ABSTRACT

CORRESPONDING AUTHOR:
Dr. Miriam George Fenn,
Associate Professor,
Department of Obstetrics & Gynaecology,
MOSC Medical College, Kolenchery,
Ernakulam District, Kerala- 682311.
E-mail: jacobchundamannil68@gmail.com

ABSTRACT: OBJECTIVE: To study all Caesarean myomectomies done at a tertiary center in South India. METHODS: 29 cases of Caesarean myomectomies were performed from 2004 to 2014, at our institution – a tertiary referral center. The type of fibroids, number and size of myomas, need for blood transfusions, and operating time and post-operative morbidity at Caesarean myomectomy were  studied. RESULTS: We had equal number of subserous and intramural fibroids, and one large sub mucous fibroid removed at surgery. 7 fibroids were very large (> 10 cm diameter). 6 patients had more than 3 fibroids removed at surgery. 8 required blood transfusions, and none of our patients required hysterectomy. CONCLUSION: The authors find Caesarean myomectomy a feasible and safe option in women with fibroids undergoing Caesarean section.

KEYWORDS: Caesarean myomectomy, leiomyomas in pregnancy.

INTRODUCTION: The incidence of leiomyomas in pregnancy is 2–4%. Elective myomectomy at the time of Caesarean section has been traditionally discouraged due to the attendant morbidity, primarily from haemorrhage. If myomectomy during Caesarean section becomes widely accepted practice, it could eliminate the need for a second operation in these patients. Only few small randomized controlled studied are available, hence the proportion of surgeons attempting this combined procedure is low, due to concerns regarding safety.¹ At times, due to its location at the lower segment, large myoma removal is mandatory in order to deliver the baby, at Caesarean section.²

British gynaecological surgeon Victor Bonney, who did extensive work on cancer cervix cases, also perfected the procedure of myomectomy and introduced his instrument also for use in the same – thereby conserving fertility of many fibroid patients, who till then were having hysterectomy.³

METHODS: This is a retrospective analysis of case records of all patients with fibroids complicating pregnancy, which underwent Caesarean section with concomitant myomectomy. Totally 29 cases have been performed in this tertiary referral hospital, during the time period from 2004 to 2014.

The above table gives the indications for which LSCS was performed in each of the 29 patients. This included 4 patients who had earlier undergone myomectomy, and now presented with recurrent fibroid in pregnancy. In 3 patients, fibroid was situated in the lower segment – and in two of these, the obstructing fibroid had to be excised first in order to facilitate delivery of the baby at C.section.

Sub serous and intra mural were the majority (14 patients each) with only one sub mucous variety of fibroid.

Large fibroids measuring more than 10cm across were 7 in number.

Only 6 patients had multiple fibroids removed at surgery (greater than 3).

As far as the procedure is concerned, intra lesional injection of vasopressin greatly helped haemostasis during dissection. Though vertical incision was used over the most dependent part of the myomas till 4 years ago, currently we use transverse incision. Tumour bed was obliterated with delayed absorbable sutures (2-0 polyglactin), taking meticulous care of the haemostasis. With the above mentioned techniques, operating time was reasonable - only 3 patients needing more than 2 hours of surgical time.

8 of our patients were transfused blood during surgery. 1 patient required 2 pints of blood transfusion.

2 patients had fever in the post-operative period, which settled without much morbidity.

DISCUSSION: With more and more women postponing pregnancy for career issues, fibroids in pregnancy will definitely be on the rise. Caesarean myomectomy, if done in well-equipped centers is a definite and safe option for these mothers. Also beneficial in terms of finances to the individual and the health sector, since interval myomectomy is avoided.

Puerperal uterine sub involution could be avoided, so also other complications related to fibroids – namely menorrhagia, anaemia and pain (From torsion or red degeneration) during subsequent pregnancy.⁴

With use of intra lesional injection of vasopressin blood loss is greatly minimized giving a good plane of dissection. Thus concomitant myomectomy along with C.section is definitely justified as a safe procedure – in our experience. Post-operative morbidity does not seem to be any higher than a routinely performed LSCS. Fertility also is not compromised as a result of the procedure.^5,6,7

OPERATIVE PHOTOGRAPHS:

Fig 1.1 Uterus showing large posterior intra mural fibroid.

Fig 1.2 myomectomy in progress.

Fig 1.3 myoma bed after closure.

Fig. 1.1

Fig 1.2

Fig 1.3

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