Annals of Tropical Medicine and Public Health

CASE REPORT
Year
: 2016  |  Volume : 9  |  Issue : 5  |  Page : 347--350

Inevitable cesarean myomectomy and delivery of baby through the same incision


Rekha Sachan1, Pushpalata Sachan2, Munna Lal Patel3, Neha Negi1,  
1 Department of Obstetrics and Gynaecology, King George's Medical University, Lucknow, Uttar Pradesh, India
2 Department of Physiology, Career Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
3 Department of Medicine, King George's Medical University, Lucknow, Uttar Pradesh, India

Correspondence Address:
Rekha Sachan
Department of Obstetrics and Gynaecology, King George«SQ»s Medical University, C-28, Sec-J Aliganj, Lucknow, Uttar Pradesh
India

Abstract

Leiomyoma is the commonly encountered benign tumor in women of reproductive age group. Cesarean myomectomy is associated with increased morbidity and mortality mainly due to the risk of associated hemorrhage. Although there are some case series that have demonstrated the safety of myomectomy during cesarean section, a 32-year-old female G2P1 + 0 was referred to the emergency department of obstetrics and gynecology with a complaint of pain in the lower abdomen with amenorrhea of 8 months. Her transabdominal ultrasound report showed a huge fibroid in the lower uterine segment of 16 cm × 12 cm × 14 cm predominantly in the anterior wall of the uterus. Here, cesarean myomectomy was done under spinal anesthesia before the delivery of alive and healthy male baby, weighing 3.0 kg successfully without any complication. Though the cesarean myomectomy is difficult and is associated with increased morbidity because of risk of associated hemorrhage; thus, we do not always recommend but it could be performed in unavoidable conditions



How to cite this article:
Sachan R, Sachan P, Patel ML, Negi N. Inevitable cesarean myomectomy and delivery of baby through the same incision.Ann Trop Med Public Health 2016;9:347-350


How to cite this URL:
Sachan R, Sachan P, Patel ML, Negi N. Inevitable cesarean myomectomy and delivery of baby through the same incision. Ann Trop Med Public Health [serial online] 2016 [cited 2019 Nov 18 ];9:347-350
Available from: http://www.atmph.org/text.asp?2016/9/5/347/190193


Full Text

 Introduction



The most common benign pelvic tumor found in female during reproductive age group is fibroid uterus. The incidence of uterine fibroid in pregnancy varies from 0.3% to 7.2%. [1] The overall incidence of fibroid uterus is about 40-60% by the age of 35 years. [2] Although the fibroids are asymptomatic benign tumor but during pregnancy size of the fibroid often increases and may produce pressure effects such as fetal malpresentation, preterm labor, torsion of the uterus, hydronephrosis, the fibroid. Mostly, pregnancy associated with fibroid remains uneventful, but about 10-30% of women with fibroid uterus may develop complications during pregnancy. [3] Combining myomectomy with cesarean section has been traditionally discouraged mainly due to the risk of hemorrhage associated with surgery as a result of increased vascularity of the pregnant uterus and uterine atonicity. [4],[5] Various methods can be adopted to reduce the amount of hemorrhage during myomectomy but during cesarean section use of these methods are limited because of the presence of viable fetus. This procedure also carries increased risk of postoperative morbidity, but few studies suggested that myomectomy may be carried out during cesarean section in selected patients. [5],[6] If these two procedures performed safely and simultaneously, the risk of anesthetic complications, multiple surgeries, adhesion, cost of the operative procedure, and hospital stay could be reduced. Usually, myomectomy is carried out after the delivery of the baby, but here we are reporting a case of fibroid uterus with a pregnancy where the fibroid was present at the incision line and occupied the whole of the lower uterine segment. It was difficult to find out an incision site to deliver the baby, so incision was given over the fibroid capsule and myomectomy was done before the delivery of the baby. The same incision was advanced through the posterior wall of fibroid bed and baby was delivered through the same incision.

 Case Report



A 32-year-old female G2P1 + 0 was referred to our emergency Department of Obstetrics and Gynaecology with a complaint of pain in the lower abdomen and amenorrhea of 35 weeks. She had previous one normal delivery. On reviewing the menstrual history, she had no complaints of menorrhagia before conception and no history of secondary infertility. Fibroid was diagnosed on transabdominal ultrasound at the time of admission. The patient was examined and procedure was carried out in accordance with the ethical standards and written informed consent was obtained. On general examination, pulse rate was 80 beats/min, blood pressure 120/80 mmHg, with mild pallor. On per abdominal examination, uterine fundal height was 36 weeks with cephalic presentation, and a mass of about 16 cm × 14 cm palpable over the lower part of abdomen in midline, which was nontender, with restricted mobility, and uterus was relaxed. On auscultation fetal heart rate was 160 beats/min regular. Investigations revealed hemoglobin 9.5 g%, blood group B+, and viral markers were negative and her obstetric ultrasound report showed single live intrauterine pregnancy with composite gestation age of 35 weeks 1 day, liquor was adequate, placenta right fundal, and effective fetal weight was 2602 g. A huge mass of about 16 cm × 12 cm × 14 cm was seen in the lower uterine segment, predominantly on the anterior wall of the uterus. Fetal distress was appeared on nonstress test, and there was fear of obstruction during labor caused by the huge fibroid occupying the lower uterine segment, we urgently decided for cesarean section. However, patient underwent cesarean myomectomy under spinal anesthesia because a huge intramural with subserous component fibroid occupying the lower uterine segment and extending to upper uterine segment, no plane was identified for incision to deliver the baby [Figure 1] so the decision to do myomectomy first was taken after opening the abdomen, whole of the abdominal incision site occupied by large myoma, transverse incision was given directly on the myometrium over the fibroid. The capsule was separated and myoma screw was fixed over the fibroid to hold it firmly [Figure 2], then rest of the capsule was separated with the help of electrocautery to reduce the blood loss. After complete dissection, the pedicle of myoma was ligated to reduce blood loss and myoma was enucleated [Figure 3] and [Figure 4]. The same incision over the posterior surface of the fibroid bed was extended through fingers because the very thin layer of myometrium was left behind [Figure 5]. Alive and healthy male baby of 2.6 kg was delivered through the same incision [Figure 6]. Uterus was closed in two layers by suturing of only single incision site with vicryl no. 0 [Figure 7] and hemostasis ensured with the help of electrocautery and proper suturing of fibroid bed before delivery of the baby.{Figure 1}{Figure 2}{Figure 3}{Figure 4}{Figure 5}{Figure 6}{Figure 7}

Myomectomy was performed within 20 min. Cesarean myomectomy was completed within 45 min with total blood loss of about 300 ml. Her immediate postoperative hemoglobin was 8.5 g%. The postoperative period was uneventful and Syntocinon drip was continued for 12 h to avoid postpartum hemorrhage. One unit packed red blood cells was transfused. The patient was discharged on the seventh postoperative day.

 Discussion



Cesarean myomectomy was discouraged in past due to high risk of hemorrhage associated with this and increased requirement of blood transfusion. [4],[5] Recently, some authors have advocated myomectomy during cesarean section to remove anterior wall fibroid. [5],[7],[8] Another retrospective study investigated the feasibility and outcome of cesarean myomectomy by using the tourniquet method with enucleation of single and multiple myomas and this was performed after delivery of the baby and in two cases where small uterine fibroids were present along the incision line, incision was made over the fibroids to enucleate them before. The mean duration of cesarean myomectomy was 54.75 ± 4.57 min. There was no significant difference in the mean duration of operation and mean blood loss between the two groups. [9] 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 but the blood loss was less than the expected amount (300 ml) because of the use of electrocautery to enucleate the fibroid and very rapid surgery. In other study, myomectomy was done prior to delivery of the baby because fibroid present directly under the incision line. Mean surgical time was 54.14 ± 3.84 min and mean blood loss was 472 mL. This study concluded that cesarean myomectomy is a feasible undertaking in experienced hands. [10] In our case, fibroid was present under the incision line in the lower uterine segment anteriorly, and delivery of baby could not be possible without removal of the fibroid; hence, myomectomy was performed first followed by delivery of the baby. A case of inevitable cesarean myomectomy was reported wherein cesarean myomectomy was done with removal of huge intramural fibroid before delivery of the baby in order to access the baby. [11] In this case, there was minimal intraoperative and postoperative blood loss. Similarly, in our case, blood loss was less than the expected amount as the separate incision was not given for myomectomy. Other similar case of unavoidable myomectomy during cesarean section was reported, without a need of blood transfusion and no any postoperative complication was reported. [12] In our case, patient had no episode of postpartum hemorrhage with minimal intraoperative and postoperative blood loss. Recently, various other studies reported successful outcome after myomectomy. Bhatla et al. did successful myomectomy in the second trimester of pregnancy for a large subserous fibroid and after that pregnancy was continued till term. [13] Adesiyun et al. had reported that future fertility and pregnancy outcome was not affected in women who had cesarean myomectomy at last delivery. [14] According to Hassiakos et al., removal of myoma during cesarean section is safe and this procedure can be done simultaneously. [15] Kaymak et al. concluded that myomectomy can be performed without a significant complication by an experienced surgeon. [16]

 Conclusion



Myomectomy along with cesarean section was not recommended mainly due to associated risk of life-threatening hemorrhage. With the advent of better anesthesia and availability of blood, cesarean myomectomy is now considered a cost effective and safe procedure in low resource setting but require expertise and experience.

Acknowledgment

I acknowledge Dr. Vandana; she is my junior resident working in the Department of Obstetrics and Gyanaecology for taking the picture during surgery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Scott JR, Disaia PJ, Hammond CB, Spellacy WN. Danforth's obstetrics and gynecology. In: Creasman TW. Disorders of uterine corpus. New York: Lippincott-Raven Publishers; 7 th ed. 1997; p. 925-39.
2Baird DD, Dunson DB, Hill MC, Cousins D, Schectman JM. High cumulative incidence of uterine leiomyoma in black and white women: Ultrasound evidence. Am J Obstet Gynecol 2003;188:100-7.
3Katz VL, Dotters DJ, Droegemeuller W. Complications of uterine leiomyomas in pregnancy. Obstet Gynecol 1989;73:593-6.
4Omar SZ, Sivanesaratnam V, Damodaran P. Large lower segment myoma - Myomectomy at lower segment caesarean section - A report of two cases. Singapore Med J 1999;40:109-10.
5Kwawukume EY. Myomectomy during cesarean section. Int J Gynaecol Obstet 2002;76:183-4.
6Roman AS, Tabsh KM. Myomectomy at time of cesarean delivery: A retrospective cohort study. BMC Pregnancy Childbirth 2004;4:14.
7Ehigiegba AE, Ande AB, Ojobo SI. Myomectomy during cesarean section. Int J Gynaecol Obstet 2001;75:21-5.
8Brown M, Myrie M. Caesarean myomectomy - A safe procedure. West Indian Med J 1997;46:45.
9Omole-Ohonsi A, Ashimi AO. Caesarean myomectomy in Kano, Northern Nigeria. Ibom Med J 2008;3:45-9.
10Ahikari S, Goswami S. Caesarean myomectomy - A study of 14 cases. J Obstet Gynaecol India 2006;56:486-8.
11Igwegbe AO, Nwosu BO, Ugboaja JO, Monago EN. Inevitable caesarean myomectomy; a case report. Niger J Med 2010;19:329-31.
12Aksoy AN, Saracoglu KT, Aksoy M, Saracoglu A. Unavoidable myomectomy during cesarean section: A case report. Health 2011;3:156-8.
13Bhatla N, Dash BB, Kriplani A, Agarwal N. Myomectomy during pregnancy: A feasible option. J Obstet Gynaecol Res 2009;35:173-5.
14Adesiyun AG, Ojabo A, Durosinlorun-Mohammed A. Fertility and obstetric outcome after caesarean myomectomy. J Obstet Gynaecol 2008;28:710-2.
15Hassiakos D, Christopoulos P, Vitoratos N, Xarchoulakou E, Vaggos G, Papadias K. Myomectomy during cesarean section: A safe procedure? Ann N Y Acad Sci 2006;1092:408-13.
16Kaymak O, Ustunyurt E, Okyay RE, Kalyoncu S, Mollamahmutoglu L. Myomectomy during cesarean section. Int J Gynaecol Obstet 2005;89:90-3.