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 Table of Contents  
CASE REPORT
Year : 2013  |  Volume : 3  |  Issue : 2  |  Page : 189-192

Elective cesarean myomectomy: A report of two cases


1 Department of Obstetrics and Gynaecology, Ahmadu Bello University Teaching Hospital, Shika- Zaria, Kaduna, Nigeria
2 Department of Obstetrics and Gynaecology, College of Health Sciences, Benue State University, Makurdi, Nigeria

Date of Web Publication13-Dec-2013

Correspondence Address:
Hajaratu U Sulayman
Department of Obstetrics and Gynaecology, Ahmadu Bello University Teaching Hospital, Shika-Zaria, Kaduna State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-9596.122984

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  Abstract 

Myomectomy at the time of cesarean section has traditionally been discouraged due to the risks of hemorrhage and increased postoperative morbidity. However with the new frontiers in surgical practice, successfully performed cesarean myomectomies in selected patients has continuously been reported. Two cases of multiple uterine leiomyoma coexisting with pregnancy were selected, counseled, and had elective cesarean myomectomy. The first patient was a 38-year-old primigravida with 22 years history of subfertility. Her antenatal period was largely uneventful. Her evaluation revealed a singleton pregnancy coexisting with multiple uterine fibroid. At 38 weeks of gestation, she had cesarean section and myomectomy. Thirty-six seedlings were removed. The largest was 12 Χ 8 cm and she lost 1 L of blood. She was discharged home on the 8 th postoperative day in good condition. The second case was a 33-year-old primigravida who was diagnosed with uterine fibroid in pregnancy. She also had an uneventful antenatal care and at 38 weeks gestational age, she had the removal of a huge intramural leiomyoma from the lower uterine segment (12 Χ 14 cm) during cesarean section to get access to the baby. She lost 1.2 L of blood and was transfused two pints of blood. Her postoperative condition was satisfactory. She was discharged home on the 7 th postoperative day. Cesarean myomectomy can be successfully performed with careful planning, patient selection, and skillful surgery. However, blood transfusion services should be available.

Keywords: Blood transfusion, caesarean section, myomectomy, uterine leiomyoma


How to cite this article:
Sulayman HU, Avidime S, Adesiyun AG, Ameh N, Ojabo AO, Abubakar AL, Rabiatu M, Aminu. Elective cesarean myomectomy: A report of two cases. Arch Int Surg 2013;3:189-92

How to cite this URL:
Sulayman HU, Avidime S, Adesiyun AG, Ameh N, Ojabo AO, Abubakar AL, Rabiatu M, Aminu. Elective cesarean myomectomy: A report of two cases. Arch Int Surg [serial online] 2013 [cited 2024 Mar 1];3:189-92. Available from: https://www.archintsurg.org/text.asp?2013/3/2/189/122984


  Introduction Top


The incidence of leiomyoma in pregnancy is estimated to be 2-4%. [1] Albeit myomectomy performed during pregnancy remains a rarity. Increasing rate of myomectomies during cesarean section has been reported in the past decade and, above all, certain studies have regarded this as an effective and safe procedure that is not associated with much bleeding or other complications. [1],[2] The objective of this paper is to demonstrate the feasibility and safety of cesarean myomectomy by presenting these two cases.


  Case Report Top


Case 1

The first patient was a 38-year-old primigravida with 22 years history of subfertility who presented in the antenatal clinic at 26 weeks gestation being referred from a private hospital for further management due to coexisting uterine fibroid. She had been given drugs for ovulation induction before she conceived. Ten years previously, she was diagnosed as having multiple uterine leiomyoma and was counseled for myomectomy. She continued to decline for fear of surgery. She was the second of two wives of a 45-year-old civil servant.

On examination, her general condition was stable with no palor, jaundice, dehydration, or pedal edema. Her blood pressure was 130/80 mm Hg. Her uterus was large for date of approximately 36 weeks gestational size for an estimated intrauterine gestational age of 26 weeks. Multiple lobulated masses were palpated. A diagnosis of multiple uterine leiomyoma in an elderly primigravida at 26 weeks gestation was made. Her genotype was AA and her blood group was O positive. Urinalysis was normal. Her Packed Cell Volume was 36%. HbSAg, Hepatitis C Virus (HCV), human immunodeficiency virus (HIV), and veneral disease research laboratory (VDRL) were negative. Ultrasound scan confirmed a live intrauterine fetus of 27 weeks gestation with coexisting multiple uterine leiomyoma which were mostly subserous, there was a large posterior cervical leiomyoma measuring 10 × 8 cm. Following informed consent, she was admitted at 38 weeks of gestation when a cesarean myomectomy was performed. The findings were those of a live female baby who was lying in an oblique position. There were multiple subserous and intramural myoma seedlings; the largest was intramural and measures 12 × 8 cm. Both tubes and ovaries were grossly normal.

Through a Kerr's incision the baby was delivered with an Apgar score of 7 and 9 in the 1 st and 5 th minutes respectively and weighed 2.5 kg. The placenta was delivered by controlled cord traction. Thereafter, a tourniquet was tied on the cervix (a size 18 F Foley's urethral catheter was improvised) and all visible leiomyoma were removed through the Kerr's incision and one longitudinal posterior incision was made to remove the cervical fibroid. A total of 36 fibroid seedlings were removed [Figure 1]. The uterus was repaired in three layers using vicryl 1 suture ensuring hemostasis and leaving no dead space. The abdomen was also closed in layers. A tube drain was placed before closing the abdomen. Two pints of blood were transfused intra operatively and her immediate postoperative condition was satisfactory. Surgery time was 2 h.
Figure 1: Showing the baby and fi broid seedlings in case one

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Postoperatively, she was placed on intravenous fluids, antibiotics, oxytocin 40 iu in 1 L of dextrose saline 8 hourly for 24 hours and analgesics. She also had two more pints of blood transfused. She was discharged home on the 8 th postoperative day in good condition. She was seen at 2 and 6 weeks postoperatively and she maintained a steady recovery. At 6 weeks postpartum, she was counseled and referred to the reproductive health unit for contraception. Histology of the removed leiomyoma cconfirmed leiomyomata with hyaline degeneration.

Case 2

This was 33-year-old primigravida who booked at 16 weeks gestation. She was diagnosed with uterine fibroids 3 years previously, when she presented with lower abdominal pains. She had no significant medical history. On examination, her general condition was satisfactory and her blood pressure was 130/60 mm Hg. She had a fundal height of 47 cm at 16 weeks intrauterine gestation and multiple solitary firm masses were palpated especially in the lower part of the abdomen. A diagnosis of multiple uterine leiomyoma in a primigravida was made. An ultrasound scan confirmed an intrauterine gestation of 16 weeks and 1 day with coexisting multiple uterine leiomyoma the largest of which measured 9.5 × 8.4 cm.

Urinalysis was normal while screening for VDRL, HbSAg, HIV, and HCV were negative. Her blood group was O-positive. She was given malaria and tetanus prophylaxis and was placed on routine hematinics. A repeat ultrasound scan at 34 weeks revealed a viable gestation with coexisting multiple uterine leiomyoma. The fetal lie was longitudinal with cephalic presentation and the placenta was anteriorly located. The patient was counseled on elective abdominal delivery because of the location of many of the fibroid in the lower uterine segment with a possibility of cesarean myomectomy with or without hysterectomy and she gave her consent. She, thereafter, had an uneventful antenatal care. At 38 weeks of gestation, there was nondescent of the fetal head into the pelvic brim and she was taken for cesarean myomectomy. Intraoperatively a huge leiomyoma measuring 12 × 14 cm prevented the placement of a Kerr's incision. There were also multiple leiomyomas in the uterus most of which were intramural, the largest measured 20 × 16 cm [Figure 2].
Figure 2: Showing the cervical fi broid in case two

Click here to view
Both ovaries and fallopian tubes were grossly normal. It was technically difficult to tie a tourniquet because of the size of the myomas. The myoma at the region of the lower uterine segment was removed via an anterior longitudinal incision. Thereafter, a transverse incision was placed on the lower segment and a live male baby with longitudinal lie and cephalic presentation was delivered. The baby weighed 3.9 kg with Apgar scores of 8 and 9 in the 1 st and 5 th minutes, respectively. The uterus was closed in three layers using vicryl-1. Further, myomectomy was stopped due to inability to tie a tourniquet and the anticipated increasing hemorrhage. The patient was rescheduled to have an interval myomectomy later. She lost 1.2 L of blood at the end of the whole procedure and she had two pints of blood transfused. Oxytocin 40 iu was placed in 1 L of dextrose saline to run 8 hourly for 24 h. The surgery lasted for one and a half hours. Her postoperative condition was satisfactory and was discharged on the 7 th postoperative day.


  Discussion Top


Almost 22-32% of uterine leiomyomas may progressively increase in diameter owing to persistent stimulation by estrogen and the profuse blood supply during pregnancy. [3] Different locations and tumor sizes of uterine leiomyomas have different effects on patients. Antepartum complication rate is said to be between 10% and 40% in some studies. [3] Such complications include miscarriage, malpresentation of the fetus, placental abruption, preterm delivery, dysfunctional labor, and increasing morbidity and mortality rates of the fetus and mother. [3],[4] In this study, the first patient had malpresentation, while the second had malposition. An excessively large tumor may induce uterine atony during labor. If the location of the leiomyoma is in the lower segment of the uterus, it may block the passage required for a vaginal delivery. A cesarean section may be suggested by obstetricians before labor onset after a prenatal evaluation as seen in our second patient. Some cases of cesarean myomectomy are done incidentally in order to get access to the baby during cesarean section. [5]

Kaymak et al., [3] found a small increase in operation time (9 minutes) and the length of hospital stay (0.6 days) in the planned cesarean myomectomy group (P < 0.05) when compared with incidental myomectomy during cesarean section. A similar finding is seen in our own report as the duration of surgery of case one was more than case two, though both were planned surgeries. Bilateral ligation of the uterine arteries can be done to reduce intraoperative and postoperative bleeding and this can potentially decrease the recurrence of the uterine leiomyoma, as reported by Liu et al. [4] This was not done in our patients which might have contributed to the extent of blood loss seen. High dose oxytocin as well as blood transfusion is used to manage some cases of uterine atony in the postoperative period when it occurs. [6] This was done in both our cases and this may have contributed to the favorable outcome. Oxytocin causes a sustained contraction of the uterus over a long period of time.

Some studies have shown that there is no significant difference in intraoperative and postoperative morbidity, mean blood loss and duration of hospital stay in performing cesarean section alone and cesarean section with myomectomy when a tourniquet is applied. [7],[8],[9] Tourniquet was applied in case one, but this was technically more difficult in case two and this must have been responsible for more blood loss intraoperatively than case one.

These cases illustrate that myomectomy during a cesarean section can be safely performed in carefully selected cases by an experienced obstetrician and with adequate blood transfusion services. The cases under review are also an advocacy for more cases of cesarean myomectomy to be performed especially in the developing world, where there is a strong aversion for surgeries among women in the reproductive age group.

 
  References Top

1.Mahendru R, Sekhon PK, Gaba G, Yadav S. At times, myomectomy is mandatory to effect delivery. Ann Surg Innov Res 2011;5:9.  Back to cited text no. 1
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2.Umezurike C, Feyi WP. Successful myomectomy during pregnancy: A case report. Reproduct Health 2005;6:1-3.  Back to cited text no. 2
    
3.Kaymak O, Ustunyurt E, Okyay RE, Kalyoncu S, Mollamahmutoglu L. Myomectomy during cesarean section. Int J Gynaecol Obstet 2005;89:90-3.  Back to cited text no. 3
[PUBMED]    
4.Liu WM, Wang PH, Tang WL, Wang IT, Tzeng CR. Uterine artery ligation for treatment of pregnant women with uterine leiomyomas who are undergoing cesarean section. Fertil Steril 2006;86:423-8.  Back to cited text no. 4
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5.Igwegbe AO, Nwosu BO, Ugboaja JO, Monago EN. Inevitable Caesarean myomectomy. Niger J Med 2009;18:334-6.  Back to cited text no. 5
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6.Andalas M, Pradipta B. Caesarean myomectomy: A case report in Zainoel Abidin general hospital, Banda Aceh. J Med Sci 2012;2:56-60.  Back to cited text no. 6
    
7.Kwawukume EY. Caesarean myomectomy. Afr J Reprod Health 2002;6:38-43.  Back to cited text no. 7
[PUBMED]    
8.Owolabi AT, Kuti O, Loto OM, Makinde ON, Adeyemi A. Caesarean myomectomy - a safe procedure: A retrospective case controlled study. N J Obstet Gynaecol 2007;2:59-62.  Back to cited text no. 8
    
9.Kant A, Manuja S, Pandey R. Caesarean myomectomy. J Obstet Gynecol India 2007;57:128-133.  Back to cited text no. 9
    


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