Unavoidable myomectomy during cesarean section: a case report

doi:10.4236/health.2011.33029

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Vol.3, No.3, 156-158 (2011) Health

doi:10.4236/health.2011.33029

Unavoidable myomectomy during cesarean section: a

case report

Ayse Nur Aksoy1, Kemal Tolga Saracoglu2, Mehmet Aksoy3, A yten Saracoglu4

1Department of Obstetrics and Gynecology, Nenehatun State Hospital, Erzurum, Turkey

2Department of Anesthesiology and Reanimation, Marmara University School of Medicine, Istanbul, Turkey;

*Corresponding Author: saracoglukt@gmai;

3Department of Anesthesiology and Reanimation, Nenehatun State Hospital, Erzurum, Turkey

4Department of Anesthesiology and Reanimation, Uskudar State Hospital, Istanbul, Turkey

Received 28 December 2010; revised 15 February 2011; accepted 28 February 2011.

ABSTRACT

Since myomectomy throughout cesarean deliv-

ery may lead to hemorrhage and uterinal atony,

it is not recommended. But, myomectomy has

been reported during cesarean section in recen t

studies. We presented a patient with large in-

tramural myoma who was diagnosed at 34 weeks

of pregnancy and operated w ith an unavoidable

cesarean-com bi ned myomectomy. A 33-year-old

unpursued primigravida was referred to emer-

gency department with abdominal pain and

amenorrhea of 34 weeks duration. A sonographic

diagnosis of myoma in pregnancy was made.

Cesare an sect ion was r equire d for f etal distress

and alive 2300 g weighted male infant with Ap-

gar score of 6 at one minute, was born. As ute-

rine incision could not be closed because of the

myoma, myomectomy was performed dur- ing

cesarean section unavoidably. A single 970 g

and 15 × 18 cm sized myoma was removed. The

physical examinations were unremarkable in the

postoperative period. Although there are case

series that have demonstrated the safety of

myomectomy during cesarean section, we con-

cluded that myomectomy during cesarean sec-

tion is not a safe procedure accept inevitable

situations.

Keywords: Pregnancy; Cesarean Sectio n; Myoma

1. INTRODUCTION

The incidence of uterine myomas varies from 0.3 to

7.2% during pregnancy (1). The size of myomas usually

increases during pregnancy and may produce pressure

injuries such as fetal malpresentation, hydronephrosis,

preterm labour and torsion of uterus depending on num-

ber, size and location of myomas. Because myomectomy

throughout cesarean delivery may lead to hemorrhage

and uterinal atony, is not recommended by some authors

(2-4). It also carries increased risk of postoperative mor-

bidity. On the other hand, some investigators suggested

that myomectomy may be performed during cesarean

section in selected patients (5-7).

In this case, we presented a patient with large intra-

mural myoma who was diagnosed at 34 weeks of preg-

nancy and operated with cesarean-combined myomec-

tomy.

2. CASE REPORT

A 33-year-old unpursued primigravida was referred to

emergency department of Nenehatun Obstetrics and

Gynecology Hospital with abdominal pain and amenor-

rhea of 34 weeks duration. The patient was examined

vaginally and ultrasonographically. The procedure was

carried out in accordance with the ethical standards and

written informed consent was obtained from the patient.

We conducted that she had regular uterine contractions,

no cephalopelvic disproportion, 3 cm of cervical dilate-

tion, vertex presentation, 34 weeks of fetus, 150/minute

of fetal heart rate and about 15 × 20 cm of abdominal

mass. Primarily, we attempted for normal progress of la-

bor. Whereas fetal distress appeared on the ultrasound

doppler principle, we urgently decided for cesarean de-

livery. Blood test showed a hematocrit of 33% and nor-

mal electrolytes levels. The patient’s blood type was A

Rhesus positive.

The patient was convinced to spinal anesthesia and

pfannenstiel incision was performed. The uterinal struc-

ture was adequate for 34 weeks of gestation and the in-

tramural myoma (15-17 cm in diameter) was situated

through the muscle wall. Uterine cavity was distorted

and lower uterine segment was deformed by myoma

A. N. Aksoy et al. / Health 3 (2011) 156-1 58

157

partially. A vertical uterine incision was made and alive

male infant with Apgar score of 6 at one minute and

2300 g weighted was born. Uterine incision could not be

closed because of the myoma. Then, the myometrium

overlying the myoma was incised and pseudocapsule

was dissected (Figure 1) by using electro-cautery to re-

duce blood loss. A single myoma measuring 15 × 18 cm

sized, 970 g weighted was removed (Figure 2). Hemo-

stasis was achieved by 1-0 and 0 vicryl sutures (Figure

3). The serosa was sutured using absorbable suture (2-0

or 3-0 vicryl). Prophylactic an tibiotics wer e used and th e

patient received antibiotics for seven days post-operatively.

Approximately 700 ml of blood loss was replaced by

colloids without blood transfusion. The operation took

place in 1.5 hours time. Intra-abdominal drain of hemovac

was placed without vacuum. The postoperative hema-

tocrit value was 30% and there were no maternal or fetal

complications. The patient was discharged from the hos-

pital at 8th postoperative day. The physical examinations

Figure 1. Dissection of the pseudocapsule and removing the

myoma.

Figure 2. The appearance of myoma after removal.

Figure 3. Final appearance after myomectomy.

were unremarkable in the four weeks period after hospi-

talisation.

3. DISCUSSION

Myomectomy is rarely performed during an ongoing

pregnancy because of the risk of uncontrolled hemor-

rhage necessitating hysterectomy. In recent studies,

Bhatla et al. (8) performed successful myomectomy in

the second trimester for a large subserous fibroid, weigh-

ing 3900 g. Then the pregnancy continued uneventfully

until term. Li H et al. (9) arised that mymectomy during

cesarean section was a safe and effective procedure.

Adesiyun et al. (10) investigated the fertility perform-

ance and pregnancy outcome in pregnants who had ce-

sarean myomectomy at last delivery. They noticed no

maternal or perinatal mortality factors. They suggested

that the future fertility and or subsequent pregnancy

outcome in patients were not affected by cesarean myo-

mectomy.

Hassiakos et al. (11) previously investigated the si-

multaneous surgical removal of myoma diagnosed dur-

ing cesarean section and they recommended that this

procedure may be applied during cesarean section.

Kaymak et al. (12) compared myomectomy during ce-

sarean section with myomas and underwent alone. They

found no significant diferences in the incidence of post-

operative fever, hemorrhage and frequency of blood

transfusion between myomectomy and control groups.

They concluded that myomectomy can be performed

without significant complications by experienced obste-

tricians during the cesarean section. In our case, we per-

formed unavoidable myomectomy in cesarean surgery

without blood transfusion and maternal complication.

Because the reclosure of the abdomen was impossible,

we performed mymectomy without any complication.

However, possible life threatening complications such as

A. N. Aksoy et al. / Health 3 (2011) 156-1 58

158

hemorrhage or disseminated intravascular coagulation

might ocur.

In conclusion, we do not always recommend but myo-

mectomy during cesarean section may be performed in

unavoidable conditions like in our present case.

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