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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 6  |  Issue : 4  |  Page : 224-227

Abdominal myomectomy is safe in the first trimester pregnancy: A Case Report


Reproductive Health/Family Planning Unit, Department of Obstetrics and Gynaecology, Ahmadu Bello University Teaching Hospital Zaria, Kaduna State, Nigeria

Date of Web Publication8-Dec-2017

Correspondence Address:
Dr. Umma S Bawa
Reproductive Health Unit, Ahmadu Bello University Teaching Hospital, Zaria
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ais.ais_28_16

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  Abstract 

Uterine myoma is the most common gynecological tumor in women of the reproductive age group. The incidence of myoma in pregnancy ranges from 0.3% to 2.6%, of which approximately 10% leads to complications. The management of uterine myoma during pregnancy in most of the cases is expectant, and its surgical removal is generally delayed until after delivery. In the last two decades, there have been increasing reports of successful myomectomy during caesarean section and even fewer cases in the first and second trimester. We report a case of huge uterine fibroids presenting to the booking clinic at approximately 13 weeks of gestation with a large for date uterus and severe lower abdominal pain. She was admitted and managed conservatively for the presumptive diagnosis of red degeneration in pregnancy. She had myomectomy on account of the distressing abdominal pain. She had an uneventful postoperative period and was discharged home on the 7th postoperative day on hematinics. She was eventually delivered a live baby weighing 2.6 kg by an emergency caesarean section following rupture of membranes prematurely at 37 weeks of gestation. We can therefore say that in carefully selected cases, particularly in cases of subserous fibroids, myomectomy in pregnancy may be safer than previously thought.

Keywords: Leiomyoma,myomectomy in pregnancy, red degeneration, subserous fibroids


How to cite this article:
Bawa US, Abdul MA, Madugu NH, Sarkin-Pawa Z. Abdominal myomectomy is safe in the first trimester pregnancy: A Case Report. Arch Int Surg 2016;6:224-7

How to cite this URL:
Bawa US, Abdul MA, Madugu NH, Sarkin-Pawa Z. Abdominal myomectomy is safe in the first trimester pregnancy: A Case Report. Arch Int Surg [serial online] 2016 [cited 2020 Jul 12];6:224-7. Available from: http://www.archintsurg.org/text.asp?2016/6/4/224/220324


  Introduction Top


Uterine myoma is the most common gynecological tumor in women of the reproductive age group.[1] In recent times, women are delaying childbirth to their late thirties, which is the time of greatest risk of the growth of myomas.[2] The incidence of myoma in pregnancy ranges from 0.3% to 2.6%, of which approximately 10% leads to complications; these complications include pregnancy loss, pelvic pain, placental abruption, hydronephrosis, premature rupture of membranes, preterm labor, intrauterine growth restriction, fetal malpresentation, and postpartum hemorrhage.[3] The prevalence of these complications is increased if there are multiple masses, if a myoma is retroplacental, and if a myoma is larger than 3.6 cm in diameter (200 cm 3).[3],[4]

The management of uterine leiomyoma during pregnancy in most cases is expectant, and its surgical removal is generally delayed until after delivery.[5],[6],[7],[8] Pain is the main symptom reported in pregnancies with uterine myoma; however, in 2% of the patients, conservative medical therapy fails.[9] Myomectomy is generally avoided during pregnancy due to the high risk of hemorrhage or other obstetrical complications as well as the fear of miscarriage and the risk of an uncontrolled hemorrhage necessitating a hysterectomy; therefore, there is no clear unanimous consensus existing, with a surgical approach reserved for cases of intractable abdominal pain and degeneration or rapid growth of myoma.[9],[10],[11] Measures to minimize blood loss include uterine tourniquet, uterine artery ligation, stepwise devascularization of the uterus, uterotonic drugs, and post caesarean uterine artery embolization.[12] Fibroids obstructing the lower uterine segment or accessible subserosal or pedunculated fibroids in symptomatic patients can be safely removed by experienced surgeons in well-equipped settings.[12] In the last two decades, there have been increasing reports of successful myomectomy during caesarean section,[7],[13] and even fewer cases in the first and second trimester. We report a case of huge uterine fibroids managed by myomectomy in Ahmadu Bello University Teaching Hospital Zaria, Nigeria.


  Case Presentation Top


Mrs. MZ was a 29-year-old gravida 3 para 2+0, two alive, whose last child birth was in 2002. She presented to the booking clinic on the 18th of March 2015 at 13 weeks of gestation with sudden-onset severe lower abdominal pain of 5 days duration and a large for date uterus. The pain was severe enough to prevent her from carrying out her daily activities. The pain increased with activity and had no relieving factor. She had no urinary symptoms or change in bowel habit. She had noticed the pregnancy was larger than other pregnancies at this gestation but she was sure of her last menstrual period. The pregnancy was confirmed with an ultrasound scan at 7 weeks of gestation. She had booked the pregnancy initially at a peripheral hospital but was referred on account of increasing abdominal pain. Examination revealed a young lady in painful distress, not pale or jaundiced, and had no pedal edema. Her pulse rate was 90 beats per minute and blood pressure was 110/70 mmhg. There was a firm abdominopelvic mass of approximately 30 weeks size. There was severe tenderness over the mass which prevented further examination. Abdominopelvic ultrasound showed a viable single intrauterine fetus at 13 weeks and 5 days coexisting with two large subserous myomas on the anterior and posterior-fundal uterine walls. The anterior fibroid measured 135 mm × 94 mm while the other measured 61 mm × 42 mm. The abdominal organs were normal but moderate calyceal dilatation of the right kidney was evident.

Result of full blood count revealed a packed cell volume of 33% with white blood count of 7.8 × 10.9 The differentials were normal. The urea and electrolytes were all within normal limit. Urine microscopy was normal and no organism was cultured.

She was admitted into the gynecology ward and managed conservatively for the presumptive diagnosis of red degeneration in pregnancy with intravenous fluids, analgesia, and antibiotics for a period of 5 days with no improvement of symptoms. The risk of torsion was entertained in view of the size and site of the fibroid. She was counseled for myomectomy on account of the distressing abdominal pain associated with the huge uterine fibroids. The risk of possible spontaneous abortion following the procedure was explained to her.

She consented and was worked up for surgery including making available two units of cross-matched whole blood. She underwent myomectomy on the 30/03/2015 under general anesthesia, and the findings were those of two huge subserous uterine fibroids measuring 18 cm × 11 cm and 10 cm × 8 cm in dimension [Figure 1] and [Figure 2].
Figure 1: Intraoperative two huge sub serous fibroids at the left and right fundal areas with Three smaller sub serous fibroid seedlings in between

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Figure 2: Gravid uterus post enucleation of fibroid seedlings

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Postoperatively, the patient was placed on antibiotics, intravenous fluids, and analgesia (combination of pentazocine and diclofenac) for 48 hours. She had an uneventful postoperative period and was discharged home on the 7th postoperative day on hematinics. The histology confirmed leiomyomata.

Her antenatal period was uneventful with a total of six antenatal care visits. She eventually delivered a live baby weighing 2.6 kg in a private healthcare facility by an emergency caesarean section following rupture of membranes prematurely at 37 weeks of gestation. This was due to an industrial action in our institution during the period. The immediate postoperative period was free of complications. The delivery details were received from the patient via a telephone interview.


  Discussion Top


There are a few reported cases of myomectomy conducted during an ongoing pregnancy in Nigeria. Many obstetricians are not comfortable with caesarean myomectomy, and carrying out a myomectomy during an ongoing pregnancy is almost out of the question.

The patient was admitted at 13 weeks of pregnancy with severe lower abdominal pain, with a sympysiofundal height of 32 cm. This is was large for date and necessitated surgical intervention. This was similar to many of the cases reported in literature where the patient does not respond to conservative management with medical therapy.[4],[9],[13]

The surgeon is usually unable to use any of the methods to reduce blood loss during the myomectomy and the risk of massive hemorrhage is a feared complication intraoperatively. The patient in question lost 550 ml of blood which is consistent with the 500 ml reported by Aziken et al. in Benin city, Nigeria. Our patient delivered by an emergency caesarean section at 37 weeks of gestation following PROM. Caesarean section is a common mode of delivery in most previous reports.[9],[10],[11],[12],[13],[14] In the case reported by Umuzurike et al. from Aba in Nigeria, the patient had a spontaneous vaginal delivery.[15]

A woman with coexisting fibroids in pregnancy embarking on vaginal delivery would also be faced with a number of complications; this includes inefficient uterine action necessitating augmentation of labor and a high chance of primary postpartum hemorrhage following it either from prolonged labor or from uterine atony. There might be difficulty in delivery of the placenta in the third stage of labor also predisposing her to have primary postpartum hemorrhage.

The decision to conduct a myomectomy is a matter of reaching a delicate balance. In general, myomectomy should be considered when conservative management fails as in this case.


  Conclusion Top


In conclusion, in carefully selected cases particularly in cases of subserous fibriods, myomectomy in pregnancy may be safer than previously thought.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Okolo S. Incidence, Aetiology, and Epidemiology of Uterine Fibroids. Best Pract Res Clin Obstet Gynaecol 2008;22:571-88.  Back to cited text no. 1
[PUBMED]    
2.
Lippma SA, Warner M, Samuels S, Olive D, Vercellini P, Eskenazi B. Uterine fibroids and gynecologic pain symptoms in a population based study. Fertil Steril 2003;80:1488-94.  Back to cited text no. 2
    
3.
Katz VL, Dotters DJ, Droegemeuller W. Complications of uterine leiomyomas in pregnancy. Obstet Gynecol 1989;73:593-6.  Back to cited text no. 3
[PUBMED]    
4.
Suwandinata FS, Gruessner SE, Omwandho CO, Tinneberg HR. Pregnancy-preserving myomectomy: Preliminary report on a new surgical technique. Eur J Contracept Reprod Health Care 2008;13:323-6.  Back to cited text no. 4
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5.
Kwawukume EY. Myomectomy during cesarean section. Int J Gynecol Obstet 2002;76:183-4.  Back to cited text no. 5
    
6.
Ezechi OC, Kalu BKE, Okeke PE, Nwokoro CO. Inevitable cesarean myomectomy: A case report. Trop J Obstet Gynecol 2003;20:159-60.  Back to cited text no. 6
    
7.
Ehigiegba AE, Evbuomwan CE. Inevitable caesarean myomectomy. Trop J Obstet Gynecol 1998;15:62.  Back to cited text no. 7
    
8.
Roman AS, Tabsh KM. Myomectomy at time of cesarean delivery; A retrospective cohort study. BMC Pregnancy Childbirth 2004;4:14.  Back to cited text no. 8
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9.
Lolis DE, Kalantaridou SN, Makrydimas G, Sotiriadis A, Navrozoglou I, Zikopoulos K, et al. “Successful myomectomy during pregnancy”. Hum Reprod 2003;18:1699-702.  Back to cited text no. 9
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10.
Bonito M, Gulem IL, Basili R, Roselli D. Myomectomy during the first and second trimester of pregnancy. Clin Exp Obstet Gynecol 2007;34:149-50  Back to cited text no. 10
    
11.
Domenici L, Di Donato V, Gasparri ML, Lecce F, Caccetta J, Panici PB. Laparotomic Myomectomy in the 16th Week of Pregnancy: A Case Report. Case Rep Obstet Gynecol 2014;2014:154347.  Back to cited text no. 11
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12.
Machado LSM, Gowri V, Al-Riyami N, Al-Kharusi L. Caesarean Myomectomy: Feasibility and safety. Sultan Qaboos Univ Med J 2012;12:190-6.  Back to cited text no. 12
    
13.
Ehigiegba AE, Ande AB, Ojobo SI. Myomectomy during cesarean section. Int J Gynecol Obstet 2001;75:21-5.  Back to cited text no. 13
    
14.
Aziken ME, Osemwenkha AP, Orhue AAE, Afinotan LU, Osughe OM, Irihogbe I. Huge Uterine Fibroid Complicating Early Pregnancy: Myomectomy and Live Birth at Term. Pak J Med Sci 2008;24:753-6.  Back to cited text no. 14
    
15.
Umezurike C, Feyi-Waboso P. Successful myomectomy during pregnancy: A case report. Reprod Health 2005;2:6.  Back to cited text no. 15
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