during cesarean section. Matrix Sci Med 2020;4:127-9

How to cite this URL:
Khurshid R, Wani S, Posh S, Ahmad A. Myomectomy of incision site uterine fibroid during cesarean section. Matrix Sci Med [serial online] 2020 [cited 2020 Oct 21];4:127-9. Available from: https://www.matrixscimed.org/text.asp?2020/4/4/127/297634




  Introduction Top


Fibroid in pregnancy is a commonly encountered clinical entity. The incidence of uterine leiomyomas in pregnancy is not uncommon, ranging from 1.6% to 10.7% depending on the size considered and the trimester of assessment.[1] The increased thickness of the myometrium complicates the detection and hence the true prevalence of fibroids in pregnancy may be much higher.[2] Most leiomyomas are asymptomatic during pregnancy and are usually diagnosed on routine ultrasound, however they can be missed on ultrasonography due to physiological thickening of the myometrium. The incidence of fibroids increases with maternal age at pregnancy.[3] Fibroids <5 cm in diameter tend to remain stable or decrease in size[4],[5],[6] and larger fibroids (>5 cm) tend to grow during the pregnancy. The risk of adverse events in pregnancy increases with the size of the fibroid.[7] Different complications with variable rates of incidence have been reported in pregnancy with fibroids which include antepartum hemorrhage, acute abdomen, laparotomy, preterm labor, feto-pelvic disproportion, malposition of the fetus, retention of the placenta, postpartum hemorrhage, red degeneration, dysfunctional labor, retained placenta, retained products of conception, and intrauterine growth restriction.[2],[8],[9],[10],[11] These complications are more commonly seen with large submucosal and retroplacental fibroids.[7] Despite the high incidence of all these adverse events during pregnancy, perinatal outcomes in these patients tend to be fair.[9]


  Case Report Top


A 29-year-old primigravida female of 38 weeks, 6 days' gestation by her last menstrual period (spontaneous conception) was admitted to our hospital on June 30. The patient did not have any symptoms related to the myoma-like pain. On examination, the patient was well oriented to time, place, and person; afebrile with a pulse rate of 90 beats/min and blood pressure 120/80 mmHg; pallor was present, and respiratory and cardiovascular system examination revealed no abnormality. On per abdominal examination, uterine height was of term size with lower pole empty, with head felt in the left iliac fossa. On the right side, a huge firm mass was felt. On auscultation, fetal heart sound was present with a fetal heart rate of 142 beats/min. Liquor appeared to be clinically adequate with no uterine contractions. Ultrasonography was done to confirm the clinical findings and on ultrasound, a large fibroid of 9.6 cm × 8.6 cm × 7.5 cm was found to be present on the anterior wall of the lower segment of the uterus. The patient was planned for elective cesarean section due to the probability of obstructed labor. The risk of hemorrhage was explained and consent for hysterectomy if needed was taken. Blood for crossmatching was sent along with other investigations, and arrangement of one unit of whole blood was done as her hemoglobin was 9.1 g/dL with a hematocrit of 32.4%.

After consultation with the anesthesiologist, the cesarean section was performed under spinal anesthesia. The abdomen was opened with midline infraumbilical incision. After take down of the bladder, a lateral incision was given on the anterior uterine wall away from the fibroid, to avoid injury to the capsule of myoma. A female newborn weighing 3100 g was delivered with an Apgar score of 8 at 1st min. The capsule of fibroid got opened during uterine incision, so the decision of myomectomy was taken. A myoma of about 10 cm × 9 cm × 8 cm size which was multilobed was removed [Figure 1], [Figure 2], [Figure 3] by giving a nick over the capsule and enucleating it. Finally, both uterine arteries were ligated. The specimen was sent for histopathological examination.
Figure 1: A multilobed myoma was removed by giving a nick over the capsule and enucleation

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Figure 2: Uterus with a large intramural lower segment fibroid

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Figure 3: A multilobed intramural lower segment fibroid of about 10 cm × 9 cm × 8 cm in size removed during cesarean section

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After removal of the placenta, high-dose oxytocin (30 IU/1000 cc. ringer lactate) was infused in 1 h. The decision of myomectomy was taken after well-informed consent. The myomectomy was done, and a single intramural myoma measuring about 10 cm × 9 cm × 8 cm, weighing 1100 g, was removed. During the procedure of myomectomy, the infusion of oxytocin was continued and injectable tranexamic acid was also given. The amount of hemorrhage was almost 1200 cc that was similar to other cesarean section cases, which was compensated with ringer-lactate solution.

The duration of the operation was around 1 h. The hemoglobin level after surgery was 8.3 g/dL. The suture line over the uterus after the surgery, was much similar to those cases of lower segment cesarean section. The histological examinations confirmed the diagnosis of myoma. The patient was discharged 2 days after the surgery and at the time of discharge, involution of the uterus was normal, and we did not face any postpartum morbidity.


  Discussion Top


Incidence of fibroids during pregnancy varies from 0.1% to as high as 12.5%. Ultrasound studies have shown that about 20% of fibroids increase in size and a similar percentage decrease during pregnancy.[12] The greatest increase in volume occurs before the 10th gestational week. Different complications with variable rates of incidence have been reported in pregnancy with fibroids which include antepartum hemorrhage, malposition of the fetus, acute abdomen, laparotomy, red degeneration, intrauterine growth restriction, preterm labor, dysfunctional labor, postpartum hemorrhage, retained placenta, and retained products of conception.[10],[11] Because of the increased vascularization of the uterus during pregnancy, women are at an increased risk of bleeding and postoperative morbidity during myomectomy. Our case showed that myomectomy during cesarean section may not be as dangerous as generations of obstetricians and gynecologists have been trained to believe. With large myomas in the lower segment of the uterus, myomectomy may be inevitable and there appears to be no absolute contraindication to myomectomy. Whereas small fibroid <2–3 cm and single, myomectomy during cesarean section probably is not indicated, especially when it is asymptomatic. With an adequate experience in myomectomy during cesarean section and use of high-dose oxytocin infusion, severe hemorrhage which is the most serious complication can be controlled.

Omar et al.[13] reported two cases of large uterine myomas situated in the anterior aspect of the lower segment, complicating pregnancy at term; myomectomy in both instances allowed delivery of the fetus through the lower segment. Burton et al.[14] reported 13 cases of incidental myomectomy at cesarean section, where only one case was complicated by intraoperative hemorrhage attributable to the myomectomy. They suggested that myomectomy in cesarean section may be safe in carefully selected patients. In a casecontrol study done by Kwawkume et al.[15] on 12 patients with myomectomy during cesarean section, involution of the uterus was normal in all the patients and there was no intraoperative hemorrhage, significantly higher than control cases.

Another study[16] has shown that myomectomy as a separate operation during cesarean section increased the rate of hemorrhage by 10%. Other studies showed[15],[17] that myomectomy during cesarean section adds the time of surgery by about 11 min, which is similar to our study.[18],[19],[20],[21]

This study concluded that cesarean myomectomy seems to be feasible and safe in selected cases where a tourniquet is applied. In our case, though the fibroid was of large size, the blood loss was less than the expected amount (300 ml) because of the use of electrocautery to enucleate the fibroid and very short surgical time.


  Conclusion Top


Myomectomy along with cesarean section was not recommended mainly due to the associated risk of life-threatening hemorrhage and postpartum morbidity. However, with the advent of better anesthesia, surgical expertise, and availability of blood, cesarean myomectomy is now considered a cost-effective and safe procedure in low-resource settings. It is better to remove large myomas in the lower segment because they can prohibit postpartum hemorrhage and sepsis, but in the case of small myomas on the fundus of uterine, myomectomy may not be indicated.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Pregnancy in women with uterine leiomyomas (fibroids). Available from: http://www.uptodate.com/contents/pregnancy-in-women-with-uterine-leiomyomas-fibroids. [last accessed on 2020 Aug 08].  Back to cited text no. 1
    
2.
Katz VL, Dotters DJ, Droegemeuller W. Complications of uterine leiomyomas in pregnancy. Obstet Gynecol 1989;73:593-6.  Back to cited text no. 2
    
3.
Laughlin SK, Baird DD, Savitz DA, Herring AH, Hartmann KE. Prevalence of uterine leiomyomas in the first trimester of pregnancy: An ultrasound-screening study. Obstet Gynecol 2009;113:630-5.  Back to cited text no. 3
    
4.
Rice JP, Kay HH, Mahony BS. The clinical significance of uterine leiomyomas in pregnancy. Am J Obstet Gynecol 1989;160:1212-6.  Back to cited text no. 4
    
5.
Strobelt N, Ghidini A, Cavallone M, Pensabene I, Ceruti P, Vergani P. Natural history of uterine leiomyomas in pregnancy. J Ultrasound Med 1994;13:399-401.  Back to cited text no. 5
    
6.
Akhtar N, Sulthana S, Zabin F. Successful outcome of pregnancy with large fibroid uterus – A case report. Bangladesh J Obstet Gynaecol 2010;25:87-9.  Back to cited text no. 6
    
7.
Ciavattini A, Clemente N, Delli Carpini G, Di Giuseppe J, Giannubilo SR, Tranquilli AL. Number and size of uterine fibroids and obstetric outcomes. J Matern Fetal Neonatal Med 2015;28:484-8.  Back to cited text no. 7
    
8.
Hasan F, Arumugam K, Sivanesaratnam V. Uterine leiomyomata in pregnancy. Int J Gynaecol Obstet 1991;34:45-8.  Back to cited text no. 8
    
9.
Klatsky PC, Tran ND, Caughey AB, Fujimoto VY. Fibroids and reproductive outcomes: A systematic literature review from conception to delivery. Am J Obstet Gynecol 2008;198:357-66.  Back to cited text no. 9
    
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Koike T, Minakami H, Kosuge S, Usui R, Matsubara S, Izumi A, et al. Uterine leiomyoma in pregnancy: Its influence on obstetric performance. J Obstet Gynaecol Res 1999;25:309-13.  Back to cited text no. 10
    
11.
Lev-Toaff AS, Coleman BG, Arger PH, Mintz MC, Arenson RL, Toaff ME. Leiomyomas in pregnancy: Sonographic study. Radiology 1987;164:375-80.  Back to cited text no. 11
    
12.
Sarwar I, Habib S, Bibi A, Malik N, Parveen Z. Clinical audit of foeto maternal outcome in pregnancies with fibroid uterus. J Ayub Med Coll Abbottabad 2012;24.  Back to cited text no. 12
    
13.
Omar SZ, Sivanesaratnom V, Damodoran P. Large lower segment myoma – Myomectomy at lower segment cesarean section, a report of two cases. Singapore Med J 1999;40:109-10.  Back to cited text no. 13
    
14.
Burton CA, Grimes DA, March CM. Surgical management of leiomyomata during pregnancy. Obstet Gynecol 1989;74:707-9.  Back to cited text no. 14
    
15.
Kwawkume EY. Myomectomy during cesarean section. Int J Gynecol Obstet 2003;76:183-4.  Back to cited text no. 15
    
16.
Dimitrov A, Nikolov A, Stamenov G. Myomectomy during cesarean section. Akush Ginekol (Sofiia) 1999;38:7-9.  Back to cited text no. 16
    
17.
Hsieh TT, Cheng BJ, Liou JD, Chiu TH. Incidental myomectomy in cesarean section. Changgeng Yi Xue Za Zhi 1989;12:13-20.  Back to cited text no. 17
    
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Ghaemmaghami F, Karimi Zarchi M, Mousavi A. Surgical management of primary vulvar lymphangioma circumscriptum and postradiation: Case series and review of literature. J Minim Invasive Gynecol 2008;15:205-8.  Back to cited text no. 18
    
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Mousavi A, Karimi Zarchi M, Modares Gilani M, Behtash N, Ghaemmaghami F, Shams M,et al. Radical hysterectomy in the elderly. World J Surg Oncol 2008;6:38.  Back to cited text no. 19
    
20.
Ghaemmaghami F, Karimi-Zarchi M, Gilani MM, Mousavi A, Behtash N, Ghasemi M. Uterine sarcoma: Clinicopathological characteristics, treatment and outcome in Iran. Asian Pac J Cancer Prev 2008;9:421-6.  Back to cited text no. 20
    
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Behtash N, Karimi Zarchi M. Placental site trophoblastic tumor. J Cancer Res Clin Oncol 2008;134:1-6.  Back to cited text no. 21
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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