Case Report | Open Access
Laparotomic Myomectomy in the 16th Week of Pregnancy: A Case Report
Myomectomy is rarely performed during an ongoing pregnancy because of fear of miscarriage and the risk of an uncontrolled haemorrhage necessitating a hysterectomy. In cases where myomectomy is undertaken, most are performed at the time of cesarean section or with a laparoscopic approach. We report a case of a successful laparotomic myomectomy in the 16th week of pregnancy. A 35-year-old primigravida was admitted to our department with acute abdominal pain and hydronephrosis (serum creatinine 1.6 mg/dL). Imaging revealed a large implant myoma compressing the bladder, ureters, rectus, and gestational chamber and causing hydronephrosis. Laparotomic myomectomy was successfully performed and pregnancy continued uneventfully until the 38th week when a cesarean section was performed. Surgical management of myomas during pregnancy is worth evaluating in well-selected and highly symptomatic cases.
The estimated prevalence of uterine myomas during pregnancy varies from 0.3 to 15% . Most uterine myomas remain asymptomatic during pregnancy but may result in obstetrical complications in about 10% of cases depending on their size, location, and number [2–4]. Pain is the main symptom reported in pregnancies with uterine myoma; however, in 2% of patients conservative medical therapy fails. In extreme cases some authors have advocated the interruption of pregnancy to relieve pain . Myomectomy is generally avoided during pregnancy due to the high risk of haemorrhagic or obstetrical complications and no clear unanimous consensus exists, with a surgical approach reserved for cases of intractable abdominal pain and degeneration or rapid growth of myoma [6, 7]. Only a few cases of myomectomy in pregnancy have been reported in the literature [6, 8–10]. In this paper we report a case of myomectomy of subserous myoma with large base of implant causing hydronephrosis in the 16th week of pregnancy.
2. Case Presentation
In January 2013, a 35-year-old primigravid Caucasian woman (BMI: 22) was referred to our university hospital in the 16th week of gestation for intractable pelvic pain. The medical history was uneventful. The patient reported a sense of pelvic heaviness, changes in urinary habits, lower abdominal discomfort, and unexplained back pain that had worsened over time. She had a normal white blood cell count but an increased value of serum creatinine (1.6 mg/dL). Obstetrical examination showed a large mass at the level of the posterior fornix. Abdominal ultrasound confirmed a viable fetus and a subserous large implant myoma (diameter of 20 cm; Figure 1), a mild bilateral dilatation of the renal pelvis (2 cm on the right-hand side and 3.5 cm on the left), and extrinsic compression of the low ureter with involvement of the initial portion of the ureters.
Magnetic resonance imaging (MRI) confirmed the diagnosis (Figure 2).
Considering the increase in symptoms that were nonresponsive to analgesic therapy, due to organ compression and the level of serum creatinine, after extensive counselling, a myomectomy was planned. Given the volume and the location of the myoma and in order to be able to manage possible complications, laparotomic incision was chosen. After accurate operative field exposure, the huge myoma was removed (Figure 3). Reconstruction of the uterine wall was carried out using a two-layer monofilament absorbable 2.0 suture (Poliglecaprone 25). Other small fibroids were observed but not removed. Estimated blood loss and operation time were 250 cc and 90 minutes, respectively, and no intra- and postoperative complications occurred. An ultrasonographic control of fetal outcome was carried out 7 days after surgery which proved normal. Antibiotics (ampicillin plus sulbactam 3 gr for three times a day) and low molecular heparin were administered for 5 and 10 days, respectively. The patient was dismissed on the 5th postoperative day. Serum creatinine at discharge was 1.1 mg/dL.
Hydroxyprogesterone Caproate (341 mg/2 mL im) was dispensed for 15 days to prevent a possible miscarriage.
The patient was closely followed up with ultrasound and physical examination every four weeks until 24 weeks of gestation, every three weeks from 24 weeks to 34 weeks of gestation, and then every two weeks. Physiological fetal growth and an uneventful antenatal period were reported until 38 weeks of gestation when a cesarean section was performed.
The patient delivered a healthy female baby weighing 3250 gr with Apgar scores of 8 and 9 at one and five minutes, respectively. The maternal haemoglobin level, two days after caesarean section, was 12.2 g/dL. Mother and baby were discharged from the hospital after three days. The 6-week postnatal visit was within the norm.
Laparotomic myomectomy is generally avoided during an ongoing pregnancy due to higher miscarriage and haemorrhage rates. Most cases are usually performed during a caesarean section at the end of the pregnancy.
In a large study of more than 6300 pregnant women, Coronado et al. reported a 1.9 times greater (95% CI, 1.6 to 2.2) incidence of complications in women with myomas compared with women without myomas .
Preterm delivery has been reported in approximately 15–20% of women with myomas, restriction of fetal growth in 10%, and malpresentation in 20% .
The increased risk of miscarriage was attributed to the increase in uterine contractions, degeneration, and growth of myoma.
The most common indication for myomectomy during pregnancy is acute severe abdominal pain that does not respond to analgesic therapy due to torsion of the subserous pedunculated myomas or rapid abnormal increase in myoma size, resulting in the compression and displacement of surrounding organs. It has been reported that if symptoms persist after 72 h of pharmacological therapy, surgical intervention must be considered [6, 12, 13].
An analysis of cases reported in the literature suggests that myomectomy during pregnancy can be considered safe. Studies have shown that women who undergo surgical intervention in the second trimester actually have better outcomes than those who opt for conservative management [10, 14] (Table 1).
In Lolis et al.’s study, of 13 patients who underwent myomectomy during pregnancy, only one miscarried, making a success rate of 92% .
The majority of interventions described in the literature are performed laparoscopically. Laparoscopy can be considered in selected cases (small, subserous pedunculated myomas). It is a valid option in the surgical management of pregnant women with symptomatic myomas, as it is less invasive and involves minimal postoperative pain and earlier postoperative ambulation .
Two cases are reported in the literature with large pedunculated myomas operated by the vaginal route .
In our case a laparotomic approach was chosen, because of the size (20 cm), the large base of implant, the location of myoma, and the acute syndrome of the patient.
Although a laparotomic approach for uterine myomas during pregnancy is rarely described, our experience suggests that it can be easily managed laparotomically by an experienced surgeon in selected cases, depending on the size, type, and position of the fibroids.
We believe that our experience provides reassurance for pregnant women with uterine myomas: the surgical management of uterine myomas during pregnancy can be successfully performed by expert surgeons on a case-by-case basis. Myomectomy during pregnancy should be performed only if unavoidable. In selected patients it could prevent miscarriage or an unacceptable obstetrical outcome. The surgical approach should be tailored to the patient and to the characteristics of the myoma. Clearly, an expert surgical and anesthesiological team is essential in order to reduce risk of complications.
Further investigation is needed to improve and better define the safety and feasibility of laparotomic myomectomy during pregnancy.
Conflict of Interests
All authors declare no conflict of interests.
- N. P. Cooper and S. Okolo, “Fibroids in pregnancy—common but poorly understood,” Obstetrical and Gynecological Survey, vol. 60, no. 2, pp. 132–138, 2005.
- J. P. Phelan, “Myomas and pregnancy,” Obstetrics and Gynecology Clinics of North America, vol. 22, no. 4, pp. 801–805, 1995.
- C. A. Burton, D. A. Grimes, and C. M. March, “Surgical management of leiomyomata during pregnancy,” Obstetrics and Gynecology, vol. 74, no. 5, pp. 707–709, 1989.
- F. S. Suwandinata, S. E. Gruessner, C. O. Omwandho, and H. R. Tinneberg, “Pregnancy-preserving myomectomy: preliminary report on a new surgical technique,” European Journal of Contraception and Reproductive Health Care, vol. 13, no. 3, pp. 323–326, 2008, Erratum in: European Journal of Contraception and Reproductive Health Care, vol. 13, no. 4, p. 438, 2008.
- K. Leach, L. Khatain, and K. Tocce, “First trimester myomectomy as an alternative to termination of pregnancy in a woman with a symptomatic uterine leiomyoma: a case report,” Journal of Medical Case Reports, vol. 5, no. 1, article 571, 2011.
- D. E. Lolis, S. N. Kalantaridou, G. Makrydimas et al., “Successful myomectomy during pregnancy,” Human Reproduction, vol. 18, no. 8, pp. 1699–1702, 2003.
- M. Bonito, L. Gulemì, R. Basili, and D. Roselli, “Myomectomy during the first and second trimester of pregnancy,” Clinical and Experimental Obstetrics and Gynecology, vol. 34, no. 3, pp. 149–150, 2007.
- M. Ardovino, I. Ardovino, M. A. Castaldi, A. Monteverde, N. Colacurci, and L. Cobellis, “Laparoscopic myomectomy of a subserous pedunculated fibroid at 14 weeks of pregnancy: a case report,” Journal of Medical Case Reports, vol. 5, no. 5, article 545, 2011.
- S. Doerga-Bachasingh, V. Karsdorp, G. Yo, R. van der Weiden, and M. van Hooff, “Successful myomectomy of a bleeding myoma in a twin pregnancy,” JRSM Short Reports, vol. 3, no. 2, p. 13, 2012.
- G. Mollica, L. Pittini, E. Minganti, G. Perri, and F. Pansini, “Elective uterine myomectomy in pregnant women,” Clinical and Experimental Obstetrics and Gynecology, vol. 23, no. 3, pp. 168–172, 1996.
- G. D. Coronado, L. M. Marshall, and S. M. Schwartz, “Complications in pregnancy, labor, and delivery with uterine leiomyomas: a population-based study,” Obstetrics and Gynecology, vol. 95, no. 5, pp. 764–769, 2000.
- S. de Carolis, G. Fatigante, S. Ferrazzani et al., “Uterine myomectomy in pregnant women,” Fetal Diagnosis and Therapy, vol. 16, no. 2, pp. 116–119, 2001.
- N. Bhatla, B. B. Dash, A. Kriplani, and N. Agarwal, “Myomectomy during pregnancy: a feasible option,” Journal of Obstetrics and Gynaecology Research, vol. 35, no. 1, pp. 173–175, 2009.
- C. Celik, A. Acar, N. Ciçek, K. Gezginc, and C. Akyürek, “Can myomectomy be performed during pregnancy?” Gynecologic and Obstetric Investigation, vol. 53, no. 2, pp. 79–83, 2002.
- V. Lozza, A. Pieralli, S. Corioni, M. Longinotti, and C. Penna, “Multiple laparotomic myomectomy during pregnancy: a case report,” Archives of Gynecology and Obstetrics, vol. 284, no. 3, pp. 613–616, 2011.
- C. C. Kilpatrick, M. T. Adler, and L. Chohan, “Vaginal myomectomy in pregnancy: a report of two cases,” Southern Medical Journal, vol. 103, no. 10, pp. 1058–1060, 2010.
- S. P. Michalas, F. V. Oreopoulou, and J. S. Papageorgiou, “Myomectomy during pregnancy and Caesarean section,” Human Reproduction, vol. 10, no. 7, pp. 1869–1870, 1995.
- E. Danzer, W. Holzgreve, C. Batukan, P. Miny, S. Tercanli, and I. Hoesli, “Myomectomy during the first trimester associated with fetal limb anomalies and hydrocephalus in a twin pregnancy,” Prenatal Diagnosis, vol. 21, no. 10, pp. 848–851, 2001.
- J. G. Joó, J. Inovay, M. Silhavy, and Z. Papp, “Successful enucleation of a necrotizing fibroid causing oligohydramnios and fetal postural deformity in the 25th week of gestation: a case report,” Journal of Reproductive Medicine for the Obstetrician and Gynecologist, vol. 46, no. 10, pp. 923–925, 2001.
- U. Hasbargen, A. Strauss, M. Summerer-Moustaki et al., “Myomectomy as a pregnancy-preserving option in the carefully selected patient,” Fetal Diagnosis and Therapy, vol. 17, no. 2, pp. 101–103, 2002.
- C. Umezurike and P. Feyi-Waboso, “Successful myomectomy during pregnancy: a case report,” Reproductive Health, vol. 2, article 6, 2005.
- F. Usifo, R. Macrae, R. Sharma, I. O. Opemuyi, and B. Onwuzurike, “Successful myomectomy in early second trimester of pregnancy,” Journal of Obstetrics and Gynaecology, vol. 27, no. 2, pp. 196–197, 2007.
- G. K. C. Leite, H. A. Korkes, T. Viana Ade, A. Pitorri, G. Kenj, and N. Sass, “Myomectomy in the second trimester of pregnancy: case report,” Revista Brasileira de Ginecologia e Obstetricia, vol. 32, no. 4, pp. 198–201, 2010.
- P. Isabu, J. Eigbefoh, F. Okogbo, S. Okunsanya, and R. Eifediyi, “Myomectomy during second trimester pregnancy: a case report,” The Nigerian Postgraduate Medical Journal, vol. 17, no. 4, pp. 324–326, 2010.
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