Laparoscopic myomectomy of a subserous pedunculated fibroid at 14 weeks of pregnancy: a case report

Antenatal myomectomy of huge pedunculated fibroid

A female patient in her 20s presented at 10 weeks of pregnancy with abdominal pain. She was known to have a 17-cm fibroid a year ago, which, on repeat imaging, was found to have increased in size to 29 cm. A 12-cm increase in size over a year therefore led to concerns that it would increase in pregnancy, causing risk of thrombosis, decrease in venous return, miscarriage, fibroid torsion, fibroid necrosis, preterm labour and uterine rupture. Following a multidisciplinary team review with obstetricians, neonatologists, gynaecologists and radiologists, the patient opted to proceed with an open myomectomy at 14 weeks gestation, which was performed successfully. The pregnancy continued uneventfully until term when she delivered a healthy girl infant at 38+2 weeks via an elective caesarean section.

Myomectomy during pregnancy; diagnostical dilemmas: two case reports and a systematic review of the literature

Myomectomy in pregnancy, until this day, remains very controversial. We present two cases of successful antepartum myomectomies performed in the second trimester of gestation. In both cases, the initial suspected origin of these tumours was the ovaries. However, as it was shortly after confirmed, since both women underwent laparotomy, the diagnosis of these masses was uterine fibroids. Both cases resulted on the live birth of two healthy infants via caesarean section. Secondarily, we conducted a thorough review of current data of myomectomies performed during pregnancy, including the characteristics and diagnosis of the myomas of pregnant women, the surgical details and complications, along with the outcomes of these gestations. Overall, the analysis of cases published in international literature, suggests that the surgical removal of myomas during pregnancy can be considered safe, given certain indications and considerations. Our review comprises of 71 women undergoing excision of fibroids during pregnancy. Only three cases ended in a miscarriage while the remaining 68 resulted in a second or third trimester delivery. However, the data concerning the safety of the procedure are scarce and originate mostly from case reports. Thus, conclusions on the exact maternal and obstetrical complication rates cannot be drawn.

Torsion of a Pedunculated Subserous Leiomyoma in a Pregnant Woman: A Rare Case Report

Torsion of a pedunculated subserous leiomyoma in a pregnant woman is a rare condition that requires prompt diagnosis and urgent surgical intervention. In this report, we present a case of torsion of a pedunculated subserous leiomyoma in a primigravid woman aged 33 years in her 30th week of gestation. A primigravid woman aged 33 years presented to our clinic in her 30th week of gestation with pain in the right lower quadrant that had developed in the last 24 hours. Our diagnosis was torsion of a pedunculated leiomyoma. The patient received a tocolytic of nifedipine and indomethacin preoperatively. Given the volume of the uterus and as a precaution to potential complications, a lower transverse (pfannenstiel) incision was preferred. The laparotomic myomectomy was successfully performed and the pregnancy continued uneventfully. Even though torsion of a pedunculated subserous leiomyoma in pregnancy is a very rare condition, prompt diagnosis and urgent surgical intervention is life saving and provides more favorable maternal and fetal outcomes. The surgical approach should be tailored to the patient and to the characteristics of the myoma and an expert team of surgeons and anesthesiologists is essential in order to reduce the risk of complications.

Myomectomy during pregnancy: an obstetric overview and two case-series

INTRODUCTION

Uterine fibroids (UFs) are the most common benign disease affecting female reproductive system, occur in 20-40 % of women, and in 10 % of pregnancies. The aim of the investigation was to summarize evidences about the management and treatment of UFs and related complications in pregnancy.

MATERIALS AND METHODS

A literature review was performed using scientific databases, including all case report and case series, using a combination of key words relating to the problem exposed. Data about gestational age at diagnosis, maximum fibroids diameter, type of surgery and gestational age at surgery, delivery and perinatal outcome were collected. Two clinical cases were also included.

RESULTS

Sixty-six articles were selected and 199 patients were included. In 76 % of patients the gestational age at myomectomy was lower than 20 weeks, in 85 % laparotomic surgery was chosen, in 41 % of cases the maximum fibroid diameter was between 7-20 cm, in 41 % of pregnancies the route of delivery was cesarean section. The eight percent of cases was complicated by miscarriage or fetal demise or neonatal death.

CONCLUSIONS

Myomectomy is a feasible procedure in those pregnancies complicated by symptomatic fibroids, though surgery in pregnancy is associated with an increased risk of obstetric complications.

Cesarean myomectomy: a case report and review of the literature

Background

Routine myomectomy at the time of cesarean section has been condemned in the past due to fear of uncontrolled hemorrhage and peripartum hysterectomy. It is still a topic of debate worldwide. However, in recent years, many case studies of cesarean myomectomy have been published validating its safety without any significant complications.

Case presentation

We describe the case of a 27-year-old gravida 2 para 1 live birth 1 North Indian woman with one previous lower segment caesarean section (LSCS) at 35 weeks with labor pains and scar tenderness. Her recent ultrasound (USG) report suggested a single live intrauterine pregnancy with an intramural fibroid of 8.6 × 6.5 cm located in the left anterolateral wall of the lower uterine segment. The patient was taken up for emergency cesarean section along with successful removal of the myoma, which was bulging into the incision line, causing difficulty in closure of the uterine wound. Prophylactically, oxytocin infusion, bilateral ligation of uterine arteries, and injection vasopressin (diluted) was administered to decrease the blood loss. The patient was discharged after 7 days without any complications.

Conclusions

Routine myomectomy at the time of cesarean section is not a standard procedure and is not accepted worldwide. However, it may be considered a safe option in carefully selected cases in the hands of an experienced obstetrician with appropriate hemostatic technique. Large multicenter randomized controlled trials should be conducted to evaluate the best practice guidelines for cesarean myomectomy.

Myomectomy during pregnancy: A systematic review

OBJECTIVE

Uterine fibroids affect 2-10 % of pregnant women. Although usually asymptomatic, they may be associated with pregnancy complications. Myomectomy is preferably avoided antenatally, however, it has been reported in symptomatic cases that did not respond to conservative management. The aim of this study was to summarize the published literature and present the reported outcomes and associated risks of this procedure.

STUDY DESIGN

A systematic research of the literature was conducted in PubMed/MEDLINE, Scopus and the Cochrane Library, including case reports and case series. An effort was made to numerically analyse all parameters included in the case reports.

RESULTS

Overall, 54 relevant articles were identified, including 97 patients. The median gestational age at diagnosis was 13 (range 6-26) weeks, while the median age at myomectomy was 16 (range 6-26) weeks. Abdominal pain, not responding to medical treatment was the most common indication for surgery. The median number of fibroids removed per patient was one (range 1-5). Most of them were subserous pedunculated or subserous and fundal. Laparotomy (78.4 %) was the principal surgical approach, however, laparoscopic and vaginal operations were also reported. The median duration of surgery was 53 (range 20-150) min. The histopathology revealed necrosis and degeneration as the main findings of removed fibroids. The pregnancy outcome was favourable in most of the cases, with few complications reported.

CONCLUSION

Based on the limited published data, myomectomy during pregnancy appears as a safe procedure in cases of symptomatic uterine fibroids not responding to conservative management and therefore it may be considered, following appropriate counselling regarding the associated risks.

Vaginal delivery after laparotomic myomectomy during pregnancy

Background

Symptomatic myomas during pregnancy are a rare condition that could however turn into an emergency because of torsion, necrosis, growth and compression leading to acute abdomen, potentially threating for pregnancy. Surgeons are usually reluctant to perform myomectomy during pregnancy because of an increased uterine blood flow and volume can give rise to a potential risk for haemorrhagic complications, while uterine manipulation can determine adverse pregnancy outcome. However, in some rare cases surgery is compulsory.

Case presentation

Here, we described a case of a successful laparotomic myomectomy performed during pregnancy at 11 weeks of gestation when an acute abdomen occurred. Surgery was followed by regular obstetrics follow-up ended with a spontaneous vaginal delivery with no pregnancy complications.

Conclusion

Although few case reports are described in literature, other authors have performed a myomectomy during pregnancy, and fewer cases have had a subsequent vaginal delivery, so that nowadays there is no clinical evidence on which to base best practice. This case shows that vaginal delivery after a laparotomic myomectomy performed during pregnancy, in selected cases, can be considered as a feasible option.

Use of pre-operative imaging for symptomatic uterine myomas during pregnancy: a case report and a systematic literature review

PURPOSE

Uterine fibroids (UFs) occur in 10% of pregnancies and may lead to severe maternal-fetal complications, mainly depending on UFs characteristics and the distance to the uterine cavity (UC). When symptomatic, UFs are managed medically. Nevertheless, in about 2% of cases, surgery becomes necessary. Entry into the UC should be avoided during myomectomy. Consequentially, pre-operative assessment of this risk could be beneficial. Ultrasonography (US) represents the gold standard for UFs assessment; however, scarce evidence has been produced to assess the role of magnetic resonance imaging (MRI). The aim of the present study was to summarize current evidence about the pre-operative use of imaging techniques for UFs during pregnancy.

METHODS

A systematic research of the literature was conducted in Scopus, PubMed/MEDLINE, ScienceDirect and the Cochrane Library, including case reports and case series. A case report was also discussed. We collected data regarding patients, imaging assessment, UFs characteristics, surgical information, timing and modality of delivery.

RESULTS

According to our search strategy, 66 articles were selected and 210 patients were included. US assessment was reported in 36 (17%) cases. MRI was reported in 10 (4.7%) cases. Only in one case, MRI was used to measure the distance between UFs and UC.

CONCLUSION

US allows an adequate pre-operative evaluation of anterior, submucosal or pedunculated symptomatic UFs in pregnancy. However, compared to US, MRI may provide a more accurate evaluation of multiple, large, intramural or posterior UFs and could measure the distance between UFs and UC more accurately.

Uterine Fibroid Torsion during Pregnancy: A Case of Laparotomic Myomectomy at 18 Weeks' Gestation with Systematic Review of the Literature

Uterine myomas are the most common benign growths affecting female reproductive system, occurring in 20–40% of women, whereas the incidence rate in pregnancy is estimated from 0.1 to 3.9%. The lower incidence in pregnancy is due to the association with infertility and low pregnancy rates and implantation rates after in vitro fertilization treatment. Uterine myomas, usually, are asymptomatic during pregnancy. However, occasionally, pedunculated fibroids torsion or other superimposed complications may cause acute abdominal pain. There are many controversies in performing myomectomy during cesarean section because of the risk of hemorrhage. Nevertheless, the majority of indication arises before labor and delivery due to acute symptoms leading to a discussion regarding the need for intervention during pregnancy. Therefore, we present a case of successful multiple laparotomic myomectomy at 17 + 2 weeks of gestational age and a systematic review of the literature in order to clarify the approach to this pathologic condition and its effect on pregnancy outcome.

Laparoscopic approach to fibroid torsion presenting as an acute abdomen in pregnancy

This case report demonstrates the safe application of laparoscopic excisional myomectomy in the first trimester of pregnancy.

Uterine leiomyomas (fibroids) are seen in up to 4% of pregnancies, and most commonly present with pain in pregnancy, which can be due to red degeneration or torsion. Most cases previously have been managed with open resection. We report the case of a 35-y-old primagravida woman, presenting with acute lower abdominal pain at 11 wk gestation. Ultrasound demonstrated an 8-cm fibroid only. She demonstrated features of lower abdominal peritonitis and was scheduled for a diagnostic laparoscopy. At operation, a torsed subserosal fibroid was found. She successfully underwent laparoscopic myomectomy with the endoGIA vascular stapler and subsequent Pfannenstiel delivery. The patient was discharged 48 h postoperatively to continue her pregnancy. This case demonstrates the safe application of laparoscopic excisional myomectomy in the first trimester of pregnancy. Previously reported cases in the literature have focused on open resection or bipolar diathermy enucleation and morcellation. A high degree of suspicion should be maintained for the diagnosis in patients presenting to the surgical service with acute lower abdominal peritoneal signs during pregnancy.

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.

A successful antenatal myomectomy

Complications that may occur while performing myomectomy in pregnancy can be prevented in a well-optimised surgery. Counselling and comprehensive peri-operative preparations are mandatory to minimise litigations and untoward events. Myomectomy in pregnancy remains a contentious issue. Degeneration of fibroid during pregnancy is common. However, conservative management suffices in majority of cases. In non-responsive conservative treatment, myomectomy may be an option. This article discusses our experience in treating a 38-year-old woman in her fourth pregnancy at 15 weeks gestation with symptomatic uterine fibroid. She had persistent abdominal pain since nine weeks gestation. She developed fever and acute abdomenat at 15 weeks and the uterus was larger than dates.Ultrasound scan confirmed single pregnancy with a large intramural fibroid showing degenerative changes. A myomectomy was performed as a preventive measure to prevent massive haemorrhage. Although performing myomectomy during pregnancy is considered controversial, complications can be minimised with properly-planned surgery.