|Year : 2018 | Volume
| Issue : 2 | Page : 102-103
Successful myomectomy in early pregnancy for a large asymptomatic uterine myoma
Juhul Patel, Sumana Manohar
Department of OBGY, Apollo Hospital, Chennai, Tamil Nadu, India
|Date of Web Publication||5-Jul-2018|
Department of OBGY, Apollo Hospital, Chennai - 600 006, Tamil Nadu
Source of Support: None, Conflict of Interest: None
The decision of myomectomy is not usually taken by OBG specialist for uterine fibroids during pregnancy because of its complications which become life threatening at times. This is why it is generally delayed until after delivery. The current case was a large, asymptomatic subserous uterine myoma of 17 cm diagnosed during pregnancy by ultrasound and successfully managed by antepartum myomectomy retaining the fetus alive in utero at 13–14 weeks' gestation. This case demonstrates that myomectomy during pregnancy in special circumstances in selected cases to prevent forthcoming events adversely affecting mother and fetus can be considered.
Keywords: Myomectomy, pregnancy, uterine myoma
|How to cite this article:|
Patel J, Manohar S. Successful myomectomy in early pregnancy for a large asymptomatic uterine myoma. Apollo Med 2018;15:102-3
| Introduction|| |
The prevalence of uterine myomas during pregnancy is estimated to be 0.3%–2.6%, of which 10% result in pregnancy complications. Although leiomyomas are usually asymptomatic during pregnancy, they may complicate its course. The complications include first trimester losses, pressure symptoms caused by the myoma on the mother and fetus, pain of “red degeneration,” premature labor, premature rupture of membranes, malpresentation, retained placenta, postpartum hemorrhage, and uterine torsion. The size, location, number of fibroids, and their relation to the placenta are critical factors. Ultrasound scanning plays a central role in diagnosing and monitoring fibroids during pregnancy and in determining the relative position of the fibroids to the placenta. The management of leiomyoma during pregnancy is medical, but in rare circumstances, surgical intervention and myomectomy may be required.
| Case Report|| |
A 33-year-old primigravida presented to our hospital at period of gestation of 14 weeks 1 day for routine antenatal examination. On examination, her height of uterus was found to be 30–32-week gestational size. On vaginal examination, we could feel the uterus separately of about 12–14-week gestational size; beside this, a huge mass of about 17 cm diameter filling whole abdomen was felt separately. Ultrasonography showed an intrauterine viable fetus of 13-week 2-day gestation with a large well-defined hypoechoic abdominopelvic mass measuring 17 cm × 10 cm with minimum vascularity seen which was extending from the left adnexa to the left side of abdominal cavity up to the left hypochondrium. The patient was counseled regarding all possible outcomes of pregnancy along with this mass, and she agreed to undergo exploratory laparotomy. On laparotomy, a huge subserosal left false broad ligament fibroid arising from left lateral surface of size 20 cm × 15 cm was found and removed [Figure 1] and [Figure 2]. Following leiomyoma removal, hemostasis was carefully achieved. Fetal monitoring by ultrasonography was carried out immediately after surgery and the fetus was found viable. Postoperative period was uneventful and the patient was given tocolysis for 3 days with uterine relaxants and micronized progesterone was continued for 4 weeks. The patient was discharged on 3rd postoperative day and followed up using ultrasonography 4th weekly. The patient delivered vaginally at term without any complications.
|Figure 1: Intraoperative picture showing gravid uterus with large broad ligament myoma (arrow)|
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| Discussion|| |
Controversy persists among reports of myomectomy being performed during pregnancy. The management of uterine leiomyoma during pregnancy is largely expectant, and its surgical removal is generally delayed until after delivery. Mortality and morbidity are slightly higher in myomectomy in the gravid uterus as compared to nongravid uterus. There is increased vascularity of the gravid uterus; thus, myomectomy performed in pregnancy has been reported to be associated with greater risk of hemorrhage and the need for blood transfusion. Additional to the general risks of myomectomy is the risk of abortion which occurs in 18%–35% of cases. An incomplete abortion may also result in severe endometritis, especially if a communication channel to the recently enucleated fibroid bed is present.
In our case, 33-year-old female presented to us for her antenatal examination at 13 weeks 2 days and was diagnosed with large abdominopelvic mass on ultrasonography. Although our patient was asymptomatic, we could not categorically rule out ovarian origin of the mass. After explaining the risks associated with such a large mass, the patient gave consent for exploratory laparotomy and myomectomy was done. The subserosal location made it easier to remove the fibroid, and hypercoagulability of pregnancy contributed to the ease in achieving hemostasis which further contributed to safety of the procedure.
A reported myomectomy during early pregnancy was in women from Latin America  presented with progressively worsening lower abdominal pain, needed laparotomy at 15 weeks' gestation; a pedunculated myoma showing degenerative changes in the fundus of the uterus was excised successfully and the pregnancy progressed normally. However, in patients like our own, a timely and well-planned myomectomy can be an option offered to the patient, avoiding morbidity and mortality associated with emergency procedures.
| Conclusion|| |
In conclusion, the decision to perform a myomectomy during pregnancy should be based on the fibroid size, location, and its rapid growth to prevent various possible forthcoming adverse events. Therefore, a carefully planned myomectomy in huge myomas in selected cases is an appropriate low morbidity option which can be offered to the patient.
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 initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]