Classical the necessary preoperative investigations the patient was

 

Classical cesarean section in case of  lower segment fibroids a case report

Abstract:

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This is a case report
of lower segment fibroids with live fetus in a multiparous woman managed by
classical cesarean section. This case report depicts the successful method of
management of such cases if encountered especially in case where  LSCS can not be done due  to the fibroids present.

Introduction:

 Leiomyoma or uterine fibroids are one of the
most common benign tumours of the reproductive age group. These may remain
asymptomatic and may present as an incidental finding in approximately 50% of
the case1. Generally the symptoms include malpresentations,
dysfunctional labour, APH, PPH and also secondary infertility3.  As these are estrogen dependent fibroid may
grow or undergo red degeneration during the course of pregnancy2. This
presents as complications in a surgery. However, in this case good preoperative
workup and mapping of the fibroid along with careful planning of the classical
cesarean section helped in the uneventful management of this patient.

 

Case report:

A 35 years old G3P2L2
came to the KEM hospital with 36 weeks of pregnancy after being referred from a
private hospital. On examination patient had normal vitals with a haemoglobin
of 10.2 mg/dl . On obstetrical examination per abdominally she was 36 weeks
pregnant with an oblique lie and an additional firm mass of around 20 x 19 cms
palpable below the umbilicus. Ultrasound showed a single live fetus of about 36
weeks of gestation, fundal placement and 2.45 kg fetal weight with multiple
fibroids :

1)   
Large fibroid of
21 x 5.6 x 11 cms extending from the fundus right up to the cervix below.

2)   
2.3 x 1.4 cms
intramural fibroid on anterior wall of uterus.

3)   
5.6 x 3 cms
intramural fibroid on lower segement of uterus.

4)   
4.7 x 3 cms
intramural fibroid on anterior wall of uterus.

After the necessary preoperative
investigations the patient was planned for classical cesarean section (Figure
1) as the Lower segment cesarean section may have led to the fibroid coming in
the line of incision and may have led to further complications in the case.

Patient underwent
classical cesarean section according to the preoperative planning. A live male
baby of 3.07 kg weight was delivered out by breech presentation. Intraoperative
observations also included the presence of multiple fibroids (Figure 2, 3):

1)   
4 x 3 cms in the
lower segment towards the left side

2)   
4 x 3 cms near
the fundus on the anterior wall

3)   
15 x 10 × 10 cms
broad ligament fibroid towards the right side extending from the intrahepatic
region to the lower segment of the uterus.

The fibroids were left
alone to avoid any complications which might have occurred as pregnancy is a
hypervascularised state of the uterus. The operation and the postoperative
period went off uneventful and the mother and the baby were both discharged on
the 7th postop day. The uterus was 20-22 weeks in size at the
discharge time. There was no any swelling of the fibroid felt at the lower
segment as was felt previously.

 

Discussion:

Incidence
of fibroids may vary from 0.1% to as high as 12.5%4. Generally the
fibroids are unaffected with pregnancy but in some cases it may increase in
size by about 10%5. Pregnancy complicated by fibroids cause the
increase in the rate of cesarean section 
due to malpresentation and difficult labour. About 10 – 30% of patients
develop complications like red degeneration, infertility and torsion6.
In this case we were lucky that there were no complications seen.

          A classical cesarean section was planned as in this case as
in the ultrasonography the fibroid was visualized from fundus to the cervix and
hence, any incision taken through the lower segment entailed the risk of going
through the fibroid and may have led to the myomectomy. In recent studies it
has been shown that even though there is not an increased risk in performing
myomectomy along with the cesarean10 but, in this patient there were
multiple fibroids present along with a huge fibroid extending from the fundus
to the cervix and myomectomy of this fibroid may have caused an extensive blood.
Therefore, the decision of not doing myomectomy with cesarean seems to be
justified.

 

Conclusion:

          This case report of the patient having multiple
fibroids with pregnancy was managed successfully with classical cesarean
section. This is a relatively uncommon presentation as per the size and the
location of the fibroids. The decision of not doing the myomectomy with
cesarean section is also justified as the size, number of fibroids and less
chances of future complications were a deterring factor.

 

References:         

1.